smiling Brazil



The institution of the National Oral Health Policy

On May 8, the President of the Republic sanctioned the bill (PL) no. 8.131, which had been pending in the National Congress since 2017, establishing the National Oral Health Policy. Now transformed into law, the PL was presented in the Federal Senate by Humberto Costa (PT/PE) and in the Chamber of Deputies by Jorge Solla (PT/BA). Both were leaders of the Ministry of Health when, in March 2004, Lula launched the program smiling Brazil, under the Unified Health System (SUS).

It was, at the time, a set of guidelines that guided the actions of the federal government in this area and guided the allocation of resources for oral health in the SUS. Soon after the first years of its implementation, the results began to appear, with positive impacts on the oral health conditions of the beneficiary populations. The success attracted the attention of specialists in this area all over the world.

But states and municipalities were not required to follow these guidelines. In the almost 20 years that followed, the federal program had the support of many mayors aligned with the Planalto and the indifference of many others from the opposition, who saw Brasil Sorridente as “a Lula program”. Michel Temer cut resources, which reached very low levels, comparable to those allocated to the area in the pre-SUS period. In the Bolsonaro government the smiling Brazil suffered the consequences of the dismantling of the Ministry of Health and the aggression against public policies. There were four years without expansion of lines of action and dwindling resources.

With the May 8 law, that changes. Brasil Sorridente is no longer just “a program of the federal government” and becomes a public policy of national scope, whose implementation by states and municipalities is now a legal requirement. In case of non-compliance, the commission of illegality by the public authority is characterized, with all the consequences provided for in Brazilian legislation, including the impeachment.

Approved unanimously in the Senate, still in 2017, the PL was sent to the Chamber where it was processed at a snail's pace by the Social Security and Family (2017), Finance and Taxation (2018) and Constitution and Justice and Citizenship (2022) committees. In the four years of the Bolsonarist government, the PL for oral health in the SUS never aroused any interest that would mobilize its bench in Congress.

So much so that, in September 2021, given the lethargy with which the matter was being dealt with, the Interstate Federation of Odontologists (FIO), sent to the Chamber of Deputies a Motion to Support the Approval of the PL for Oral Health in the SUS, with a few thousand signatories. The essence of the Motion of the Interstate Federation of Odontologists said that “there is no health without oral health” and asked for urgency in the approval of the oral health law in the SUS.

Lula's election completely changed the scenario. In just a few months, the PL was approved in the Chamber, sent to the Planalto and sanctioned. The May 8 act ended a long process, whose origin dates back to the early 1980s and the proposal to create the SUS.

Prior to the enactment of the 1988 Constitution, municipalities were not, formally and legally, obligated to do anything in terms of health. The largest cities maintained, in some cases, emergency services. Santas Casas de Misericórdia and other philanthropic services experienced chronic financial crises and depended on supplementary allocations from state budgets. Access to health services was not, however, a right.

After 1988, the Constitution ensured (art. 196) health as “a right for all and a duty of the State” and established the decentralization of public administration of the health system as one of the guidelines of the SUS. As a result, the municipalities were strengthened as autonomous federative entities and, taking advantage of this relative devolution of powers within the scope of the Executive, assumed the provision of public health services.

It prevailed among the SUS defenders and right to health, the hypothesis (sometimes belief) that local power, however close to the population, would be more prone to democratic relations than centralized federal power. But it was really just a belief. It would soon be realized that many mayors only used administrative decentralization to get rid of the responsibility that the 1988 Constitution attributed to them, simply transferring financial resources so that third parties, private individuals, could provide public services.

The so-called “privatization of the SUS” is currently one of the main difficulties for the system to fulfill the mission assigned to it in 1988. Thus, a type of local power hostile to democratic radicalization and perpetuator of the nepotism, clientelism and patrimonialism. Exceptions – and there are many – only confirm the rule.

This kind of 'neocolonelismo', which takes root in modern Brazilian agribusiness, flatly refuses popular participation in local health councils and updates, in a new guise, the concentration of political power in the hands of the heirs of hereditary captaincies and sesmarias – and their servants – which, crossing the Empire, the Old Republic and the modernizations of the XNUMXth century, reaches the present with vigor. It updates, but does not surpass, the pattern of political domination detailed by Victor Nunes Leal in the classic Coronelismo, hoe and vote: the municipality and the representative regime in Brazil.

With the promulgation of the Constitution, in 1988, it was necessary to regulate its provisions in law. In the area of ​​oral health (but also in other “health”, such as mental, child, woman, indigenous, among others) it was considered that its explicitness, reiterating it as a right of all, was not necessary in the legislation regulation, as this would be implicit in article 196, which referred to “health” as a right for all. For this reason, these “health” were not made explicit in Laws 8.080 and 8.142 of 1990.

In fact, for these “health” the explicitness was not necessary, since all states and municipalities normally assumed that yes, they were “health” and, therefore, needed to be performed, as a public service.

This aspect is relevant to understanding the meaning of a law, specific, of oral health in the SUS, be approved now, in 2023. Many rightly ask why this happened only 35 years after the creation of the SUS. “But isn't oral health part of the SUS? Why is a law like this needed?” – they ask.

For many oral health professionals who participated in the health system reform process that led to the creation of the SUS, there was no doubt that the principle of comprehensive health, enshrined in art. 198 of the 1988 Constitution, which states “comprehensive care, with priority given to preventive activities, without prejudice to assistance services”, was enough for oral health not to be left on the sidelines of the SUS.

But that's not what happened and only in some counties oral health was seen as inherent to health and, therefore, implemented within the SUS. This occurred, in general, in municipalities with large demographics and, above all, in periods of municipal management aligned with the federal government. The practice prevailed, and continues to do so in most municipalities, of receiving resources for “oral health” from the federal government and using them without any complementation, providing the population with one or a few dentists.

In general, the work they carry out is isolated and without sanitary planning, according to traditional and outdated care models in the area. The result is usually a deepening of the population's degree of dental mutilation. Questioned, mayors and secretaries limit themselves to complaining about the low amounts “paid by the SUS”, reinforcing the conception of the SUS, not as a universal health system in a federative Republic, but only as a kind of “federal bank that pays suppliers”.

Although the consequence of this neglect and abandonment can be perceived in the mouths of Brazilians, the data that translates them is little known, even by health professionals and public managers: currently, the SUS dental care coverage only burdens 1,4% of federal resources intended for health care, while this percentage ranges between 6% and 10% in Western European countries. The scarcity of public resources for oral health penalizes the population, especially the poorest, who are forced into poor quality private services, as SUS accounts for only 0,6% of extraction and restoration needs dentures in the population aged 5 to 85 years. The economic elite and segments of the middle class solve their needs in the private sector. With prohibitive prices for the majority, this segment does not cover more than a fifth of the population. The “assistance void” of services with some quality is enormous.

Hence, the relevance of the law signed by Lula on May 8. Therefore, at this stage, the aim is to correct the legislative failure of 1990.

But it is necessary to go much further. “Oral health in the SUS” is not enough if the care model does not change. We need much more oral health in the SUS and the urgent development of a care model that, reversing the current pattern of prioritizing therapeutic actions to the detriment of prevention, significantly reduces the occurrence of diseases in the mouth, as emphasized by the Minister of Health, Nísia Trindade, speaking at the act of presidential sanction to Bill No. 8.131. More than enabling “more access to public dental services”, he said, it is necessary to deepen the degree of care in the area, advancing towards the integrality of health.

Lula, in turn, recalled what he had once said to doctors from São Paulo, in the presence of former minister Adib Jatene, that “all parts of the human body are treated as a matter of public health, except the mouth”. She pointed out that it is not just about treating those who are sick, but also about taking care of “the quality of water and food”, “educating the child”, valuing disease prevention. Brasil Sorridente, she emphasized, “is an extraordinary thing because recover not only the smile, but the dignity of the human being, the pride of the person”.

The next step, now that the law has been sanctioned by Lula, is the publication of a decree that regulates it.

It is on the agenda of the National Health Council to carry out the 4th. National Oral Health Conference. The decree, however, cannot wait for the conference, which can correct any errors that the decree presents. Lula asked for haste in the execution of the government's plans. With the word, therefore, the Ministry of Health.

*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic).

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