Transformative Education
for Health Professionals

More Dentists or Larger Oral Health Workforce? What is the solution?

More Dentists or Larger Oral Health Workforce? What is the solution?

 Oral Health Screening Camp in a Deprived Neighbourhood of Delhi NCR

Good health is resolutely recognized as one of the central pillars of sustainable development. Attainment of highest standards of health for all citizens is an aspiration across the globe. This vision requires an efficient, responsive and dynamic health system. Health workforce or Human Resources for Health (HRH) of a country form one of the most vital components of this well-functioning health system by managing services, delivering interventions and assessing the disease profile.

Oral Health: action plan for promotion and integrated disease prevention

The profile of oral diseases have changed considerably in the past few decades. Many high-income countries have shown significant improvements in their oral health indicators. However, for the low and middle-income countries (LMICs), the same does not hold true. Oral health inequities are widening within and between LMICs, and are majorly attributable to inequitable access to health care, as well as widening disparities in socioeconomic status.

The 2016 United Nations High-level Commission for Health Employment and Economic Growth set out a vision to address these issues, proposing actions to stimulate the creation of health and social sector jobs as a means to advance inclusive economic growth, paying specific attention to the needs of low- and lower middle-income countries.

The Commission report call for health workforce to be reoriented and “geared towards the social determinants of health, health promotion, disease prevention, primary care and people-centred, community-based service”1.

The report also emphasized the WHO work on people-centered health services, “that is focused and organized around the health needs and expectations of people and communities, rather than on diseases“; and services “such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative services, through different levels and sites of care within the health system and according to their needs throughout the life course“2

This supports the implementation of 2007 WHO World Health Assembly resolution on oral health; action plan for promotion and integrated disease prevention.

 

Oral health workforce for LMICs in the era of sustainable development

The United Nations, in the year 2015 announced the Sustainable Development Goals (SDGs) which provide a framework for integrating actions across multiple sectors to enable unimpeded human development to proceed in a manner that optimizes the use of planetary resources without endangering sustainability. Health is placed centrally in the broader framework of SDGs, which strive to tackle the wider determinants of health. One of the major targets aspired by health SDG is to ‘’substantially increase health financing, and the recruitment, development, training and retention of health workforce in developing countries especially in least developed countries and small island developing states’’3.

This target has major implications for oral health in LMICs as a strong oral health workforce can be the enabler of equitable and improved oral health outcomes across the region and play a pivotal role in achieving Universal Health Coverage.

The LMICs, world over are undergoing through a ‘Health Workforce Crisis’. There are 10 major HRH challenges that are being faced by the under-developed and emerging economies of the world. These are:

  • A numerical inadequacy of trained HRH;
  • Inequitable distribution of HRH: Rural: urban; inter-region variability
  • Need-demand paradox in the labour market. A need for a greater number of human resource exists at the country level, but adequate positions are not available, especially in the public sector
  • A large increase on the supply side in many countries but questions persist on the quality and applicability of training
  • Cross-disciplinary perspective is missing in HRH training
  • Partnerships between medical/ nursing/ allied health schools are sporadic with little incentive to collaborate
  • Career pathways poorly delineated
  • No guidelines for enhancing workforce performance in a rapidly evolving field
  • Absence of tangible incentives for life-long learning
  • Absence of a clearly defined public health cadre

 

An Indian case study

India is a very good example of a country that presents the paradox of a lagging pacesetter.  Despite producing one of the highest number of trained dental personnel, India is grappling with a huge oral health workforce crunch (Figure 1). The number of registered dentists in India is 120897 as per the recent available estimates4. There are 291 dental colleges in India with, 23,800 graduate students and 3418 postgraduate students passing out every year5. The overall dentist: population ratio is 1 dentist for every 15713 citizens in India6. However, there are wide inequalities that exists in the distribution of dental workforce between urban and rural areas. There is concentration of 3.2% dentists where 68.84 % of the Indian population resides (rural areas) and 96.8% concentration of dentists where 31.80% of population resides (urban areas)7. This rural-urban distribution is the worst among the different categories of health professionals (Figure 2). The rural areas have a dentist to population ratio of 1:2,50,000 in comparison to 1:10,000 for the urban areas6. Despite having a large pool of dental colleges and a high concentration of dentists, the dentist: population ratio in urban areas is still lesser than the ideal dentist-population ratio of 1:7500 as advised by the World Health Organization8. There is no official data available for the number of currently practicing dental hygienists in India. Latest population projections indicate that India requires an additional dental workforce of 75000 professionals to man the different levels of health care in the Indian health system9.

 

Figure 1. India: Rural Urban Distribution of Health Workforce Source: National Sample Survey Office; Government of India 2012-13 

Increasing the number of dentists is not the only solution

The need of the hour is to produce an oral health workforce with the right skill mix. This skill mix must be enabled by establishment of new training institutions; improved training programmes with access to skill labs and simulation centres; standardization of training and accreditation and development of regional health knowledge institutes to coordinate the training of several categories of oral health workforce, promote teamwork, inter-professional education and producing professionals capable of meeting local needs. E-learning techniques must be encouraged and included in training the health workforce and there is a need to develop robust educational and quality practice standards that are enforced and monitored through effective policies.

Many LMICs have started taking action on workforce equitable distribution, diversification, quality, retention of the health workforce. However, there still exists a big knowledge gap between recommendations and their implementation. The pipe dream of achieving universal oral health coverage not only requires health-financing schemes that cover the costs of oral health care but also systems of oral health-care delivery that can absorb that many now-fragmented services and provide accessible treatment and prevention universally to those in need.

 

Figure 2. Global Distribution of Dentistry Personnel (Population/ Ratio) Source: FDI Data Hub for Global Oral Health, World Dental Federation, 2015

Therefore, in answer to the question posed in this blog, increasing the number of dentists is not the only solution to overcome the human resource issues in LMICs.

There is a need to develop a health-care workforce that displays a deeper range of skills, and features greater attention to health management and community-based caregivers. The response of the oral health community will require a shift in education and health service delivery towards promoting health equity though action on the social determinants of health and integrated people centred health services.

 

Dr. Manu Raj Mathur MPH PhD
Senior Research Scientist & Associate Professor
Public Health Foundation of India
 

References:

1.        World Health Organisation. High-Level Commission on Health Employment and Economic Growth.; 2017.

2.        World Health Organisation.Framework on integrated people-centred health services. 2017.

3.        United Nations. Transforming our world: the 2030 Agenda for sustainable development. General Assembly. New York; 2015.

4.        CBHI. National Health Profile. Central Bureau of Health Inteilligence - Minstry of Health and Famlily Welfare. 2015.

5.        Ministry of Statistics and Programme Implementation. Number of Registered Allopathic Doctors And Dental Surgeons, Open Government Data (OGD) Platform  

           India. 2013.

6.        Reddy KV, Moon NJ, Reddy K E CS. Time to implement national oral health policy in India. ;58:267-9. Indian J Public Heal. 2014;58(4):267–9.

7.        Gambhir RS, Brar P, Singh G, Sofat A, Kakar H. Utilization of dental care: An Indian outlook. J Nat Sci Biol Med. 2013 Jul;4(2):292

8.        WHO. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. 2007.

9.        Planning Commission of India. High Level Expert Group Report on Universal Health Coverage for India. Working Papers. 2011.

 

Recommendation area: