Oral health indicators in the Interfederative Pacts of the Unified Health System : development in the 1998-2016 period

Introduction: In recent decades, the Ministry of Health has been recommending the use of indicators for the assessment and monitoring of health care. Over the years, it has instituted interfederative pacts dealing with health indicators, including oral health indicators, with the purpose of encouraging health system managers to incorporate the monitoring and assessment of actions in their practice, as well as enabling the follow-up of the performance of services. Objective: To analyze the development of oral health indicators propounded in the interfederative pacts of the Unified Health System (SUS) in Brazil between 1998 and 2016. Material and method: Documentary research based on government guidelines issued during the analyzed period. The variables studied were the characteristics of publications and indicators (denomination, method of calculation, source and purposes). Result: In the period of 1998-2016, oral health indicators were proposed in the pact on primary care indicators (1998-2006), in the Pacts for Health (2007-2011), and in the resolutions of the tripartite intermanagerial committee (2012, 2013 and 2016). Changes were identified over this period, characterized by the inclusion and exclusion of indicators, and by a drastic reduction in the number of indicators, eventually leading to only one retained indicator: “Proportion of tooth extractions in relation to procedures.” Conclusion: There were changes in oral health indicators over the analyzed period, characterized by periods of advancement and regression, eventually resulting in a single indicator related to mutilating actions (tooth extractions), effective in 2016. Descriptors: Indicators of health services; oral health; health management.


INTRODUCTION
Health indicators are essential to health management and planning.They support the making of public policy and the setting of priorities to meet the needs of the population 1 .In the last decades, the Brazilian Ministry of Health instituted the interfederative pacts with the purpose of encouraging Unified Health System (SUS) managers to incorporate the monitoring and assessment of 19/24   actions in their practice, as well as enabling the follow-up of the performance of services.
The pacts are designed to provide a tool for negotiation by the three federated entities, and set down the goals to be achieved and the previously recommended and agreed upon health indicators 2 .They contain a minimum list of indicators-including those for oral health management-to be adopted by municipalities and states, as well as the technical guidelines for calculating the indicators, and the deadlines and flows of the pact-building process at the national level 2 .
In general, both the indicators and the factors that may influence their use in public service practice are still rather unknown, despite the availability of a great deal of information regarding their importance and purpose.In a previous study, the following difficulties and limitations in the use of health indicators were pointed out by managers: slowness, lack of integration of health systems, and lack of training for managers on how to operate the system 3 .
Contributing to this state of affairs is the lack of a theoretical background enabling the description and systematic assessment of the various indicators for oral health management, published in the governmental guidelines for the different health services in Brazil, as well as the unavailability of data needed to calculate these indicators and information about their source.This issue has been little addressed in the field of oral health.Bordin, Fardel 4 analyzed the temporal evolution of oral health indicators from 2008 to 2010 in the databases of the Informatics Department of SUS (DATASUS), and pointed out that, ever since the government guidelines were instituted to steer the pact-building process and provide a list of indicators to be agreed on by managers, the proposals put forth for oral health indicators have been meager.
Bearing these aspects in mind, it is important to evaluate the importance given to oral health in this process of pact building and monitoring of health indicators.Over the years, the use of indicators has made it possible to analyze the quantity and quality of the oral health services provided, and determine whether they are appropriate and enough to meet the existing demand.The indicators also show if the actions planned should be improved and changed, and determine the level of compliance of these actions to SUS principles, among other information.
It is important that the indicators proposed in the Interfederative Pacts be well known in their historical perspective, so that federated entities may be guided in the national process of goal setting and health management planning.Therefore, the aim of this study was to analyze the development of oral health indicators propounded in the interfederative pacts between 1998 and 2016 in Brazil.

MATERIAL AND METHOD
The study was set up as a documentary research, based on the government guidelines of the Interfederative Pacts issued between 1998 and 2016.This period was chosen because 1998 marked the beginning of the series of pacts proposed by the Ministry of Health.The interfederative pacts were analyzed for publication characteristics (document type, denomination, document number, issuing year or publication year) and oral health indicator characteristics (denomination, method of calculation, data gathering source and purposes).Documentary research to gather data was carried out by one of the study researchers, using the Ministry of Health website as its source.The following descriptors and similar key words were used in the document search strategy for the study: indicators and oral health.In addition, new searches were performed in said source according to the references found.
The research was not submitted to a research ethics committee, because the documents analyzed were available on a public domain website.

RESULT
The government guidelines set forth in the Interfederative Pacts presenting oral health indicators from 1998 to 2016 were issued in the form of ordinances by the Ministerial Office ("Gabinete Ministerial", GM) of the Ministry of Health ("Ministério da Saúde", MS) and Resolutions of the Tripartite Intermanagerial Committee ("Comissão Intergestores Tripartite, " CIT) (Table 1).Oral health indicators were found in the Pact on Primary Care Indicators In general, the guidelines were issued annually, and the indicators remained in effect for the same year in which they were published, except for Ordinances No. 3925/1998 5

Oral Health as Addressed in the Pact on Primary Care Indicators
An analysis of the oral health indicators set out in the historical series of the Pacts of Primary Care Indicators, effective for the period between 1999 and 2006 (Table 2), reveals that five indicators were proposed 5  Coverage of preventive dental procedures in the population aged 0 to 14 years.

X X X
Coverage of first dental consultation X X X X X Ratio of community dental procedures to the population aged 0-14 years X X X X particularly noteworthy, since this was the starting point of the series of these pacts 5 .This Pact defined an oral health indicator to be followed up by primary care managers for the year 1999, namely the "Coverage of preventive dental procedures in the population aged 0 to 14 years, " which was maintained until 2001 5,8,9 .The method for calculating this indicator involved different dimensions, and the individual and community procedures were discriminated in the different age groups for the purpose of calculation 5 .This indicator was replaced by three new indicators in 2002 5,[10][11][12] , two of which remained in place until 2005 12 , and one, until 2006 13 .
An analysis of the pacts revealed that the "Coverage of community procedures" indicator underwent two changes over the time period considered, regarding its denomination and method of calculation.As of year 2000, the community and individual procedures, as well as the different age groups, were no longer discriminated for the purpose of calculation.In 2002, this indicator was renamed "Ratio of community dental procedures to the population aged 0-14 years" 10 .GM/MS Ordinance No. 779 of July 17, 2000, referring to the Pact on Primary Care Indicators of 2000, stated that the "Concentration of preventive dental procedures in the population aged 0 to 14 years" indicator would reflect the degree of reach of the actions taken to prevent dental illnesses in the defined population 8 .The ordinance also stated that this indicator could be used to support the planning, management and evaluation of oral health policies and actions 8 .
One of the modifications implemented in the pact-building process of the indicators was made in 2002.Ordinance No. 1121 (July 17, 2002) provided that the indicators of the Primary Care Pact were to be denominated according to the type of aggreement established, as follows: core indicators, compulsory agreement indicators, and complementary indicators (optional agreement) 10 .
In the 2002 pact, two indicators were considered as core indicators: "Coverage of first dental consultation" and "Ratio of community dental procedures to the population aged 0 to 14 years." The "Proportion of tooth extractions in relation to individual basic dental actions" 10 was a complementary indicator.
The same indicators of the 2002 pact were maintained for the 2003-2005 period 6,11,12 .In 2006, three more indicators were added 14 ; moreover, this year corresponds to a phase of greater progress in the evolution of the indicators, with the reinstatement of the indicator of preventive measures and the inclusion of new and important indicators related to basic and specialized care procedures (Table 2).Regulation of the Pact for Health involved implementing operational guidelines for the SUS management process, and for the transition and monitoring of the Pacts for Life and Management, thereby unifying the processes of agreement regarding indicators and targets.However, the complete unification of these processes occurred only in 2007 14 .In the time period between 2007 and 2011 (Table 3), changes were made to the oral health indicators, with the exception of 2010 [14][15][16][17] , at which time new indicators were incorporated, and others were excluded.

Oral Health Indicators
In 2009, Ordinance No. 2669 (November 3, 2009) was issued with the list of Pact for Health indicators for the 2010-2011 biennium, in the various priority areas; however, oral health indicators for 2010 20 were not included in this list.Only at the end of that year, with the issuing of Ordinance No. 3840 (December 12, 2010), was oral health included in the monitoring and assessment of the Pact for Health; this ordinance established the guidelines, instructions and deadlines for the 2011 target adjustment process 17 .The following indicators were established to follow up the basic care strengthening actions: "Population coverage by the Oral Health Teams of the Family Health Strategy" and "Average community action of supervised toothbrushing" 17 .
A proposal for a new pact was made in June 2011, when Decree No. 7508 (June 28, 2011) was issued 21 .This decree defined new criteria, pact-building tools, and action-monitoring tools to be used by the federated entities, through the COAP.The publication of Ordinance No. 1580/12 released managers from the obligation of complying with the Pact for Health or signing the Term of Management Commitment ("Termo de Compromisso de Gestão"), and established the COAP as the appropriate federative tool to formalize interfederative relationships 22,23 .
The two oral health indicators used in the transition from the Pact for Health to COAP in 2012 (Table 4) aimed at guaranteeing equitable and timely access of the population to quality services 23 .
While awaiting the finalization of the pact reorientation process, CIT Resolution No. 04 (July 19, 2012) was published in August 2012.It provided for the tripartite agreement on the rules regarding sanitary responsibilities within the SUS for the purpose of making the transition from the operational processes of the Pact for Health to the COAP system 18 .This resolution contained the guidelines, objectives, targets and indicators for 2012.
In 2012, the Ministry of Health published a manual with the targets and indicators making up the COAP, and added a set of different indicators to the list for that year 23 .The indicators of the Pact for Health were maintained, and two new and different indicators were incorporated addressing oral health, related to Healthcare Work Management and Education Program (Table 4).
Resolution No. 5/2013 defined three oral health indicators for the 2013-2015 triennium (Table 4).Although this resolution reduced the number of indicators in comparison to 2012, it maintained important indicators for the monitoring of actions.However, the issuing of Resolution No. 2/2016 in 2016 excluded all previously proposed indicators, and retained only one: "Proportion of tooth extractions in relation to procedures" 19 .

DISCUSSION
An analysis of the development of the oral health indicators set forth in the Interfederative Pacts issued over the years (1998 to 2016) reveals a decrease in these indicators, and the keeping of only one indicator as of 2016.This result shows how important it is to encourage the incorporation of different oral health indicators, include indicators that enable monitoring, and highlight the relevance of oral health in the pact-building and follow-up processes.
The analysis of the evolution of the Pacts on Primary Care Indicators (1998-2006) showed that the proposal of a single indicator from 1999 to 2001 ("Coverage of preventive dental procedures in the population aged 0 to 14 years") represented a situation in which little emphasis was placed on the monitoring of the oral health actions conducted and the dental services provided.This situation coincides with the period of exclusionary practices, which persisted for a long time in the country, where public dental care was provided to school children on a priority and scheduled basis, whereas, care was provided to the rest of the population according to spontaneous demand.
Only as of 2002 were new indicators incorporated to monitor health actions.Thereafter, oral health gained relevance in the monitoring process, with the inclusion of indicators related to the coverage of dental services and the assessment of the care actions related to mutilating (tooth extractions) and individual basic procedures (restorative and preventive).
In the period between 1999 and 2003, the Pact on Primary Care Indicators was progressively signed by the federation entities and municipalities, and the pact-building process underwent important changes regarding its performance and indicators for assessment 24 .However, in the field of oral health, the changes in indicators occurred only in 2002.Although the indicators in this year were designated as core and as complementary indicators, the latter were intended to be monitored by managers, albeit optional 24 .
Between 2003 and 2006, the pacts were established by specific ordinances, and, with the exception of 2006, the set of oral health indicators remained unchanged.It is also noteworthy that, despite implementation of the National Oral Health Policy in 2004 25 , no new indicators were proposed for the 2004 and 2005 pacts, demonstrating that oral health still required efforts, discussions and pact-building efforts to advance through the appropriate proposals to assess the basic care provided.In 2006, virtually all indicators were replaced; however, the denomination, calculation formula or purpose of those that remained effective up to that time were modified.Nevertheless, the evaluation of service coverage, and preventive and restorative actions was maintained.
The goal persued by the Ministry of Health in drafting a proposal to develop management pacts between the three federated entities 2 was to guide SUS municipal managers in the process of evaluation and monitoring of Primary Care.Nevertheless, it was observed that the indicators proposed in 2006 in the field of oral health were insufficient.
The indicators of the Pact for Health in place during 2007-2011 represented a promising proposal for evaluating services in the field of oral health, and included an assessment not only of the impact of actions carried out by the services in this area, but also of the population's level of access to the services offered.However, there was an interruption in the propounding of oral health indicators in the Pact for Health for 2010, and the indicators and targets for 2011 were presented only at the end of 2010.
Following the transition period, COAP 2012 innovated by including indicators related to the process of permanent education of health professionals, with the purpose of contributing toward adequate training, allocation, qualification and valuation of SUS professionals, in addition to promoting the democratization of labor relations 18 .In the 2013-2015 triennium, several indicators were proposed.However, contrary to expectations, there was a gradual decrease in the number of oral health indicators.In 2016, the only indicator proposed for the monitoring of actions in this area was the "Proportion of tooth extractions in relation to procedures, " similar to the "Proportion of tooth extractions in relation to individual Thus, despite the potential contribution expected from the indicators set forth in the COAP, there was a drastic reduction in the number of indicators for the oral health area.This situation is similar to that experienced at the beginning of the Interfederative Pacts, when only one indicator was used for this area.Therefore, it is recommended that dialogues be established with the participation of players from different areas (management, social control, and academia, among others) to identify and establish a list of indicators covering aspects inherent to the monitoring and planning of actions in the field of oral health.
Over time, ministerial ordinances were found to reassert the role of interfederative pacts as legal instruments for monitoring and assessing health actions and services related to basic care.However, in the oral health area, these instruments were inconsistent in terms of the proposed indicators, inasmuch as they maintained a single indicator in certain periods, and incorporated new ones in others.This situation points to the need for selecting appropriate indicators to allow systematization of the monitoring and an assessment of actions, thus promoting effective management of oral healthcare within the SUS.

CONCLUSION
In conclusion, there were changes in the oral health indicators between 1998 and 2016, characterized by periods of advancement and regression, and eventually leading to only one indicator retained in 2016 related to mutilating actions.
The findings of this study highlighted the trajectory of the indicators recommended for oral health management, and identified gaps that may negatively influence the decision making and public policies required to meet the needs of the population.
(1998-2006), in the Pacts for Health (2007-2011), and in the Organizational Contract of Public Healthcare Action (COAP), mentioned in the CIT Resolutions of 2012, 2013 and 2016.
and No. 2394/2003 6 , in which the indicators were published in advance for the following year, i.e., 1999 and 2004, respectively.The same situation occurred with the COAP indicators for the years of 2014 and 2015, published in Resolution No. 5 (June 19, 2013) 7 , which defined the same indicators for the 2013-2015 triennium.Ordinance No. 2669 (November 3, 2009) 20 was issued in 2009, and defined the indicators for the 2010 Pact for Health, but they did not concern oral health.

2 .
since its institution, as of the issuing of Ordinance No. 3925 in 1998.Changes made over time were characterized by the replacement, expansion, and later exclusion of the vast majority of the indicators proposed initially.The Pact on Primary Care Indicators published in 1998, when Ordinance GM/MS No. 3925 (November 13, 1998) was issued, is Table Oral health indicators of the pact on primary care indicators for the 1999-2006 period ORAL HEALTH INDICATORS Pact on Primary Care Indicators 1999 2000 2001 2002 2003 2004 2005 2006 : Starting from the Pact for Health to the Organizational Contract of Public Healthcare Action (COAP) The series of Pacts on Primary Care Indicators ended in 2006 with the publication of the Pact for Health, signed by the three levels of administration.This edition of the pact established new forms of relationship and negotiation among SUS managers, comprising three components: The Pact for Life, The Pact in Defense of SUS and The Pact for Management.
Rev Odontol UNESP.2018 Jan-Feb; 47(1): 18-24 Oral health indicators in the Interfederative Pacts… 23 23/24 basic actions, " which was part of the list of indicators of the Primary Care Pact in the 2002 to 2006 period.

Table 3 .
Development of oral health indicators of the pact for health in the 2007-2011 period Estimated population coverage by the Oral HealthTeams of the Family Health Strategy X SOURCE: Ordinances GM/MS Nos.91/2007 14 , 325/2008 15 , 48/2009 16 and 3840/2010 17 .*Indicatoradvocated by the Primary Care Pact of 2006, titled Coverage of the Community Action of Supervised Toothbrushing.In 2008, it was renamed Community Annual Average of Supervised Toothbrushing.In 2011, with the issuing of Ordinance No. 3840/2010, this indicator began to be recorded as average of the community action of supervised toothbrushing.

Table 4 .
Evolution of oral health indicators of the Organizational Contract of Public Healthcare Action (COAP) in the 2012-2016 period X Proportion of residents of basic area medical residency programs (medical clinic, pediatrics, obstetrics-gynecology, geriatrics), multiprofessional, oral health, and pharmaceutical care residency programs working in Primary care services in the region X SOURCE: CIT Resolution No. 4/12 18 ; CIT Resolution No. 5/13 7 , and CIT Resolution No. 2/16 19 . 1 Program for the Training of High-School Level Health Professionals.