|Year : 2022 | Volume
| Issue : 2 | Page : 120-124
Public health dentists as nodal-officers for effective implementation of national health programs - A proposed model
B Rudraiah Chandrashekar1, BC Manjunath2, S Suma3
1 Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, Mysuru, Karnataka, India
2 Department of Public Health Dentistry, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India
3 Department of Orthodontics and Dentofacial Orthopedics, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, Mysuru, Karnataka, India
|Date of Submission||11-Nov-2021|
|Date of Decision||22-Jan-2022|
|Date of Acceptance||26-Mar-2022|
|Date of Web Publication||8-Jun-2022|
B Rudraiah Chandrashekar
Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, SS Nagar, Mysuru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandrashekar B R, Manjunath B C, Suma S. Public health dentists as nodal-officers for effective implementation of national health programs - A proposed model. J Indian Assoc Public Health Dent 2022;20:120-4
| Introduction|| |
India is one of the top three fastest-growing economies in the world today. Despite making rapid strides in the economy over the last few decades, India is still categorized under lower-middle-income countries (LMIC) by World Bank. Inconsistent socio-economic status of the vast Indian population and fluctuating health indicators are primarily responsible for this situation of being labeled as LMIC. Despite advances in economy, the investment on health-care delivery under public sector has always been around 2% of gross national product or less, while the WHO recommends this to be at least 5%–6%.,
| Advantage of Rich Demographic Dividend Against Triple Burden of Disease|| |
According to a projection by World Bank, by 2021, more than 34% of Indian population is expected to be in the age range of 15–35 years. This rich demographic dividend is expected to facilitate a sustained economic growth over the next few decades. However, with epidemiological transition, India is currently facing “triple burden of disease” which intimidates the expected benefits from demographic dividend. The increasing noncommunicable diseases and injuries along with unfinished eradication of communicable diseases contribute to this triple burden of diseases in the country which increases the demand for health care over an extended period.
| Exponential Growth in Health workforce with Intimidating Maldistribution|| |
We are witnessing an exponential raise in trained medical and dental workforce in the country in the last two decades. The number of allopathic doctors increased from around 6 lakhs to 12 lakhs, Ayush doctors from around 1.8 lakhs to 7.8 lakhs, dentists from around 24,000 to 2.7 lakhs.
Intake of medical students for the academic session 2020–2021 was 82,926 from 542 medical colleges. Intake of students in AYUSH was 52,720 and Bachelor of Dental Surgery intake was 26,949 from 313 dental colleges in the country.
The total intake of MDS in public health dentistry was 233 from 79 colleges and total number of master of public health (MPH) seats in the country was 1190 from 44 institutions. With this increase in the intake, health workforce is expected to further rise exponentially in the next two decades. More than 75% of the health workforce graduating in the country reside in urban areas creating a situation of lack of employment. Rural India always lacks the requisite health workforce.
| Global Hub for Health-care Delivery under Medical Tourism with Lack of Basic Infrastructure at Grassroots Level|| |
Recent advances in health-care technology and ever-increasing specialist health-care workforce in the country have made India one of the favorite destinations under medical tourism for foreign nationals. Medical tourism is showing an upward trend in India. The revenue generated through medical tourism in mid-2020s in the country was estimated to be around US$ 5–6 billion. Around 4,95,056 Foreign nationals have received medical care under medical tourism in India in the year 2017 alone. This clearly highlights the potential for India to become a global hub for affordable quality health-care services for the population of the world in the decades to come. Despite these rapid advances in health-care delivery, the basic infrastructure for health-care delivery under public sector has always been deficient in most states.
| Robust Health-Care Delivery in Public Sector on Paper with Lack of Effective Implementation|| |
Health-care delivery system under primary, secondary, and tertiary care through referral system looks absolutely robust, at least on paper, to cater to the health-care needs of the population at an affordable cost [Figure 1]. Lack of effective implementation of services and follow-up at all levels of health-care delivery is a major concern leading poor utilization of services. A medical officer at primary health centers (PHC) level is responsible for coordinating the implementation, monitoring, and evaluation of services rendered both at the center and through field activities. He is also responsible for coordinating the training of health-care workers. Multiple tasks expected by PHC medical officers will compromise the quality of service rendered at the center and field activities.
| Well Conceptualized National Health Programs with Lack of Constant Monitoring and Evaluation|| |
We have well-conceptualized national health programs for the most common communicable and noncommunicable diseases in the country. Although most of these programs have contributed to the improvement of health status to a certain extent, the achievement has always been less than the set targets to be achieved for any period. Benefits offered through these programs and other schemes have not been fully utilized by the beneficiaries. We do not have a systematic third-party monitoring and evaluation of these programs and schemes. It is time for all these programs to be evaluated impartially for their efficiency rather than mere effectiveness. This requires trained public health workforce to coordinate implementation, monitoring, evaluation, and surveillance of all national health programs and health-related schemes in the country.,,
| Ambitious Ayushman Bharat Scheme with many challenges and Opportunities|| |
In the background of increasing out of pocket expenditure for health care by general population and possibility of some catastrophic health-care expenditure pushing the families into poverty (lakh people per year), the Government of India has launched the ambitious Ayshman Bharat scheme on September 23, 2018, based on health policy 2017. This is regarded as the largest health assurance scheme in the world. The proposed target is to convert subcenters and PHC as health and wellness centers. One hundred and fifty thousand health and wellness centers are proposed to be established.
A model incorporating dentists and trained public health workforce in the country is proposed here which gives an opportunity to utilize the raising dental and public health workforce for effective implementation of all existing national health programs and Ayushman Bharat scheme.
| Discussion on Proposed Model|| |
Indian economy is showing an upward trend over the last few decades. Although an exponential growth in health-care workforce is witnessed in the last few decades, the increasing health, dental, and public health workforce has not substantially contributed in proportionate health and oral health promotion among the general population. We have an array of national health programs which are well conceptualized. However, unfortunately, none of these national health programs have been able to achieve the set time-bound targets. Most of these national health programs are coordinated through primary health-care system with increased burden on existing workforce in public sector, which compromises the quality of work rendered. India is one of the favorite destinations for health care under medical tourism for foreign nationals. However, we lack basic health and oral health-care services at gross root levels. The ambitious Ayushman Bharat scheme aimed at providing universal health coverage using an integrated approach is a bold decision by the Government of India, but, with a huge challenge of offering the required comprehensive services to an extensive population. Oral health is an integral component of general health and promotion of oral health through common risk factor approach is the need of the hour. FDI Vision 2030 also call for an integrated approach in which oral health-care delivery is empowering, evidence-based, integrated, and comprehensive. We are proposing a model which provides an opportunity to optimally utilize the raising dental and public health workforce for effective implementation of national health programs and coordination of services under Ayushman Bharat Scheme.
Under this model
- A dental assistant/dental hygienist could be appointed at the level of health and wellness center. Ayushman Bharat Scheme proposes to establish 1,50,000 health and wellness centers to provide comprehensive services at primary level which are universal and free of cost. A dental assistant/hygienist can be trained in integrated basic health-care delivery as will be done by a trained multipurpose health worker. They should be given the responsibility of mentoring, monitoring, and evaluating the performance of health workers at the village level while reporting the details of services rendered to the PHC level
- A dentist with a basic orientation on national health programs may be appointed at each PHC. Dentists at PHC level are expected to render the basic oral health-care services besides assisting the medical officer for coordinating various national health programs and effective implementation of various health-care schemes at PHC level with proper follow-up. This will reduce the workload (especially the fieldwork) on the PHC Medical officer. These dentists should mentor, monitor, and evaluate the performance of dental assistants/dental hygienists at lower levels of primary health care while reporting the services rendered and achievements to the community health center (CHC) level
- Each PHC should be attached with a mobile health unit and portable dental equipment. These mobile health units are expected to render basic health and oral health-care services at the doorsteps of the people while referring the cases which cannot be treated to the PHC
- Mobile health unit should have the provision to facilitate telemedicine and tele-dentistry. This will enable rendering specialist consultation at primary level of care which is expected to reduce unnecessary referrals to the secondary level of care
- A public health dentist with 3 years of specialized training that comprises public health and dental public health competencies may be appointed at the level of CHC and above for coordinating the implementation, monitoring, and evaluation of all national health programs and health-care schemes under the CHC. Public health dentists with 3 years of master's program with competencies in public health and dental public health should always be the first choice as a nodal officer at the level of CHC and above rather than any other clinical specialist. The public health and dental public health competencies of a public health dentist will facilitate coordinating the integrated delivery of health and oral health care at the community level. When the required number of public health dentists is not available, then, a person with MPH which is a 2-year program may be considered as an alternate to public health dentist at the CHC level in view of their expertise in coordinating public health programs at community level. A specialist in public health should always be the nodal officer at CHC level. This is a public health specialist position and a person with either MDS in public health dentistry or MPH will possess the required public health expertise and competencies to coordinate and execute field activities under various national health programs and health-care schemes. These public health experts who serve are nodal officers should be accountable for mentoring, implementation, monitoring, and evaluating the performance of all cadres of health workforce working under various national health programs and health-care schemes under the CHC. They should coordinate the activities of all PHCs under the CHC while reporting the details of services rendered under the CHC to the district level
- A public health dentist with at least 5 years of experience in public health/dental public health should be made as nodal officer for coordinating the implementation, monitoring, and evaluation of all national health programs and health-care schemes in the district. These nodal officers should be accountable for mentoring, executing, monitoring, and evaluating the performance of all health workforce in the district working under different national health programs and health-care schemes while reporting the periodic performance indicators of the district to the state nodal officer
- A senior public dentist with at least 10 years of service in public health/public health dentistry or a specialist in community medicine should coordinate the implementation, monitoring, and evaluation of all these programs at the state level. He/she should be accountable for implementation, monitoring, evaluation, and surveillance of all health programs and health-care schemes in the state while reporting the performance indicators of the state to the national level.
Health-care delivery under public sector and effective implementation of national health programs in India rely heavily on district health offices. The appointment of public health dentists as nodal officers will help in periodic review of the progress made in each national health program and health-care schemes at the district level while mentoring and motivating health-care workforce the CHC and PHC levels. A senior public health dentist with 10 years of experience or a specialist in community medicine acting as a state nodal officer will have the expertise and competency to review the progress in key performance indicators periodically under each national health program and health-care schemes at the state level. Model is diagrammatically depicted in [Figure 2].
|Figure 2: Proposed model of health care delivery with public health dentists as nodal officers at the level of community health center and above|
Click here to view
- It is expected that the proposed model will facilitate in repositioning exponentially increasing dental and public health workforce in various national health programs while fixing responsibility and accountability
- The model will facilitate optimal utilization of mobile health units for integrated delivery of health and oral health-care services at grassroots level
- It provides an opportunity for private–public partnership
- It is expected to strengthen the existing health-care delivery in public sector while redressing the problem of unequal distribution of health workforce in the country
- All these are expected to promote health and oral health status in the general population.
The proposed model and expected outcomes although are hypothetical and rudimentary, need to be pilot tested in a district or a state. The pilot testing for at least 3 years following the implementation will give us the basic data to present the expected outcomes using either predictive or projection model. It amounts to hypothetical projection without concrete primary data at least from a pilot study or from previous such studies in the country.
The challenges for health-care delivery under the WHO theme 2018 “Universal health coverage: Everyone, Everywhere” are lack of health awareness, lack of access, lack of trained health-care workforce in public health sector, lack of affordability and increasing cost of health-care services, and more importantly lack of accountability in public health programs. The hypothetical model may address some of these challenges by enhancing health awareness, improving access, optimally utilizing the raising dental and public health workforce while fixing accountability on service providers at all levels of health care with third party monitoring and evaluation on the progress made in each key performance indicator.
The other biggest challenge for this model is the huge financial investment required for recruitment of additional staff, infrastructure development, and implementation of programs for such an extensive population.
Assuming that a state has 30 district hospitals, 320 community health centers, 2000 PHCs and 10,000 subcenters, and at an approximate minimum consolidated salary of 1.5 lakh/month at state level, 1 lakh/month at district level, 75,000 at CHC level, 50,000 at PHC level and 25,000 at health and wellness center levels will require an additional budget of 37,71,50000 for a month. This along with a front-end investment of around 100 crores is essential for upgrading the PHCs into health and wellness centers with an attached mobile health unit having teleconsultation facility. These recruitments should be made on contract basis for 3 years with further extension based on performance.
The increasing health-care expenditure in various national health programs and health-care schemes without proportionate timebound improvement in health and oral health indicators highlights deficiencies in existing health-care delivery system. The proposed model provides an opportunity to optimally utilize the increasing dental and public health workforce to fill the available/expected vacancies under Ayushman Bharat scheme while fixing accountability to deliver the required services at all levels of health care.
The model program should be implemented through trisector partnership. The central government may invest around 60% of the required annual budget, state government may account for 25%, the corporate sector (industries and corporate hospitals) within the state should invest around 10% of annual budget under corporate social responsibility with a necessary tax rebate for such contributions and 5% can be through nongovernmental organization (NGOs) and other philanthropic organizations. The private sector, NGOs, and village panchayats may be roped in at every stage, right from planning, implementation, monitoring, and evaluation on the achievement of time-bound targets in each national health program. Third-party evaluation may also be undertaken at periodic intervals. This provides an opportunity to overcome the health workforce deficiency, especially in rural areas.
| Conclusion|| |
Vision 2030 document by FDI world dental federation proposes strategies and call for integration of oral health into general health. This is expected to reduce oral health inequalities while reducing the global burden of oral diseases. The model integrates oral health care into general health care providing opportunity for effective prevention and management of oral diseases leading to improved health and wellbeing though universal health coverage. Oral health professionals and public health dentists are expected to collaborate with wide range of health workers while delivering sustainable, needs-based, and population-centric healthcare. This model provides an opportunity to optimally utilize a trained public health workforce to coordinate and implement various public health programs.
We are thankful to the Principal, JSS Dental College for his kind support and encouragement.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]