|Year : 2022 | Volume
| Issue : 1 | Page : 4-8
Redefining dental public health competencies in India. “Dr. Mohandas Bhat Oration”. The 25th IAPHD National Conference, November 20, 2021
Ramaiah International Centre for Public Health Innovations, Bengaluru, Karnataka, India
|Date of Submission
|Date of Acceptance
|Date of Web Publication
Director, Ramaiah International Centre for Public Health Innovations, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:
Chaudhury N. Redefining dental public health competencies in India. “Dr. Mohandas Bhat Oration”. The 25th IAPHD National Conference, November 20, 2021. J Indian Assoc Public Health Dent 2022;20:4-8
| Contribution of Dr. Mohandas Bhat
Dr. Mohandas Bhat is known for his invaluable contributions to public health dentistry not only in India but worldwide. As a founding faculty member of the Government Dental College, Bengaluru, he established the first orthodontics department in South India and the Department of Preventive and Social Dentistry. He was instrumental in starting a master's programme in Preventive and Social Dentistry in India as well as in Brazil. His work at national and international level for furthering the cause of oral health research has received many accolades and he was very aptly referred to as a “Karma Yogi” par excellence. I salute Dr. Bhat for his selfless service to the society and especially so for championing the path of public health dentistry in India.
| Public Health in the Context of Sustainable Development in a Post Covid World
On November 1, 2019, an international panel of experts released “The Global Health Security (GHS) index” of 195 countries in terms of preparedness to prevent, detect and respond to impending infectious disease threats in near future. Just exactly 3 months later, on January 30, 2020, the World Health Organization declared the novel coronavirus outbreak a public health emergency of international concern and the rest is history. It revealed the overestimation of the preparedness of some countries that scored very high on the GHS index (for example, the United States, the UK, and the Netherlands) and underestimation of the preparedness of other countries with relatively lower scores on the GHS index (for instance, Vietnam, China, and Cuba). It signifies that our understanding of the 21st century public health emergency preparedness is limited by conventional knowledge of disease outbreak and prevention, which calls for urgent reconsideration as the world has started very early signs of recovery from the most dreaded pandemic in last 100 years, notwithstanding the newer variants of the virus emerging frequently. It also reminds us of the increasing importance of the “One Health” concept, where humans, animals, and the environment co-exist as interdependent variables.
On November 13, 2021, representatives from nearly 200 countries who had assembled at the 26th United Nations Climate Change Conference of the Parties (COP26) agreed, after 2 weeks of intense negotiations, on the final text of “The Glasgow Climate Pact” deal, which pledges heightened action to curb carbon emissions, and additional funding for low-and middle-income countries (LMIC), especially when LMICs are striving for economic growth by trading off with tight environmental control on one hand and for providing access to quality of life and healthcare amidst large disparities thrown up by communicable, maternal, neonatal, and nutritional diseases on the other, while at the same time, being increasingly threatened by emerging epidemics of noncommunicable diseases.
The COVID-19 pandemic and Climate Change, both pose an oft-repeated yet very important question for us – Is India's public health system prepared to confront another pandemic like the COVID-19 in the coming years, especially in the context of the critical pace of ongoing climate change and an already struggling public health delivery system that has not been able to guarantee minimum access to quality preventive and curative health care to the vulnerable groups of the population. The Ayushman Bharat scheme, believed to world's largest universal health coverage plan, is a bold step by Government of India, which is undoubtedly commendable, but is not enough given the public health delivery system is deficient in both infrastructure and human resources for health. Most recently, during the second wave of the COVID-19 pandemic, most of the government hospitals in India were overburdened, unequipped, and understaffed. Needless to debate whether in 75 years of independent India, the status of public sector health-care facilities remains highly compromised and private sector remains far from being well-regulated despite the fact that maximum facilities are available in the private sector.
It also reminds us to reconsider our strategies toward a healthier future for the vulnerable populations by recognizing and prioritizing conditions that have common linkages and pathways for prevention and control. One of them is oral health, a global problem of immense magnitude but victim of negligence. It is estimated that 3.5 billion people in the world are suffering with oral diseases, of which 796 million are estimated to be suffering with periodontitis. There is evidence suggesting a relationship between periodontitis and COVID-19 mortality. It was reported that COVID-19 patients with painful or bleeding gums were found to have 71% higher risk of mortality when compared to COVID-19 patients without periodontitis. Oral health-care services are among the most disrupted essential services due to the COVID-19 pandemic in more than 60% of the countries.
| The Demographic Dividend and the Paradox of Human Resource for Health Shortage
The estimated overall gap in the number of doctors in India projected for year 2024, is anywhere between 3.02 lakhs and 6.12 lakhs and there is a current deficit of nurses to the tune of 24 lakh. On the other hand, with progressive economic growth of India over the last two decades, India is poised to reap the benefits of a demographic dividend, thanks to a burgeoning class of young, educated, highly skilled and computer educated skill force. However, the labor force participation rate in India has been declining, particularly among youth aged 15–29 years in the rural areas and among women. On the contrary, the brain drain of talented pool of Indian workforce has remained huge. While the government of India has launched both a new National Health Policy in 2017 and a brand-new National Education Policy in 2020 that can complement each other in fulfilling the glaring gaps of skilled human resources for health and yet, it will be unfortunate if we cannot reap the opportunity to encash the availability of large number of young people to become skilled health workers to fill the shortage of human resources for health.
A recent study forecasts the need for trained professionals in public health cadre in India to reach 45000 by 2026 besides a large number of vacancies for professionals in other allied health roles. It is unlikely that the existing public health training programs in India can produce as many qualified and skilled professionals in just another 4–5 years. In the context of increasing demand for public health trained professionals, India can leverage the availability of 2.8 lakh registered dentists across the country.
| Oral Health Policy in India
The relationship between oral health and overall health is well established, particularly because poor oral health is associated with increasing disease burden due to cardiovascular diseases, diabetes, cancers, pneumonia, and premature birth. A high-level Meeting of the UN General Assembly on the Prevention and Control of Noncommunicable Diseases (2011) suggested inclusion of oral health care in the common approach to prevention and control of NCDs a decade ago. Most recently, the draft resolution (EB148/CONF./3) of the 148th session of executive board of WHO, proposed on January 19, 2021 and later approved in May 2021, has urged member states to frame oral health policies, strengthen cross-sectoral collaborations in line with the sustainable development goals targets for 2030. The resolution has urged Member States to address key risk factors of oral diseases common with other noncommunicable diseases such as high intake of free sugars, tobacco use and harmful use of alcohol, and to enhance the capacities of oral health professionals, while at the same time, also recommending a shift from curative to a preventive approach including promotion of oral health within family, schools and workplace settings, as well as timely, comprehensive and inclusive care within the primary health-care system. The executive board agreed that oral health should be firmly embedded within the noncommunicable disease agenda and that oral health-care interventions should be part of universal health coverage programs.
India's National Oral Health Policy (NOHP), which is an extension of National Health Policy 2017, is currently under preparation by the Ministry of Health and Family Welfare. It envisions that all citizens of India enjoy the highest possible level of dental and oro-facial health. NOHP aims not only to establish a baseline for oral disease burden by 2025 but also to reduce the morbidity and mortality from dental and orofacial diseases by 15% by 2030. Achieving the proposed objectives under NOHP (2021) requires a multi-sectoral approach for strengthening the existing health systems coupled with adequate investments in research and program implementation.
GOI's flagship program Ayushman Bharat aims to achieve universal health care by providing comprehensive and need based health-care services, via two main components-”Health and wellness centres (HWCs)” and “Pradhan Mantri Jan Arogya Yojana” (PMJAY). The PMJAY provides Rs 5 Lakhs coverage per family for secondary and tertiary health care services. Whereas, HWCs deliver comprehensive primary health care (CPHC), which is a package of 12 primary healthcare services including basic oral healthcare. However, the operational guidelines of CPHC (under Ayushman Bharat scheme) have not clearly defined “basic oral healthcare”. The service delivery framework of CPHC mentions components of basic oral healthcare that will be delivered at community level, at HWCs (at sub centre level), and at referral centers but the corresponding operational guidelines and the training manual for frontline health workers are not available yet. It goes without saying that introducing quality oral health care into the primary health care system in India would require trained professionals in public health dentistry, which requires governments to create sufficient number of positions nationwide. Indian association of public health dentistry (IAPHD) can play a significant role in bridging these gaps by providing technical assistance to the government via capacity building of primary care workers on oral health conditions, their diagnoses and management at primary care level and public health dentists can come in handy in training of primary care workers as well as in quality assurance for care delivery.
| Public Health Competencies and Public Health Dentistry
The core competencies in public health from most of the curricula practiced in universities worldwide include, among others-Global burden of Disease, Globalization of Health and Health care, and Social, Economic, and Environmental Determinants of Health. Second, competencies also include “soft skills” such as communication, collaboration and partnering, ethics and professionalism, capacity strengthening and socio-cultural and political awareness. All public health training in India including that of public health dentistry should consider these competencies mandatorily in their curricula. The American Board of Dental Public Health has identified ten new competencies for the 21st century dental public health specialists that include managing oral health programs for population health, ethical decision making, evaluating systems of care that impact oral health, designing surveillance systems to measure oral health status and its determinants, communication on oral and public health issues, advocacy to protect and promote both public oral health and overall health, appraisal of evidence to address oral health issues, oral and public health research and integrating social determinants of health into dental public health practice. We can consider these competencies for students of public health dentistry in India while thinking globally and acting locally. However, while aligning with international curricula, it is important to consider a curriculum best suited to India in the specific geographical, socio-cultural and epidemiological contexts of India.
In addition, from a post COVID-19 and sustainable development perspective, it is pertinent to consider how technology can aide health-care providers in addressing local yet challenging problems of health-care delivery system in India and other LMICs. The days are not afar when with GIS mapping, big data and behavioural economics, machine learning and artificial intelligence and possibly virtual reality – capacity building of health care workers and public health professionals shall be far easier and cost-effective, although every innovation comes with its trade-offs. Therefore, if not a high level of competency, an exposure would help future public health professionals build expertise in one or more of these skill areas depending on the opportunities and demand.
Trained strategically in the light of the above competencies, a public health dentist will understand the critical needs for integration of oral health care within the overall health care delivery system. However, unlike in USA and many European countries, oral health has failed to draw attention of the policy-makers in India. As mentioned already in the beginning of this paper, this concern remains valid even after the launch of India's PMJAY where oral health care has not received adequate recognition, because a basic minimum package of oral health care is yet to be defined, in order to be included in such coverage, among other reasons. Under such circumstances, IAPHD has a greater role to play in the advocacy for integration of oral health in India's health care programs and schemes. In the same tone therefore, a competency building curriculum for public health dentists should be contextually relevant for India that can have two priority objectives for all graduating public health dentists:
- Advancement of overall public health agenda in the Indian context
- Advancement of oral health as an integral part of overall public health agenda of India.
The first objective is universal for all trainees of public health irrespective of the speciality they come from. Building on common elements from public health competencies identified by various groups across the world,,,,, the essential competencies needed by every new age public health professional could be summarized in the following five broader domains [Table 1], which are not necessarily exhaustive:
The second objective could have two sub-components– (a) specific to public health dentists who are entrusted with promoting oral health in the context of overall health care delivery and (b) for nondentists, engaged in public health delivery system who have a role to play in promoting and integrating oral health in the health care delivery system, at all levels.
| Precision Public Health
As we all know, conventionally there are two major public health approaches– the “high risk” approach and the “population” based approach. While both have their unique pros and cons, a new dimension has been emerging in recent times– the “targeted vulnerable population” approach, which seeks to reduce health inequities, while also improving overall public health by specifically identifying those at higher risk of ill-health and addressing their health needs early. It goes without saying that oral health is not only associated with many metabolic and chronic health conditions but also with quality of life. With advancement of precision public health, there will be increasing relevance of pro-actively targeting the vulnerable groups as it is going to be more cost efficient.
We are at an age of genomics, epigenomics, exposomics and the big data revolution, where precision medicine is fast emerging as the way to treat human disease, though it has its own distinct advantages and disadvantages, especially because the research data bases for such approaches are not fully representative of the global population and developing countries are far from catching up with it at present. However, all countries will definitely benefit from precision public health in the long run, as large-scale data mining, machine learning and artificial intelligence are going to make both acute and chronic disease epidemics more predictable and therefore much more manageable and cost-effective. Precision public health is about providing the right intervention to the right population at the right time, by using highly accurate methods for measuring disease, pathogens, exposures, behaviours as well as susceptibility that could allow better assessment of population health, better development of health policies and better targeted programmes for preventing disease. Therefore, future public health professionals will significantly improve their work efficiency by building competencies that precision public health will demand in future-a point to ponder for all public health agencies and organizations.
| Final Thoughts
Finally, it's not about individual competencies that will solve the nagging problems of public health in resource poor settings in India and other LMICs, rather it is the collective capacity of the health workforce as well as various other human resources that will together help us win the war against both predictable and unpredictable catastrophes of human health. A peep into the world of game theory will help us understand why collaborative strategy has higher probability of winning a progressively higher competitive game of health care that is going through rapid changes in regulation and market dynamics among multiple players and factors.
Thus, oral health advocates and public health organizations must work collaboratively to each other's mutual leverage in the increasingly tough war of public health challenges in a globalized world.
The author offers sincere thanks to IAPHD executive committee for the invitation to deliver this prestigious oration. Much gratitude goes to Dr. Pushpanjali K (Immediate Past President, IAPHD and Professor of Public Health Dentistry at Ramaiah University of Applied Sciences) as well as to Dr. Pallavi Gupta and Dr. Santhosh Kaza of Ramaiah International Centre for Public Health Innovations for reviewing the manuscript in preparation for the oration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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