Oral health: Public funding and public awareness
The article has been authored by Dr Dileep Mavalankar, director, Institute of Public Health, Gandhinagar and Dr Payal Rajender Kumar, student, dental health, Johns Hopkins.
The Government of India has taken a series of positive and progressive steps to transform the health terrain of India, way before the Covid struck. This includes enhanced financing, a string of proposed planned and implemented medical and tertiary care Institutions, innovative public health programmes like Ayushman Bharat-Health & Wellness Clinics, Pradhan Mantri Jan Arogya Yojna, the establishment of the National Health Agency and the launch of the ambitious National Digital Health Mission. Similarly, the regulatory terrain was transformed with repealing the Medical Council of India Act, enacting the National Medical Council Act, the establishment of National Medical Commission and making progressive changes in medical education and increasing the undergraduate and post-graduate seats. This progressive build up helped India sailing through the tough times of Covid. However, when it comes to dental and oral health, there are miles to go. On the regulatory side also, the government is still jostling with the Dental Council of India (DCI) on one hand and the proposed Dental Commission of India bill which is pending in Parliament.
When it comes to dental and oral health, India is one of the most paradoxical countries in the world. On one hand, it has a very high oral health disease burden and, on the other, it has the second highest dentist to people ratio in the world! India has approximately one dentist for every 5,000 persons against the World Health Organization norm of one dentist per 7,500 persons. Despite such a high ratio of dental practitioners, it is estimated that about 50% of school children are suffering from dental caries and more than 90% of adults have periodontal (gum) diseases This is clearly due to lack of any national programme for oral health.
Though the history of primary health care dates back to the Bhore Committee, 1946 and subsequent establishment of the primary health care network, oral and dental public health has always been a neglected area. The physical infrastructure for preventive and curative dental and oral health care is almost non-existent at the community health centre (CHC) and primary health centre (PHC) levels. It barely exists at district hospital level with state-to-state variations. Even in places where manpower is deployed, the facilities are sub-standard, poor in quality and there is a constant lack of materials and supplies to provide proper treatment. Public health experts on the dental and oral health care are limited to teaching faculties in the department of preventive and community dentistry with little or no involvement in the planning and execution of programmes, policies, and research studies. Dentists are rarely represented in national- or state-level policy making and programme committees.
Recently, the government has made a provision for dental and oral care under the health & wellness package, however, it is yet to see light of the day on ground. Focus of public funding has often overlooked oral and dental health. One can estimate this from the fact that according to 2019 data only 3% (i.e. 7,337 out of 254,283) of registered dentists are employed in government service.
In this scenario, people are ignorant about dental and oral health care and its systemic manifestations. The lack of adequate preventive and curative facilities at the PHC/CHC levels has created undue pressure on district hospitals and dental colleges hospitals. One sees witness long queues in most of the government dental colleges, resulting into lack of access to quality care. As a result, there is over-dependence on the private sector for curative and restorative care. The private fee-for-services model neglects the preventive, promotive and public dental and oral health.
Though, there are enough trained dental surgeons in India, the regional and spatial distribution is very skewed. There is a disproportionate shortage of dentists working/practising in rural areas--according to one estimate, there is one dentist for about 2,50,000 persons in rural areas against the national average of one dentist for every 5,000 persons. Similarly, dental colleges are concentrated in the southern states of Maharashtra, Karnataka and Tamil Nādu. This has caused a serious demand and supply mismatch and disruptive regional variations.
Dental and oral health has significant bearing on systemic diseases and overall quality of life. Poor dental health is related with atherosclerotic vascular disease, pulmonary disease, diabetes, pregnancy-related complications, osteoporosis, and kidney disease. Diabetes has a true bidirectional relationship with periodontal disease and there is strong evidence that treating one condition impacts the other positively.
Dental public health is regulated under the archaic DCI Act under the aegis of the DCI. The DCI treats dental public health or community and preventive dentistry as one of the nine specialty disciplines of dentistry. Countrywide, there are less than 200 post-graduate seats under the preventive and community dental health departments.
There is urgent need for a drastic increase in public finance for dental public health and changes in the regulatory architecture. The implementation of dental health packages under the health & wellness centres (HWC) need to be expedited on a priority basis. The Centre should nudge the states to make adequate and commensurate investments in dental public health especially in the rural areas where private service providers are non-existent. Each PHC/HWC should be equipped with a fully operational preventive, promotive and curative dental health unit. There is a need to launch a systematic advocacy and oral health campaigns for the desired optimum dental and oral health outcomes in India.
Internships in dental colleges need to be reorganised in such a way that every student is effectively deployed to service rural areas during one-year rotatory internship as is done for MBBS and BAMS interns.
Given the clustering of educational Institutions in south India, there is a need to incentivise the establishment of new dental colleges in the unserviced areas or north and central India on the pattern of one parliamentary constituency one medical college scheme.
Further, there is urgent need to un-shackle the dental public health from the sole control of DCI to place it under the aegis of both DCI/National Dental Commission and University Grants Commission so as to enable universities and public health schools to offer courses in dental public health.
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The article has been authored by Dr Dileep Mavalankar, director, Institute of Public Health, Gandhinagar and Dr Payal Rajender Kumar, student, dental health, Johns Hopkins.
