Dental care for persons with disabilities: discretion on the frontline

Carneiro, Joana Danielle Brandão; Pereira, Ana Paula Chancharulo de Moraes; Bousquat, Aylene; Frazão, Paulo

doi:10.11606/s1518-8787.2023057005318

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Sumário

Original Article • Rev. Saúde Pública 57 • 2023 • https://doi.org/10.11606/s1518-8787.2023057005318 copy

Dental care for persons with disabilities: discretion on the frontline

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To depict the influence of discretionary actions exercised by frontline professionals and organizations on the implementation of diverse modalities of access to specialized dental care within the Care Network for Persons with Disabilities.

METHODS

A case study conducted in two Brazilian health regions characterized by distinct means of access to specialized dental care employing documentary analysis and interviews with key stakeholders across the period spanning from July to December 2019.

RESULTS

In the referenced access region, there was a notable centrality of Primary Health Care (PHC) in caregiving, wherein planning and assessment were integral components of institutional routines. Where spontaneous demand scheduling was accepted, sporadic exchanges of information were evident between PHC units and specialized facilities. The coordination role in caregiving was not vested in PHC teams, and activities such as planning and assessment were not assimilated into organizational routines.

CONCLUSIONS

The implementation of policies for specialized dental care for persons with disabilities relied on the coordination furnished by PHC and the orchestration of planning and assessment endeavors aimed at establishing an integrated care network. This implementation proved subject to the discretionary authority of frontline professionals and organizations, highlighting the significant role of relational and institutional environments in the context of public policy implementation within a decentralized and regionalized healthcare system.

Public Policy; Dental Care; Disabled Persons

Region A	Region B
“The Basic Health Unit is the preferred point of entry in the region” (E_R1).	“The point of entry is through referral from the UBS. They seek the UBS, Emergency Care , Emergency Care Unit, or Family Health Strategy (when applicable), and, if the dentist does not provide treatment, they create a document referring the patient to be treated at the DSC” (E_R4).
“I think that, if our DSC is functional today, it’s since basic care started working well and is effective. “Otherwise, the DSC can’t be organized if basic care doesn’t work properly, according to the protocol” (E_R2)	“So, the patients are aware that, once they arrive here with their institute card showing their affiliation, along with their medical report stating that they have special needs, they will receive care here without the need of a referral” (E_R5).
“We must work as a network—the DSC, basic, and specialized care. Only then things will work as they should” (E_R3).	“For a patient to enter the unit, they must go through the orientation group [OG], which determines whether they fit the profile or not. Once accepted, they are assisted by a group of professionals who assess the users and determine their actual needs and may list them as a priority, or not” (E_R6).

Region A	Region B
“We provide matrix support to basic care, conducting training four times a year. And this is agreed upon with basic care.” (E_R2).	“Basic care is quite fragmented. The increasing number of diabetics each day is a clear sign of the failure of basic care” (E_R7).
	“[PHC] coverage is lacking throughout nearly 30% of Salvador[...] We really wished primary care coverage would reach it there; I believe many of our problems would be solved if we could achieve greater coverage” (E_R8).
	“Not the special cases [PwD]. I handle everything here. I don’t refer them, except for patients who are not special cases [PwD], who are now returning to the UBS” (E_R8).

Region A	Region B
“If you don’t know the regulation, you won’t know how to make the DSC work. And there’s a regulation for everything. The production demanded by the Ministry is ludicrous, some municipalities can’t handle it. So, it’s a matter of knowing the regulation and saying, ’Now you have to make it happen!’” (E_R2).	“There’s no action planning” (E_R9).
“I read the regulation, we read it together, discussed it in team meetings, I brought the regulations and think that’s important. I conveyed the regulations so they would fully understand them” (E_R2).	“[They hold team meetings] at least every 2 months, because of the professionals’ workload (the whole team)” (E_R8).
	“We treat patients, but there are no goals. Usually, the Type III DSC performs 190 basic procedures for PwD, of which at least 50% must be restorative” (E_R8).

Organization of the RCPD-SB
Theme Categories	Region A	Region B
Access	Only through PHC referral.	Referenced by the PHC or another specialized service, or through open demand.
The PHC in Care Coordination	Yes. Conducted matrix support on the subject (RCPD), established care pathways, rehabilitation actions, and scheduling of timely appointments available for referred users.	Did not coordinate, particularly due to low population coverage. No counter-reference took place from the DSC to the PHC.
Planning, Monitoring, and Evaluation	Monthly evaluation and monitoring in team meetings, using indicators and a specific instrument created by the DSC management. The steering group worked as a device for sharing information and decisions.	Excluded from the routine of RCPD-SB services. Each service would define its work process and did not always follow the standards established in regulations and ministerial policies. Lacked room for sharing information.

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E-mail: revsp@usp.br

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[1] Correspondence: Joana Danielle Brandão Carneiro Avenida Dr. Arnaldo, 715 01246-904 São Paulo, SP, Brazil E-mail: joanadani9@gmail.com