Abstract

The aim of this study was to analyze, by an integrative review of the literature, the possible impacts of financial crises on oral health indicators in different countries, as well as to verify the measures adopted in order to compare with the Brazilian reality. A search for articles that met these criteria was carried out in PUBMED, EMBASE, Lilacs, SCOPUS and also in the gray literature. At the end, nine studies were included. The results indicate that the population with higher vulnerability, lower income and lower educational level are the most affected, independently of the evaluated indicator (untreated dental caries, access to dental care services and hygiene habits). When protective measures with allocation of financial resources were taken, disparities decreased. It was concluded that, faced with economic crises, oral health is no longer a priority, which impacts access to care for the less favored social strata.

Key words
Oral Health; Health Management; Health Status Indicators

Introduction

Brazil is experiencing a complex scenario, from both an economic and political point of view, with direct effects on the health sector. The consequences of the world’s economic crisis that hit several countries in 2008 have been perceived in Brazil since 2011, with an increase in the unemployment rate and a decrease in demand by industries. This situation was aggravated by the political crisis, in which Legislative and Executive disputes, somehow modulated by the Judiciary, led to institutional destabilization and the consequent impeachment of President Dilma Roussef in 2016, aggravating the scenario of political instability in the country.

Contexts such as these, which involve economic recession and political crisis, cause the destabilization of institutions and decrease in funds for crucial areas, such as health¹1 Labonté R, Stuckler D. The rise of neoliberalism: how bad economics imperils health and what to do about it. J Epidemiol Community Health 2016; 70(3):312-318.^,22 Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, Souza Noronha KVM, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 6736(19):1-12.. These fiscal adjustments, preferably achieved by cutting costs, are adopted with the justification of adjusting the economy and promoting the country’s growth³3 Deweck E, Oliveira ALM, Rossi P. Austeridade e Retrocesso: Impactos Sociais Da Política Fiscal No Brasil [livro na Internet]. São Paulo: Brasil Debate e Fundação Friedrich Ebert; 2018. Disponível em: http://brasildebate.com.br/wp-content/uploads/DOC-AUSTERIDADE_doc3-_L9.pdf
http://brasildebate.com.br/wp-content/up... . The greatest example of this situation in Brazil was the approval of Constitutional Amendment N. 95, in December 2016, which deals with the New Fiscal Regime (NFR)⁴4 Brasil. Emenda Constitucional no 95 de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências [documento na Internet]. Diário Oficial da União; 2016. Disponível em: http://www.planalto.gov.br/ccivil_03/constituicao/emendas/emc/emc95.htm
http://www.planalto.gov.br/ccivil_03/con... . Starting on December 16, 2016, when it was approved, a number of provisions were introduced into the Transitional Constitutional Provisions Act that programmed a new fiscal regime with a cap on federal government spending, a cap that spared neither the Health nor the Education sectors and will be in effect for the next twenty (20) years.

One can observe, at the international level, that the adoption of fiscal austerity policies that affect the health sector is not new in the current capitalist world. In response to the 2008 financial crisis, for instance, countries with Universal Health Systems such as England, Germany, and Spain have adopted austerity policies that limit public health spending, aiming at controlling the public deficit¹1 Labonté R, Stuckler D. The rise of neoliberalism: how bad economics imperils health and what to do about it. J Epidemiol Community Health 2016; 70(3):312-318.^,55 Giovanella L, Stegmuller K. Crise financeira europeia e sistemas de saúde: universalidade ameaçada? Tendências das reformas de saúde na Alemanha, Reino Unido e Espanha. Cad Saude Publica 2014; 30(11):1-19.

6 Borges FT, Fernández LAL, Campos GWS. Políticas de austeridade fiscal: tentativa de desmantelamento do Sistema Nacional de Salud da Espanha e resistência cidadã. Saude e Soc 2018; 27(3):715-728.^-77 Santos IS, Vieira FS. Direito à saúde e austeridade fiscal: o caso brasileiro em perspectiva internacional. Ciên Saude Colet 2018; 23(7):2303-2314.. However, in the case of the Brazilian austerity policy, spending will be stagnant in actual terms and for a fixed period of two decades, being more radical than the measures adopted by the other countries.

If economic crises are enough to worsen people’s health, by increasing poverty and changing other social determinants of health, the austerity policies reinforce this process by reducing social protection and decreasing the allocation of resources to the health system³3 Deweck E, Oliveira ALM, Rossi P. Austeridade e Retrocesso: Impactos Sociais Da Política Fiscal No Brasil [livro na Internet]. São Paulo: Brasil Debate e Fundação Friedrich Ebert; 2018. Disponível em: http://brasildebate.com.br/wp-content/uploads/DOC-AUSTERIDADE_doc3-_L9.pdf
http://brasildebate.com.br/wp-content/up... . In this context, recent studies have already indicated the worsening of Brazilian basic health indicators after the new fiscal regime was introduced, suggesting that the reduction in health investments is already affecting health promotion, prevention and attention policies²2 Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, Souza Noronha KVM, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 6736(19):1-12.^,88 Paes-Sousa R, Rasella D, Carepa-Sousa J. Política econômica e saúde pública: equilíbrio fiscal e bem-estar da população. Saude e Debate 2018; 42(3):172-182.. In the specific case of oral health, an even more damaging scenario can be foreseen, given that limitations in the provision and access to oral health services make untreated dental caries, even currently, the most common morbidity among all diseases worldwide, a fact that makes it a considerable economic burden for the individual and society⁹9 Righolt AJ, Jevdjevic M, Marcenes W, Listl S. Global-, Regional-, and Country-Level Economic Impacts of Dental Diseases in 2015. J Dent Res 2018; 97(5):501-507.

10 Kassebaum NJ, Smith AGC, Bernabé E, Fleming TD, Reynolds AE, Vos T, Murray CJL, Marcenes W, GBD 2015 Oral Health Collaborators. Global, Regional, and National Prevalence, Incidence, and Disability-Adjusted Life Years for Oral Conditions for 195 Countries, 1990-2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors. J Dent Res 2017; 96(4):380-387.

11 Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreño CC, Kearns C, Benzian H, Allison P, Watt RG. Oral diseases: a global public health challenge. Lancet 2019; 394(10194):249-260.^-1212 Watt RG, Daly B, Allison P, Macpherson LMD, Venturelli R, Listl S, Weyant RJ, Mathur MR, Guarnizo-Herreño CC, Celeste RK, Peres MA, Kearns C, Benzian H. Ending the neglect of global oral health: time for radical action. Lancet 2019; 394(10194):261-272.. However, even considering the world scenario, Brazil is currently the only country in the world to include oral health care and assistance in its public health system (Brazilian Unified Health System - SUS)¹³13 Paim JS, Temporão JG, Penna GO, Santos NR, Pinto LF. Sistema Único de Saúde: 30 anos de luta! Ciên Saude Colet 2018; 23(6):1704. for more than 200 million inhabitants, with a public, universal system that includes different levels of care.

Recent changes in the guidelines of the main public policies, including oral health policy, may severely compromise the progress made by the country. The continuity of the National Oral Health Policy (Política Nacional de Saúde Bucal, PNSB) or the “Smiling Brazil” program depends on political will and popular movement, as traditionally in Brazil, government programs are not synonymous with State programs¹⁴14 Pereira AC, Mialhe FL, Pereira SM, Meneghim MDC. O mercado de trabalho odontológico em saúde coletiva: possibilidades e discussões. Arq em Odontol 2010; 46(4):232-239.^,1515 Cascaes AM, Dotto L, Bomfim RA. Tendências da força de trabalho de cirurgiões-dentistas no Brasil, no período de 2007 a 2014: estudo de séries temporais com dados do Cadastro Nacional de Estabelecimentos de Saúde. Epidemiol Serv Saude 2018; 27(1):1-10.. Considering that the allocation of resources for oral health has been historically neglected before the existence of the “Smiling Brazil” program, one can presuppose a challenging scenario.

Other countries have experienced major economic crises and the results experienced by the health sector actions, whether successful or unsuccessful, can be used as basis for the planning of national measures, if one looks at the specific features. Given the above-mentioned facts, the aim of this study was to assess, based on an integrative literature review, the impact of financial crises on oral health indicators. In view of the findings, it was observed how the countries proposed coping with this scenario and a critical-reflective discussion was intended, considering the current Brazilian scenario.

Methods

Study Design and Question

The integrative literature review was carried out and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement¹⁶16 Hutton B, Salanti G, Caldwell DM, Chaimani A, Jansen JP, Mulrow C. The PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions: Checklist and Explanations. Ann Intern Med 2015; 162(11):777-784. and the study question was: “What is the impact of financial crises and austerity policies on oral health indicators?”

Search Terms and Strategy

Based on the question, a search was carried out using specific terms extracted from Mesh and Emtree to allow the adequate strategy. A systematic search was carried out in July 2019 on electronic databases including PubMed, EMBASE, Scopus and Lilacs to identify studies that analyzed the association between financial crises and austerity policies with oral health indicators. There was no language or date restriction and the combination of terms with their synonyms, as well as the results found for each electronic database on the day of the search is shown in details in Chart 1.

A search was also carried out in the gray literature and contact was made with researchers from the area to retrieve unpublished studies (Chart 2).

Finally, the references of relevant articles included for full-text reading were also checked to assess the inclusion of additional studies.

Eligibility criteria

Only primary studies that specifically associated the impacts of an economic crisis and/or austerity policy on oral health indicators were included. Review studies, letters, editorials and opinion articles were excluded.

Study selection

The database search resulted in 180 articles. Additional searches were made on Google Scholar, including analysis of the first 10 pages (100 articles). The 262 references were then exported to Rayyan QCRI¹⁷17 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5(1):210., a tool used to remove duplicates and to screen titles and abstracts according to the eligibility criteria. At the end of the entire selection process, 9 studies were included, as shown in Figure 1.

Data extraction

A previously created Excel spreadsheet was used to extract the following data: (author/year, assessed economic crisis, assessed impact on oral health, authors’ conclusions).

Results

Chart 3 shows the characterization of the nine included studies, containing information on the study design and purpose, economic crisis, country and oral health indicator evaluated. The recent economic crisis that affected the United States was the most evaluated one (04 studies). Other assessed countries were Iceland (01 study), Finland (01 study), Greece (01 study) and Spain (01 article). One study aimed to assess the effect of the economic crisis on 23 European countries. No studies were found evaluating the Brazilian context.

The main assessed indicators were access to oral health services and untreated caries. Only one study evaluated the incidence of maxillofacial fractures as an indicator.

Chart 4 shows the results and conclusions found by the authors of the 9 included studies.

In the overall context of the several countries, it can be said that the effects of crises affect the most vulnerable and low-income population with the least schooling. It can also be observed that when protective measures are taken, including increased financing, oral health inequities decrease.

Discussion

The association between economic conditions and health outcomes is a complex one and may involve multiple and interrelated pathways. There are scarce studies that assess the impact of economic crises on the oral health indicators of the population. However, in general, some predictions can be made for Brazil if the results are evaluated considering the particularities of our country and our policy.

The oldest study we found assessed the impact of the 1990s economic recession on the use of oral health services in Finland¹⁸18 Suominen-Taipale L, Widström E. Does dental service utilization drop during economic recession? The example of Finland, 1991-94. Community Dent Oral Epidemiol 1998; 26(2):107-114.. It was hypothesized that the crisis would have reduced the demand for oral health services, but such an outcome was not confirmed in the overall context, as only the group of patients subsidized by the government showed a significant reduction in the demand for oral services during the study years. The increase in the number of dental surgeons in the country increased the competition among them, reducing the costs of treatment and partially counterbalancing the effects of the economic crisis. However, it is noteworthy that this competition favored particularly the social strata with high income and high level of schooling.

At this point, we draw a parallel with the Brazilian reality. The number of dentists in the country was already considered high in 2004, the year the “Smiling Brazil” program was launched. However, this did not result in better access to oral health care for the population, a fact that is evident when we observe that, at that time, 28 million Brazilians had never been to the dentist²⁷27 Brasil. Ministério da Saúde (MS). Projeto SB Brasil 2003: Condições de Saúde Bucal Da População Brasileira 2002-2003: Resultados Principais [relatório na Internet]. Brasília: MS; 2004. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/condicoes_saude_bucal.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . Until then, the Brazilian public dental assistance was focused on the curative maternal-child model, with severe problems of distribution of human resources in a country of continental dimensions, which, without planning, became mutilating and elitist²⁸28 Gabriel M, Cayetano MH, Galante ML, Carrer FC. A Global Overview of the Geographical Distribution of Dentists?: A Scoping Review. JDR Clin Transl Res 2018; 3(3):229-237..

With the implementation of “Smiling Brazil” program, the Brazilian population had this demand met through the offer and expansion of public oral health services. Even though the issue of the distribution of professionals has not yet reached optimal levels, public oral health policies started to encourage professionals to go to countryside and regions with greater vulnerability, aiming at a more equitable provision of dental services¹⁵15 Cascaes AM, Dotto L, Bomfim RA. Tendências da força de trabalho de cirurgiões-dentistas no Brasil, no período de 2007 a 2014: estudo de séries temporais com dados do Cadastro Nacional de Estabelecimentos de Saúde. Epidemiol Serv Saude 2018; 27(1):1-10.^,2929 Peres KG, Peres MA, Boing AF, Bertoldi AD, Bastos JL, Barros AJD. Redução das desigualdades sociais na utilização de serviços odontológicos no Brasil entre 1998 e 2008. Rev Saude Publica 2012; 46(2):250-258.. The positive impact of these measures can be perceived also by the improvement achieved in the Brazilian epidemiological scenario, according to results from SB Brasil 2010³⁰30 Brasil. Ministério da Saúde (MS). Resultados Principais SB Brasil 2010 [relatório na Internet]. Brasília: MS; 2011. Disponível em: http://189.28.128.100/dab/docs/geral/projeto_sb2010_relatorio_final.pdf
http://189.28.128.100/dab/docs/geral/pro... and SB São Paulo 2015³¹31 Pereira AC, Frias AC, Vieira V. SB São Paulo: Pesquisa Estadual de Saúde Bucal 2015: Relatório Final [relatório na Internet]. Águas de São Pedro: Livronovo; 2016. Disponível em: http://www.saude.sp.gov.br/resources/ses/perfil/profissional-da-saude/areas-tecnicas-da-ses/e_book_relatorio_sb_sp_2015.pdf
http://www.saude.sp.gov.br/resources/ses... , at national and local levels, respectively.

Moreover, it should be noted that in Brazil, it is estimated that at least 80% of the population depends exclusively on public dental care¹⁵15 Cascaes AM, Dotto L, Bomfim RA. Tendências da força de trabalho de cirurgiões-dentistas no Brasil, no período de 2007 a 2014: estudo de séries temporais com dados do Cadastro Nacional de Estabelecimentos de Saúde. Epidemiol Serv Saude 2018; 27(1):1-10.^,3232 Cascaes AM, Camargo MBJ, Castilhos ED, Silva AER, Barros AJD. Private dental insurance expenditure in Brazil. Rev Saude Publica 2018; 52:24., which, compared to the subsidized Finnish population, would be the most severely affected, increasing oral health disparities. Considering that the Finnish government postponed plans to extend health insurance to cover dental services for the entire adult population due to economic constraints¹⁸18 Suominen-Taipale L, Widström E. Does dental service utilization drop during economic recession? The example of Finland, 1991-94. Community Dent Oral Epidemiol 1998; 26(2):107-114., one can assume that oral health is often outside the list of governments’ priorities, when it comes to ensure the access of their populations to health care.

Thus, the importance of the “Smiling Brazil” program is emphasized, concerning the expansion of dental services in the Brazilian public service. The continuity of public policies that combine the provision of health services based on principles of equity and quality of care are determinant for the advance, in future results, in terms of access and use, problem-solving and improvement of oral health conditions of the population¹⁵15 Cascaes AM, Dotto L, Bomfim RA. Tendências da força de trabalho de cirurgiões-dentistas no Brasil, no período de 2007 a 2014: estudo de séries temporais com dados do Cadastro Nacional de Estabelecimentos de Saúde. Epidemiol Serv Saude 2018; 27(1):1-10.. However, recent political and economic crises at global and national levels indicate several changes in this scenario, a situation that may negatively affect the oral health of the population.

Economic crises have some consequences, and among them, an increase in unemployment rates and an effect on the decrease of the Gross Domestic Product (GDP), which results in a substantial loss of wealth. In the US case, citing Medicaid, such situation caused dentists in some states to experience a sharp reduction in demand for care during the 2007-2009 crisis. With the unused capacity and increased reimbursement offered by Medicaid, there was a growing interest by these professionals for the program. This has allowed the Medicaid-assisted population to have more access to dental services, which significantly increased the use of dental services. One of the highlighted points was that the professionals were attracted to the program because there was an update in the reimbursement values offered by the government²³23 Beazoglou T, Douglass J, Myne-Joslin V, Baker P, Bailit H. Impact of fee increases on dental utilization rates for children living in Connecticut and enrolled in Medicaid. J Am Dent Assoc 2015; 146(1):52-60..

Medicaid is a social resource program aimed only at the low-income North-American population. With the crisis and high unemployment rates, more people started being assisted by the program. And it was precisely the financial investment amidst the crisis (through increases in reimbursements to professionals) that allowed access to dental care services to increase²³23 Beazoglou T, Douglass J, Myne-Joslin V, Baker P, Bailit H. Impact of fee increases on dental utilization rates for children living in Connecticut and enrolled in Medicaid. J Am Dent Assoc 2015; 146(1):52-60.. This situation is highly relevant to the Brazilian context, even though there is a big difference between the policies of the two countries.

Also in this context, when analyzing access to services without restricting Medicaid evaluation, it was observed that when the result is evaluated in aggregate form, despite the occurrence of a decline, there is no statistically significant difference regarding the rate of dental care service use among the population as a whole. However, there is a significant variation by age and poverty level. Differently from the pediatric population, adults (even low-income ones) are not necessarily assisted by Medicaid. And it was precisely among this population that the impact of the crisis was most significant¹⁹19 Wall TP, Vujicic M, Nasseh K. Recent trends in the utilization of dental care in the United States. J Dent Educ 2012; 76(8):1020-1027..

This investment situation is exactly the opposite of what has happened in Brazil, because with the economic crisis, the number of SUS-dependent patients tends to increase. However, the investment and continuity of the “Smiling Brazil” program has been severely hindered, mainly due to the precariousness of the service and, to some extent, in a perverse manner, by denying it to the population that needs it the most. The deactivation of Dental Specialty Centers (nationwide), the increasing termination of Family Health Teams’ accreditation (especially in Rio de Janeiro) and the implementation of the current National Primary Care Policy³³33 Brasil. Ministério da Saúde (MS). Portaria no 2436 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 (SUS). Diário Oficial da União; 2017.^,3434 Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde Atenção Básica no Brasil. Saude e Debate 2018; 42(116):11-24. support this throwback movement in relation to social policies, which is also observed in other fields of SUS, and not only regarding oral health. In contrast, the literature indicates that, at the macro level, health policies should build an agenda to fight inequities, aiming to reduce the exposure of vulnerable individuals to health-harming factors, while minimizing the impact of the (social, economic) consequences of oral diseases. This can be achieved by promoting oral health care in an accessible, appropriate and effective way, directed to the population groups on the margins of society, most susceptible to oral diseases³⁵35 Watt RG. Social determinants of oral health inequalities: implications for action. Community Dent Oral Epidemiol 2012; 40:44-48..

Faced with the economic crisis, the indicator “untreated dental caries” was evaluated in the United States²⁰20 Abasaeed R, Kranz AM, Rozier G. The impact of the Great Recession on untreated dental caries among kindergarten students in North Carolina. J Am Dent Assoc 2013; 144(9):1038-1046. and Spain²⁴24 Calzón Fernández S, Fernández Ajuria A, Martín JJ, Murphy MJ. The impact of the economic crisis on unmet dental care needs in Spain. J Epidemiol Community Health 2015; 69(9):880-885., respectively. Both studies showed an increased need for dental treatment in the assessed population. In this context, in Spain, publicly-funded dental care for adults was limited to acute cases (urgent care) and acute pathologies. This population was the most affected regarding oral health, indicating the need to rethink the offer of public dental services in the local area²⁴24 Calzón Fernández S, Fernández Ajuria A, Martín JJ, Murphy MJ. The impact of the economic crisis on unmet dental care needs in Spain. J Epidemiol Community Health 2015; 69(9):880-885.. This type of consequence of the financial crisis places oral health at a non-priority level in health systems, so that care actions are restricted to damage limitation, typical of the surgical-restorative dental paradigm, which has been so strongly opposed in the last decades, and that, possibly, will gain support again, even in Brazil, with the support of the austerity policies and containment of expenditures signaled by the federal government.

Regarding the oral health habits after the crisis that affected Iceland, it was observed that there were no major differences in the population, although specific groups deserve special attention in times of crisis, such as the economically vulnerable groups²¹21 McClure CB, Saemundsson SR. Effects of a national economic crisis on dental habits and checkup behaviors - a prospective cohort study. Community Dent Oral Epidemiol 2014; 42(2):106-112.. From this perspective, one must consider that oral diseases disproportionately affect disadvantaged social segments, evidencing, from an epidemiological point of view, the influence of social gradients on oral health³⁶36 Sheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol 2000; 28(6):399-406.. This fact indicates the importance of actions aimed at oral health promotion and protection, encouraging the development of healthy habits and strongly associated to the increased oral health resolutivity in Primary Health Care³⁷37 Aquilante AG, Aciole GG. O cuidado em saúde bucal após a Política Nacional de Saúde Bucal - "Brasil Sorridente": um estudo de caso. Ciên Saude Colet 2015; 20(1):239-248..

Faced with the crisis in Greece, the indicator “incidence of maxillofacial fractures” was analyzed, with an increase in fractures caused by interpersonal violence²²22 Rallis G, Igoumenakis D, Krasadakis C, Stathopoulos P. Impact of the economic recession on the etiology of maxillofacial fractures in Greece. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119(1):32-34.. This finding needs to be analyzed concerning two aspects. First, considering the issue of violence, and bearing in mind that Brazil is known to be a country marked by violence (in traffic, interpersonal) and, finally, because this situation has an impact on health services. The result found by Rallis et al.²²22 Rallis G, Igoumenakis D, Krasadakis C, Stathopoulos P. Impact of the economic recession on the etiology of maxillofacial fractures in Greece. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119(1):32-34. is also expected for Brazil. But, moreover, it is necessary to emphasize that maxillofacial fractures, in general, demand more complex care, very often requiring extensive surgery in hospital settings. Thus, the increase in its incidence has a greater impact on costs for the public health system, as they require continued investments in addition to oral health actions in primary care, implying oral health actions at secondary and tertiary levels, which are necessarily onerous to public finances.

Moreover, the greater coverage of dental care is significantly associated with lower income inequality in this access²⁵25 Elstad JI. Dental care coverage and income-related inequalities in foregone dental care in Europe during the great recession. Community Dent Oral Epidemiol 2017; 45(4):296-302., a fact that reinforces the importance of public policies aimed at guaranteeing access to good-quality dental care, such as the “Smiling Brazil” program, and its strengthening is required from the point of view of management and the defense of financial investments to ensure the fight against inequalities in oral health in Brazil. Therefore, we consider that the decrease in the allocation of resources or the lack of investments that guarantee the offer of oral health services may compromise the access of the most vulnerable patients and, thus, aggravate the discrepancies in oral health. This finding becomes critical when contextualized in a country of continental dimensions such as Brazil, marked by blatant regional differences that affect all sectors of society (mainly education and health), and which, if not handled in an inclusive manner, tend to be aggravated.

Hence, it seems important to highlight that the economic and political crisis that has been affecting Brazil since 2014, with a falling GDP, rising unemployment rates and falling per capita income, combined with an austerity scenario with budgetary limitations with the publication of the Constitutional Amendment N. 95, an increase in the Untying of Union Revenues (DRU, from desvinculação de receitas da União in Portuguese) from 20 to 30% and tax exemptions have had consequences on health indicators in Brazil, regarding this study, those related to oral health. This is particularly important if one considers that budgetary constraints brings with them difficulties in costing and the maintenance of sufficient human resources to meet local demands, leading to lack of assistance. Thus, taking into account the basic principles of economics, economic austerity itself is a demand feedback process, with has a profound impact on health indicators.

It was concluded that, faced with the economic crises, oral health is no longer a priority as a nucleating center of policies, which impacts on the access to care for the less favored social strata. In this regard, oral health conditions that, even nowadays, are considered a public health problem and, therefore, frequent, preventable and of known control, may re-emerge among the most vulnerable individuals, while situations of greater complexity might require greater investments, considering the specifics of the local reality.

References

Publication Dates

History