20 years of experience with the Brazilian Unified National Health System: strides and challenges for oral health
Since enactment of the 1988 National Constitution and the creation of the Unified National Health System (SUS), Brazil has witnessed numerous changes in the country's public policy field. The number of municipalities without dental care resources has decreased. School dental clinics have been transferred to the primary health care network, thereby creating the conditions for greater integration between dental care activities and other programs. Population groups previously excluded from their most basic rights have begun to access programs organized specifically according to life cycles, ethnic characteristics, and social context. Resources from the National Health Fund have regularly financed programs for topical fluoride application and supervised brushing in schools, inclusion of oral health teams in the Family Health Strategy, and public clinics with specialized dental services, among other initiatives. Despite the positive overall impact of the Brazilian health reform on oral health policies, we can expect to face several challenges in order to maintain oral health on the public policy agenda in the coming years.
The system's under-financing will increasingly require the elaboration of shared management strategies, in keeping with the principles of universal coverage, comprehensiveness, and equity of care. Changes in the world of work will particularly (but not exclusively) require that health system administrators and professionals place a special focus on mapping sources of knowledge both within and outside their organizations. Data and experiences previously restricted to certain individuals, groups, and health service units will need to be submitted to different types of analytical treatment and transformed into relevant information. Cost-effectiveness assessment of health practices and technologies and accessible resources to increase the quality of care constitute essential areas for generating knowledge (the demand for which tends to increase). In addition, there is a clear need to implement strategies to expand the supply of training opportunities, ensuring not only the new necessary skills, but especially the conditions for committing and retaining health teams and for increasing coverage by the services.
In the field of oral health management, a complex agenda is emerging, involving the environment, dental service providers, research and knowledge output, manufacturers of inputs, materials, and equipment, and human resources training. In relation to the environment, a key aspect is the need for management of water for human consumption as a public good and an essential vehicle for access to fluoride.
In the health care system, particularly relevant issues relate to the distribution of service units according to levels of care, installed capacity, and their various legal and institutional formats, along with more specific issues related to types and modalities of the services supplied, user enrollment in areas/territories, resources, funding sources, payment systems, and results.
Priority should be direct to research including health system demands and implementation of measures with manufacturers to improve the quality of materials and equipment and expand access to inputs for oral hygiene.
Finally, it is necessary to strengthen the exchange between training institutions and local health system managers in a common agenda, leading to a growing linkage of actions aimed at surmounting the liberal, private-oriented tradition, while training professionals and citizens fully committed to the National Health System.
Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brasil