Equity and provision of public dental services in the State of Paraná, Southern Brazil
Equidad y provisión de servicios públicos odontológicos en el estado de Paraná, Sur de Brasil
Márcia Helena BaldaniI; Eurivaldo Sampaio de AlmeidaII; José Leopoldo Ferreira AntunesIII
IDepartamento de Odontologia. Universidade Estadual de Ponta Grossa. Ponta Grossa, PR, Brasil
IIDepartamento de Práticas em Saúde Pública. Faculdade de Saúde Pública. Universidade de São Paulo. São Paulo, SP, Brasil
IIIDepartamento de Odontologia Social. Faculdade de Odontologia. Universidade de São Paulo. São Paulo, SP, Brasil
OBJECTIVE: To assess the association between socioeconomic indicators of provision of public dental services and allocation of financial resources in health and to identify whether this association reinforced the promotion of vertical equity.
METHODS: A cross-sectional ecological study was conducted based on data obtained from the Brazilian Ministry of Health data system for 399 cities in the State of Paraná (Southern Brazil) between 1998 and 2005. Socioeconomic condition was measured by the Human Development Index in the cities studied, as well as by some indicators of income, education and sanitation, which were obtained from the Brazilian Institute of Geography and Statistics database. Data were analyzed using nonparametric statistical tests: Spearman's rank correlation coefficient, Friedman and Mann-Whitney tests.
RESULTS: A redistribution trend of federal resources for primary health care in municipalities was seen. The provision of dental health services increased after the government launched the Family Health Strategy. An expanded provision of dental procedures was reported during the study period with a pro-equity trend of the utilization of dental services in primary health care.
CONCLUSIONS: There was seen a redistribution or pro-equity trend in the provision of dental services in the state of Paraná with higher per capita provision of resources or services in cities with the lowest socioeconomic indicators. This trend is consistent with the recent programmatic guidelines of the Brazilian Ministry of Health.
Descriptors: Dental Health Services, supply & distribution. Dental Care. Health Services Accessibility. Equity in Access. Health Inequalities. Socioeconomic Factors.
OBJETIVO: Analizar la asociación entre indicadores socioeconómicos, de provisión de servicios públicos odontológicos y de distribución de recursos financieros en salud, y identificar si el sentido de las asociaciones ocurre a favor de la equidad vertical.
MÉTODOS: Fue realizado un estudio transversal de abordaje ecológico, con datos del Ministerio de la Salud relacionados con 399 municipios del estado de Paraná, Sur de Brasil, en el período de 1998 a 2005. La condición socioeconómica fue estimada por medio del Índice de Desarrollo Humano de los municipios, así como por indicadores socioeconómicos de renta, educación y saneamiento básico obtenidos en las bases de datos del Instituto Brasilero de Geografía y Estadística. Los datos fueron sometidos a pruebas estadísticas no paramétricas: coeficiente de correlación de Spearman, Friedman y Mann-Whitney.
RESULTADOS: Hubo tendencia redistributiva de los recursos federales transferidos a los municipios para el costeo de la atención básica, intensificada a partir del lanzamiento de la Estrategia Salud de la Familia. Se observó expansión de las acciones de salud bucal en el período analizado, bien como tendencia pro-equidad en la oferta y utilización de los servicios odontológicos en atención básica.
CONCLUSIONES: Hubo tendencia redistributiva, o pro-equidad, en la provisión de servicios odontológicos en el estado de Paraná, con mayor provisión per capita de recursos o servicios para municipios con peores indicadores socioeconómicos. Esta tendencia se mostró compatible con las directrices programáticas recientes del Ministerio de la Salud.
Descriptores: Servicios de Salud Dental, provisión & distribución. Atención Odontológica. Accesibilidad a los Servicios de Salud. Equidad en el Acceso. Desigualdades en la Salud. Factores Socioeconómicos.
Socioeconomic inequality is a striking characteristic of the Brazilian context and it has far-reaching health consequences, especially oral health. Although it is one of the states of greatest economic importance in Brazil, Parana has the worst indices of poverty and social exclusion of the South of the country, as well as major socioeconomic inequalities among the municipalities.17,18
The socioeconomic gradient in health has been observed in many countries, regardless of the nature, extent and efficiency of their respective health systems. This situation is even reflected in the access to health services and their quality.20 Studies have indicated that the individuals who live in the worst socioeconomic conditions have less access to oral health services, both in Brazil as worldwide.3,8,16 Researches have also shown that the increased supply of public health services increases the probability of access for individuals with low socioeconomic status.14
The Sistema Único de Saúde (SUS - Brazilian National Health System), because of its doctrinal and organizational characteristics, is considered one of the main achievements of Brazilian people to consolidate their social rights. The principle of equity as positive discrimination, also called vertical equity,20 has been guiding health policies in Brazil since the Ministry of Health published the Basic Operating Norm in 1996 (NOB/SUS 1996), and has been mainly applied to primary care funding mechanisms. Since then, some studies have shown the redistributive characteristics of the resources transferring policies, through the Minimum Level Primary Care Fund (PAB), which has benefited mainly the very poor municipalities.10,11,13,19
In this context, family health is a primary care strategy that seeks to effectively incorporate the SUS principles of universal access, integrality and equity. Oral health services were incorporated to the Estratégia Saúde da Família (ESF - Family Health Strategy) activities in December 2000, aiming to expand collective access to actions that promote, prevent and recuperate oral health and consequently improve its epidemiological indicators. Since it was launched, those municipalities that are demographically smaller,1,12 and those characterized by their reduced fiscal capacity, low socioeconomic level of their population and average health service provision10 have strongly adhered to the program.
Within the scope of the oral health services, some evidence have been found regarding the possibility of applying the principle of vertical equity at the aggregate level in some Brazilian states, including Paraná.2,7,9
The aim of this study was to analyze the association between socioeconomic indicators, provision of public dental services and allocation of resources, and to identify if the direction of such associations are in favor of vertical equity.
A cross-sectional ecological study was conducted, involving Parana's 399 municipalities, using data for the period between 1998 and 2005. The information was obtained from the Parana State Department of Health (SES - PR) and from the databases of the Ministry of Health (DATASUS) and the Instituto Brasileiro de Geografia e Estatística (IBGE - Brazilian Institute of Geography and Statistics).
In order to identify vertical equity, unfair inequalities or inequities were considered to be the differences in socioeconomic conditions, once their association with oral health inequalities in oral health and access to services has been widely observed.3,8,16
The socioeconomic conditions of the municipalities were measured by reference to the Human Development Index (HDI) for 2000.ª Some other indicators, provided by the IBGE Demographic Census for 2000 were: a) habitation: proportion of residents in homes linked to water and sewage networks; b) income: average monthly income of the head of the household and the proportion of heads of household whose income is insufficient (less than two minimum salaries, or with no income); c) education: literacy rate of those over ten years of age.
The provision of public dental services in 2003, considered as the outcome of this investigation, was measured from variables that sought to include the three fields to which the concept of equity applies when it comes to analyzing and planning public policies, as suggested by Viana et al:22 a) the distribution of resources; b) supply or opportunity for access; and c) service utilization. The variables were obtained from the databases of the Ministry of Health (DATASUS).
The variables relative to the funds allocated to healthcare correspond to the total expenditure on health care by the municipalities and to the per capita expenditure using the municipalities' own funds. These informations were obtained from the Sistema de Informação Orçamentária em Saúde (SIOPS - Health Budget Information System) database. Data relating to the total federal resources transferred to the municipalities for primary health care (total of the PAB transfers per inhabitant) and the incentive fund for dental care in the ESF (variable amount of the PAB, per capita, earmarked for dental care in the Family Health Strategy) were provided by the SUS Sistema de Informação Ambulatorial (SIA-SUS - Outpatient Information System).
The offer and use of public dental services were considered a proxy of the population's access to these services, in accordance with the methodology used in the work of Viana et al.22 The variables we selected as the indicators of the extent of the offer of services were: the number of dental surgeons in the SUS in 2002 per inhabitant, taken from the Medical-Sanitary Assistance Survey (AMS), which is available in the SIA-SUS; and the number of pieces of dental equipment in the SUS in 2003 per inhabitant, obtained from the health service network databases, also taken from the SIA-SUS. To quantify use of the services, we obtained data about the supply of dental services in primary care in the SUS in 2003 per capita as far as concerned the number of: a) basic dental care actions (outpatient dental procedures); b) collective procedures (annual epidemiological check-ups, supervised cleaning, mouthwashes with fluoridated solutions, health education); c) preventive procedures (intensive therapeutic application of topic fluoride, the control of biofilm and the application of dental sealants); d) restorative procedures (total number of fillings using amalgam, composite, silicate, light cure materials and crowns with pins); e) the removal of deciduous and permanent teeth, as well as the remains of dental roots.
For the variables of funds, supply and use of public dental services, besides information relative to 2003, we collected data for the years 1998, 2000 and 2005. This enabled us to identify the possible impact of recent public health policies on the provision of public dental services in the State, as far as concerns the principle of vertical equity.
Data relative to the socioeconomic indicators and the provision of public dental services were analyzed and interpreted using descriptive statistics. By applying the Kolmogorov-Smirnov test for normality,6 we saw that there was no normal distribution pattern for most of the dental service provision variables, even after they were logarithmically transformed. As a result we used non-parametric statistics.
The equity analysis was carried out using the Spearman (rs) correlation, considering the indicators of dental service provision and the funds allocated to health as dependent variables and socioeconomic condition indicators as explanatory variables. We tried to identify the significant correlations and the direction of the associations. Any actions that indicated a redistributive tendency or a greater per capita provision of resources or services to those municipalities with the worst socioeconomic indicators, were considered to be associations that favored equity.
We analyzed any possible differences in the evolution of the provision of public dental services, between 1998 and 2005, in the municipalities that had extreme socioeconomic inequality indicators. Information relating to the percentage of heads of household with insufficient income living in municipalities located in the first quartile was compared with the same information for municipalities in the last quartile. The variation in the indicators of service provision in the period and its statistical significance to each group was analyzed using Friedman's non-parametric test for dependent samples. The Mann-Whitney non-parametric test was used for analyzing the differences between the quartiles in each period.
Table 1 shows the socioeconomic and public dental service provision indicators for municipalities in the State of Paraná. The inequality among the municipalities was pronounced and that the averages did not reflect this variation. The average rate, both for the number of pieces of dental equipment as well as dentists in public service, was close to 1:2,000 and 1:2,500 inhabitants, respectively. However, the rate varied from 1:100 inhabitants to more than 1:20,000. This same variability was also observed for all types of procedure. The average number of collective procedures in the municipalities accounts for more than half of all dental procedures in primary care. In the state, 202 of the municipalities included oral health actions in the Family Health Strategy.
Table 2 shows the associations between the public dental service provision variables and the socioeconomic condition variables. As far as the allocation of funds to health care is concerned, the municipalities presenting the largest total expenditure per capita were those with the worst living conditions' indicators. These municipalities also invest more of their own funds in health care and receive the largest amount of PAB transfers per capita. As far as concerns the financial incentive passed on to municipalities for dental care in the ESF, a larger figure per capita for those with the worst socioeconomic indicators was observed.
With regard to the extent of the supply, there was no significant association between the number of pieces of dental equipment and dental surgeons working in the public service and the HDI-M. However, significant associations for isolated indicators were observed, showing that the municipalities with the higher number of dentists and pieces of dental equipment per 1,000 inhabitants had the worst social conditions as for sanitation, income, income concentration and schooling levels are concerned (Table 2). With regard to service utilization, a larger number of significant associations was observed for the total number of basic dental care actions, collective procedures, restorative procedures and teeth extractions in those municipalities with the worst social indicators.
The analysis of the associations between the number of extractions and other types of dental procedure showed a trend towards a greater offer of this particular procedure in municipalities where the ratio dentist/ SUS/ inhabitant (rs = 0.263) and the number of collective (rs = 0.197), preventive (rs = 0.215) and restorative (rs = 0.548) procedures per capita are bigger (figures not shown in the tables).
Figures 1 to 3 correspond to the graphs using the medians of public dental service provision indicators, considering the quartiles of those municipalities with the biggest (73.5% or more) or smallest (58.5% or less) proportion of heads of household with insufficient income. The evolution of total expenditure on health per capita indicates a marked increase as from 2000, as well as a redistributive tendency, with significant differences between the groups in 2005 (Figure 1a). As for the variation of the PAB transfers, the variable fraction of the PAB relative to the incentive for oral health actions in the ESF (Figure 1b and 1c), there was a significant increase in the amounts passed on to both groups in the period; such amounts were always larger to the group with the worst social condition. In 2005, the median amount per capita of the incentive for dental care in the ESF for the group of municipalities with the largest number of heads of household with insufficient income was 2.5 times greater than for the group located in the best socioeconomic conditions quartile.
As for primary dental care procedures (Figure 2a), there was an increase in the number of basic dental care actions per capita between 1998 and 2000. The significant differences between the groups reinforce the redistributive trend towards primary dental care actions seen in Table 2. Also, in Figures 2b and 3 there was a significantly larger number of collective, restorative and extraction procedures per inhabitant in those municipalities with the worst socioeconomic conditions. As for preventive procedures (Figure 3a), there was a considerable reduction in these procedures in the group with the smallest proportion of heads of household with insufficient income and an increase in the other group. The only significant difference between the groups for these procedures occurred in 1998, with a larger amount per capita in those municipalities located in the quartile with the best social conditions. In the period studied there was an special increase in the number of preventive and collective procedures for municipalities with the worst socioeconomic conditions and the number of extractions reduced substantially (Figure 3c).
We have analyzed the effects of health policies on equity in the provision of dental services for all municipalities located in the State of Paraná, which are under the influence of the SES-PR. Considering the possible differences in these municipalities caused by this initial differentiation, the results obtained do not allow any inference to be made relative to other states, despite the fact that all of them are subject to the same policies at the federal level. Since the study had an ecological design,15 the data for all the municipalities, including the state capital (Curitiba), had the same weight when it came to studying the association between variables.
Since dental care started being organized as part of the public health services, Parana has proved to be a pioneer when it comes to implementing programs and policies in the oral health field. It has been considered as an example of how dental services in Brazil should be organized. This study identified an increasing tendency in the evolution of the funds invested in health care and the provision of outpatient primary dental care services in the municipalities in Paraná between 1998 and 2005. This was more pronounced for those municipalities located in the quartile with the biggest proportion of heads of household with insufficient income.
Corroborating previous studies, we identified the redistributive tendency of the federal resources that were transferred to the municipalities for minimum level primaty care fund, including for dental care; this tendency intensified when the ESF was launched. We also saw a negative association between total investment in health care and use of own funds per capita in the municipalities and socioeconomic indicators. This reinforces the tendency that favors equity in the allocation of funds to health care that we initially identified. However, the efforts that started with the creation of the PAB have not proved sufficient when it comes to compensating for the inequalities that exist between municipalities in the equanimous organization of health systems. Some studies have suggested that, in order to move forward in terms of redistribution, fund allocation policies in Brazil, in addition to demographic and socioeconomic characteristics, should also consider epidemiological indicators,21 the quality of the health systemsb and the municipalities' self-funding capacity.c
The scope of this study did not allow us to deal directly with access to services, but we did analyze the possibility of access through their offer. According to Mobarak et al,14 the possibility that individuals who live under the worst socioeconomic conditions have on accessing health services is associated with increased supply. In this study, in the neediest municipalities, there is a trend to exist a larger number of dentists and pieces of dental equipment per inhabitant. We also saw that there is a tendency towards equity in the use of primary dental care services.
Associations between the number of extractions and socioeconomic indicators were stronger than for other types of dental procedure and favorable to vertical equity. Analyzing the association between extractions and other procedures for Parana in 2003, we found results that were different from those reported for the States of Santa Catarina7 and Rio Grande do Sul.5 There is a tendency towards more extractions, collective, preventive and restorative procedures per capita in those municipalities where the dentist/ SUS/ inhabitant ratio is higher. This finding suggests that, in addition to the population that usually has access to dental care, other population groups, previously excluded, may be receiving treatment. Additional information, such as the proportion of adults and elderly in the municipalities, for example, might contribute towards investigation of this hypothesis.
In the municipalities with the worst socioeconomic indicators we observed a pronounced reduction in the number of extractions carried out in 2005. This was accompanied by a corresponding increase in the number of preventive and collective procedures. These findings, along with the redistributive results for preventive procedures, differ from those that were observed for São Paulo9 and may be attributed to SES policy program differences.
One of the limitations of this study is the impossibility of analyzing intra-municipal service levels. Despite it being shown that there is a negative association between living conditions and most of the dental service provision indicators, it cannot be affirmed that the individuals who received them were the neediest, because the validaty of conclusions based on the analysis of aggregate data may always be affected by ecological fallacy. Neither does a cross-sectional analysis provide sufficient evidence to say there is equity in the supply and use of services, because it is not possible to establish any causal relationship between service distribution and the living conditions and quality of the health systems determinants. This analysis allows us to point out associations that can be translated as a "tendency towards equity" when they indicate positive discrimination in favor of the neediest municipalities. On the other hand, an assessment of inequalities over time may lead to dissimilar conclusions depending on the form of analysis used; if it is carried out using relative or absolute figures and whether it is weighted for population size or not.
As for the methodological difficulties we experienced with regard to the quality of the data used, the official SUS sources have significant limitations due to recording inconsistencies at the municipal level and the quality control of this information at the state and federal levels. Future analyses should, accordingly, include intra-municipal aspects.
This study identified equanimous results that are apparently related to the implementation of dental care provision in the ESF. At the ecological level a similar result was reported by Machado et al10 for the ESF in Minas Gerais, albeit not related to dental care in the program. We saw that the worse the living conditions, the greater the number of the population covered by the ESF oral health teams. At the individual level, Barros et al4 identified that the ESF, unlike immunization and pre-natal programs, which are also universal in their scope, provided wider coverage among those living under the worst social conditions. However, this coverage was still inadequate since a small proportion of this population - precisely the neediest - had no access to these services. To continue with the analysis of equity in the provision of public dental services, we recommend that studies should be carried out that consider use and access at the individual level. There should also be an analysis of the extent of horizontal equity, to see if population groups that have the same needs are receiving similar standards of dental care.
In July 2004 the Ministry of Healthd published an ordinance increasing by 50% the incentives for the ESF and dental care for municipalities with a low HDI and small populations. A similar mechanism was used in a resolution coming out of the SES-PR which also passed on an amount to municipalities in accordance with their HDI. At the same time, by means of a national oral health policy, known as Brasil Sorridentee [Smiling Brazil], launched in 2004, additional incentives were included, such as dental supplies and equipment. This study identified an increase in the tendency towards equity in the provision of dental services in municipalities in Paraná in 2005. But since the data analyzed refer only to a year prior and subsequent to the introduction of federal incentives for dental care, it was not possible to confirm if this policy managed to change any existing trend, since the trend line prior to 2000 was not available, because of limitations in the SIA-SUS itself, nor was the line after 2004.
In conclusion, this study showed a redistributive, or pro-equity, tendency in the provision of dental services in the State of Paraná. This is compatible with the program guidelines from the Ministry of Health, as recorded in the NOB/SUS 1996, which relate to the implementation of Minimum Level Primary Care Fund (PAB) and above all to the inclusion of oral health teams in the Family Health Strategy. In the epidemiological assessment of the data relating to health service management, the effort for collecting this information was valued. The possibility of reproducing the methodology used should serve as an incentive to the application of this type of study in other geographical units and the various authorities managed by the SUS.
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Márcia Helena Baldani
Av. Carlos Cavalcante, 4748 Bloco M
84030-000 Ponta Grossa, PR, Brasil
Article based on the doctoral thesis by Baldani MH, presented to Faculdade de Saúde Pública, Universidade de São Paulo in 2006.
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