The Oral Health Surveillance Policy in Brazil : progresses and challenges

This comprehensive critical review, carried out in a descriptive-discursive style, presents the oral health surveillance policy currently in force in Brazil. Based on an appraisal of the national and international literature on the subject of health surveillance, it examines the formulation of a scientifi c and political agenda for oral health surveillance, which is anchored in the institutions of the Brazilian Public Health System. The accomplishment of this agenda is exemplifi ed by the presentation of the most recent Brazilian Oral Health survey (SBBrasil 2010). A conclusive summary is presented on the search for a theoretical and methodological convergence of both the identifi cation of the obstacles and weaknesses still detectable in this policy, and the recognition of its virtues already confi rmed by important advances and achievements. DESCRIPTORS: Health Public Policy. Public Health Dentistry. Dental Health Surveys. Dental Health Services. Public Health Surveillance. Review. Review DOI:10.1590/S0034-8910.2013047004329 2 Oral Health Surveillance in Brazil Moysés SJ et al In Brazil, currently, health surveillance is understood to a structural component of the utmost importance in organizing and managing the practice of the Sistema Único de Saúde (SUS, public health care system).a This understanding was confi rmed by the creation of the Sistema Nacional de Vigilância em Saúde (SNVS, National Health Surveillance System).b The Brazilian initiative of establishing and developing the SNVS is in line with the view predominant in the international health community, which is increasingly recognizing the importance of strengthening and consolidating national health care systems, covering essential public health functions, among them health surveillance.22,23 Bringing about the main global health care targets means putting into action political processes and organizing movements by societies and nation states, without which comprehensive health care and the wellbeing of the population cannot be developed. With these global targets in mind, there are essential tasks to be performed by health care bodies in order to improve health care practices by strengthening their institutional capabilities.c From more general health care objectives, such as the Millennium Development Goals, to objectives focused on more specifi c programs, such as those for controlling HIV/ AIDS5 or for monitoring and assessing oral health,24 success depends on the existence of health care systems capable of effectively and effi ciently executing critical public health functions, providing key actions and services. The World Health Organization (WHO) describes health care systems as a set of six interlinked blocks: i) providing services; ii) health care workforce performing well; iii) the functioning of health care information systems; iv) provision of and access to essential products such as vaccines and health care technologies; v) adequate fi nancing and vi) leadership and governance.37 This paper is particularly interested in understanding the abovementioned third block, the functioning of health care information systems and their overlap with the concept of health surveillance. Therefore, the central objective of this article was to approach the concept of health surveillance, as applied in the oral health area, and its conceptual and operational developments in Brazil, using the most recent national oral health epidemiological survey – the SBBrasil 20101 Project. INTRODUCTION

In Brazil, currently, health surveillance is understood to a structural component of the utmost importance in organizing and managing the practice of the Sistema Único de Saúde (SUS, public health care system).a This understanding was confi rmed by the creation of the Sistema Nacional de Vigilância em Saúde (SNVS, National Health Surveillance System).b The Brazilian initiative of establishing and developing the SNVS is in line with the view predominant in the international health community, which is increasingly recognizing the importance of strengthening and consolidating national health care systems, covering essential public health functions, among them health surveillance. 22,23inging about the main global health care targets means putting into action political processes and organizing movements by societies and nation states, without which comprehensive health care and the wellbeing of the population cannot be developed.With these global targets in mind, there are essential tasks to be performed by health care bodies in order to improve health care practices by strengthening their institutional capabilities.c From more general health care objectives, such as the Millennium Development Goals, to objectives focused on more specifi c programs, such as those for controlling HIV/ AIDS 5 or for monitoring and assessing oral health, 24 success depends on the existence of health care systems capable of effectively and effi ciently executing critical public health functions, providing key actions and services.
The World Health Organization (WHO) describes health care systems as a set of six interlinked blocks: i) providing services; ii) health care workforce performing well; iii) the functioning of health care information systems; iv) provision of and access to essential products such as vaccines and health care technologies; v) adequate fi nancing and vi) leadership and governance. 37This paper is particularly interested in understanding the abovementioned third block, the functioning of health care information systems and their overlap with the concept of health surveillance.
Therefore, the central objective of this article was to approach the concept of health surveillance, as applied in the oral health area, and its conceptual and operational developments in Brazil, using the most recent national oral health epidemiological survey -the SBBrasil 20101 Project.

METHODS
The methodology is based on participative research, 7,10 as the authors were also involved with formulating and implementing the oral health monitoring policy and the SBBrasil 2010.
A critical and comprehensive review of the relevant literature was undertaken, 6,11 from a theoretical and contextual point of view.As highlighted by Bastos,3 this review was guided by the criteria of quality and readability.Whenever possible, the RATS (Relevance, Appropriateness, Transparency, Soundness) checklist was used.The PubMed/Medline and SciELO databases were used, complemented by non-repeated references found in the BVS/Bireme database and institutional documents from the Brazilian Ministry of Health, the Pan-American Health Organization, the Conselho Nacional de Secretários de Saúde and the US Centers for Disease Control and Prevention.The following search terms were used: surveillance; health status; oral health surveillance; oral health surveys.

CONCEPTS OF HEALTH SURVEILLANCE AND THEIR APPLICATION IN ORAL HEALTH
In Brazil, there are various conceptual possibilities, and even different expressions, such as "surveillance of health" and "surveillance in health" for the term health surveillance.d,e This undoubtedly refl ects the irradiation of a polisemic expression and varied use within health care services and academic research, in different contexts and at different times. 1,16,21,28r the purposes of narrative simplicity and clarity in this review, this "multi-faceted" conceptual construct will be understood as "the systematic collection, analysis and interpretation of data on specifi c health problems which affect the population, essential to the planning, implementation and evaluation of public health care practice, being integrated with the rapid dissemination of information to all of those responsible for prevention and control of aforesaid health problems". 1,17,34,35alth surveillance is an effort to integrate actions by the health care sector concerning various dimensions of the health-disease process, especially from the point of view of social determination.With a more totalizing vision, it seeks to develop new proposals for the deployment of health systems, with the premise of an immersion in the territorial context of the actions. 9 is important to note the mistake made when, in diagnoses of living conditions and health status, the elements constituting the production and reproduction of social life, in different places, are taken to be content disconnected from the territory -not only in a physical, but also a human sense.Recognizing social dynamics, habits and customs is of great importance in determining vulnerabilities and risk and protection factors for human health, originating in interactions of social groups in specifi c geographical spaces. 20erefore, health surveillance has a more encompassing concept, beyond simple analysis of the situation or institutional integration between environmental and epidemiological health surveillance.It foresees interventions in health problems; the emphasis is on problems which require continuous attention and monitoring; operationalizing the concept of social determination and its implications on factors of protection and risk and preventing harm; coordinating actions of promotion and prevention and care; inter-sector actions; actions within the territory; and interventions informed by evidence on the type of operations which promote health. 2,12,25,26e area of oral health should play a strategic role in the health care system, contributing to the scientifi c, technological and organizational development of surveillance practices, aiming to understand and act on the population's levels of health. 24 countries with longstanding traditions of epidemiological surveillance applied to oral health, such as the USA, the national oral health surveillance system was established under the leadership of the Association of State and Territorial Dental Directors and with substantial support from the Division of Oral Health at the Centers for Disease Control and Prevention. 18This was considered the fi rst step in routinely supporting oral health programs recording and explaining the needs of the population, in parallel with impact studies produced by respective oral health programs, with standardized, viable methods.
In 1999, seven indicators of oral health were approved for surveillance in the USA, with another two added later.Four indicators are for adults and the elderly: having visited the dentist within the last year and dental prophylaxis within the last year for those aged ≥ 18; prevalence of total edentulism and loss of six or more teeth for those aged ≥ 65.Data from the Behavioral Risk Factor Surveillance System are used for these indicators.Another three indicators are for students in the third grade: percentage of treated dental caries or lack of f Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention.and Health Promotion.National Oral Health Surveillance System: oral health indicators.Atlanta; 2010 [cited 2013 Aug 18].Available from: http://www.cdc.gov/nohss/caries; percentage of untreated dental caries; percentage of dental sealants in at least one permanent molar.In addition, there are two other, comprehensive, indicators: percentage of the population served by the fl uoridated public water supply, monitored through reports from the Water Fluoridation Reporting System, and the prevalence of cancer in the oral cavity and pharynx.
The US National Oral Health Surveillance System website f was launched in 2001, with data on adults and on fl uoridated water for all of the states.Indicators for children and adolescents were added later.These data are now electronically available for the majority of states (including the District of Columbia), depending on the indicator, functioning as a "situation room" which helps to signal the progress of each state towards the desired improvement in the oral health indicators monitored.
Notwithstanding this national progress, there is repeated criticism in the US indicating the impending need to develop new techniques for constructing surveillance systems for diseases, conditions and behavior in the area of oral health at national, state and local levels to deal with new challenges. 4The critical endeavors brought new components to advance the surveillance system, in the sense of collecting relevant data within a useful timespan: i) focus data collection at a state and local level; ii) seek to integrate other existing national surveillance systems, and those which are in progress; iii) use only visual (not tactile) examination protocols to collect data on oral health/disease; iv) concentrate on a variety of diseases, conditions and behavior; and v) analyze the data consistently and quickly, without wasting any time.
In a wider international context, the health care services in various countries are currently under enormous systematic pressure due to epidemiological, nutritional and demographic changes, which translates as a triple disease load (living with communicable diseases, strongly dominated by chronic non-communicable diseases/conditions, plus external causes).New proposals to deal with this situation, including in the area of oral health, have been discussed.A multi-component approach, derived from the concept of social determination of the health-disease process, inequalities in health care and on the "chronic disease model" is what is sought. 33,36 is certainly the case that new approaches for the Brazilian situation also need to be thought of, implementing the model of the health care networks, with the emphasis on health surveillance and promoting health and having the health care coordinator in primary health care. 19Such an approach requires an additional effort from public health in constructing programs involving networks of partnerships, timely monitoring of epidemiological population profi les, interventions in risk factors and behavior, implementing strategies of prevention (based on robust evidence) and rigorous assessment of actions and services, as systems of support in decision making.
In the SUS, these responsibilities are shared between federal, state and municipal level, including health surveillance as a structural component of managing the system.Many issues have been confronted with regards the decentralized management structure, stable and fair fi nancing, reorganization and requalifi cation of the health care information systems, institutionalizing periodic monitoring and evaluation cycles, strengthening health promotion competencies, epidemiological surveillance of communicable and non-communicable diseases and health problems, sanitary and environmental surveillance and monitoring health status, working with social determination of the health-disease process and risk/protection factors for oral health.
The structure and the establishment of the strategic component of oral health surveillance, within the National Oral Health Care Policy, meets the directives which were widely debated and approved by the 3 rd National Conference on Oral Health.g Among other objectives, this component aims to analyze the epidemiological profi le of diseases and health problems, enabling the oral health problems of the Brazilian population to be understood, discussed and faced. 14,27ral health surveillance includes the SBBrasil Project, which positions this component as part of the routine for managers and front line health care service workers, aiming to establish a culture of oral health surveillance which reaches to more decentralized levels of the SUS; the municipal health care networks. 30,31

THE ORAL HEALTH SURVEILLANCE SYSTEM IN BRAZIL
From August 2004, the General Coordination of Oral Health set in motion a series of discussions with the Health Surveillance Department at Brazilian Ministry of Health, with the aim of incorporating oral health into surveillance practices.Considering the convergence of the purposes and the characteristics or oral health problems, the General Coordination for Surveillance of Non-Communicable Health Problems and Diseases was chosen as the ideal locus for establishing this partnership.These discussions originated from the perspective initially outlined in the SBBrasil Project, formerly known as the SB 2000, which, despite representing the most extensive and comprehensive diagnosis of the Brazilian population's oral health conditions, did not place oral health as part of the routine of health surveillance managers, administrators and technicians, although the original scope suggested this need. 30e justifi cations for developing a new oral health surveillance strategy are due to the lack of systemization of this component in the national oral health policy at a federal level, with the same gap found at state and municipal levels, the following diffi culties having been identifi ed: 1) oral health surveys carried out by the Brazilian Ministry of Health and/or with its support in 1986, 1996 and the SBBrasil 2003 had heterogeneous methodologies, with temporal variations in the data collection, large concentrations of specifi c efforts, focus essentially on normative data (except the SB 2003) and, fi nally, they did not establish the desired culture of health surveillance at a local level; 2) Disarticulation and lack of integration in health care surveillance and other surveillance systems in the country, with the laudable exception of the Mortality Information System, regarding deaths from oral cancer; 3) Lack of oral health data in other important systems, such as the Primary Care Information System, bearing in mind that this is an administrative system and does not contain indicators relevant to oral health; 4) Oral health data within the SUS Outpatients Information System, which is also an administrative system, serving only as a health care reference, i.e., for carrying out orthodontic procedures. 13,14e National Oral Health Care Policy named Brasil Sorridente (Smiling Brazil) was launched by the federal government in 2004, creating the conditions necessary for establishing a new structural conception of the strategy of oral health surveillance within the SUS, making room for this area to be included in the SNVS.One of the fi rst products of this discussion was the inclusion of the thematic model of oral health in the planning of research in 2006, investigating risk and protection factors in the health of schoolchildren aged 13 to 15 in the National Survey of Schoolchildren's Health, a cross-sectional population based study carried out between March and June 2009.h Also in 2006, the Brazilian Ministry of Health established the Technical Assessor Committee to structure and establish oral health surveillance strategies within the National Oral Health Care Policy (CTA-VSB).The committee was established with the aim of "assessing the Primary Health Care Department, Technical Area of Oral Health (DAB/SAS/MS), in identifying priorities and formulating technical directives in the area of Oral Health Surveillance, as well as systematic evaluations of the data quality".i The agenda of the CTA-VSB included carrying out forums with surveillance technicians in states and state capitals, providing a wide-ranging discussion of the national policy of non-communicable disease and health problems and the possibilities of including oral health topics.An agenda was also created referring to some of the functions of health surveillance: epidemiological profi ling of oral health problems; integration with academic research services and centers; proposals for monitoring and evaluating local, regional and national level interventions; predictions of demand and organizing service provision; professional training; and formulating policies specifi c to oral health surveillance.][15] From this perspective, the surveys were initially established as a way of collecting nationwide primary data.
The CTA-VSB also made suggestions to deal with technical and operational issues, such as structuring a Network of Collaborating Centers.These Centers, based on the regional integration of health care services and universities, were thought up as strategies for producing analyses of the oral health situations in the regions under their infl uence, above all to overcome the fragility of services aimed at surveillance issues at the state and municipal level.
The fi rst large scale national response from establishing oral health surveillance in the SNVS was the SBBrasil 2010 Project. 32The Project was integrated between sectors and shared with a wide community of interested parties, having been submitted for public consultation in 2009 and, through eight Collaborative Centers, the Management Group responsible for executing the project was formed.
With the participation of the National Health Board, the National Board of State Health Care Departments and the National Board of Municipal Health Care Departments, the SBBrasil was supported by administrators in the 27 states, as well as the state capitals and the municipalities selected to take part in the research.
The SBBrasil 2010 took place between 2009 and 2010 and evaluated the principal health care problems for public health (dental caries, periodontal disease, malocclusion, edentulism and fl uorosis), as well as socioeconomic data regarding use of health care services, perceived health and impacts of oral health on daily life.
With around 2,000 SUS workers from the three governmental spheres, as well as from universities, involved, 37,519 individuals were interviewed in their homes, with the aim of understanding the Brazilian population's oral health in 2010, thus enabling administrators to use the results in both planning and evaluating actions and services.Individuals aged fi ve and 12, and those in the 15 to 19, 35 to 44 and 65 to 74 years old age group were examined and interviewed in the 27 state capitals and in 150 municipalities, of various sizes, in the interior (30 in each macro-region).j,k The SBBrasil Project, therefore, is a key surveillance strategy for producing primary data on oral health, contributing to constructing a National Oral Health Care Policy guided by epidemiological based models of care. 29,32e main results of the SBBrasil 2010 l show, for example, that Brazil moved from average to low prevalence of dental caries according to the classification adopted by the WHO.m The research revealed a 52% decrease in the need for prostheses in adolescents aged 15 to 19, and a 70% decrease in adults aged 35 to 44.However, among challenges still to be faced, the research highlighted the need to reduce regional inequalities, for advances in prosthetic rehabilitation in the elderly aged 65 to 74 and in improving oral health epidemiological indices in fi ve-year-old children.
In concordance with Roncalli, 29 carrying out the SBBrasil 2010 showed that it is possible to construct policies and operations with better integration between academia and health care services.Also, of particular interest to public oral health care services, it showed that it is possible to produce scientifi c knowledge with the effective participation of this network, with mechanisms of incorporation in the day-to-day activities of the services.
Implementing oral health surveillance strategically integrated in the SNVS is a key element in sustaining the National Oral Health Care Policy and for the population to progressively recognize good practice in the SUS.This article underwent the peer review process adopted for any other manuscript submitted to this journal, with anonymity guaranteed for both authors and reviewers.Editors and reviewers declare that there are no confl icts of interest that could affect their judgment with respect to this article.The authors declare that there are no confl icts of interest.