Reforms in Oral Health Services in Nepal

Saujanya Karki

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Nepal is modelling for its federal state with seven provinces and seven hundred and forty-four local bodies. These local bodies have jurisdictions over collecting taxes and manage them accordingly. The local bodies now can decide on the investment in health and organize effective health care services. Different thoughts and views were presented on the formation of the health services with a vision of improving health and well-being of its citizen. Oral health can be integrated with the overall health care system. The know truth social, economic, political, and geography of Nepal is a barrier to sustain development. These factors when combined with the expectation of the citizen can be the root breakers.

Initial Plan

  1. Oral health Policy and its implementation

An approach of inclusion of oral health in national health policy and treating the oral health as a part of general health. At this stage, oral health policy should illustrate the importance education, provision of services and oral health promotion. Additionally, it should be focused on research to outline the distribution and pattern of the oral diseases, the impact of the oral problems on quality of life and well-being, and association of oral health with social, political or economic structure. The oral health policy should prioritize the periodic population oral health surveys of children and adults.

  1. Resourcing oral health

This includes the strengthening of the oral health workforce and facilities. The development of the oral health care system with a structured organogram can be planned. The structured system should emphasize the production and distribution of skilled work force, and the management of current workforce. Furthermore, the system should provide knowledge and skills on need assessment, professionalism and skills to work as a team, and continuous learning opportunity. Team should comprise the clinician, hygienists, therapist, nurses, and oral health community workers. This structure will lead to a high degree of oral care and coordination. The hiring and mobilization of the professionals should be done effectively by the local bodies itself. The ratio of the oral work force to the population should be monitored regularly. The development and digitalization of oral health care information (patient information) systems have vital role in improving the oral health care.

  1. Strategies to provide services

Availability of oral services in primary health care, models on community led preventive oral health program, and oral health education and promotion should be focused at this stage. The concept of 3-stage referral system can be implemented (Fig.1)

Future Plan

  • Strengthening the role of primary health center.
  • Introduction of the dental health insurance (except cosmetic treatments).
  • Supervision and Evaluation of the quality dental services.
  • Development of the oral health information system into next level.
  • Ensuring the capabilities of research and innovation from municipal 1

 

ORAL HEALTH DISPARITIES IN NEPAL and THE ROLE OF GOVERNANCE

Saujanya Karki

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“I am having terrible pain on my lower back tooth for couple of days, I can’t eat and this is more often (2-3 times in a year)” says a 63-year-old man a resident of Salena-6, Doti, Nepal. A statement from a mother, “My son always complains about the tooth decay and doesn’t eat or sleep properly often”. A 35-year-old lady covering her mouth with her hand says, “I am embarrassed to smile because I have broken teeth in front region”. Similar statements were common while travelling to various places of Nepal during School Oral Health Project: Nepal which was conducted during winter 2015 and spring 2016. These wider statements highlight the oral problem having negative impact on quality of life. In other word, the consequences of oral disease also have considerable impacts on well-being and quality of life. For example, children with tooth decay cannot eat or sleep properly because of dental pain. Likewise, an adult with severe gum disease (periodontitis) and tooth loss cannot chew well which have negative impact on general health and well-being.

The link between oral health and general health has been discussed and described over few years. It has been proven in literature that oral diseases and non-communicable diseases share the common risk factors. On the other hand, several systemic diseases manifest oral symptoms. Disease free mouth, oral well-being and healthy living are human rights to health.

When significant improvement in oral diseases are seen in the western communities, the increasing trend is observed in developing countries like Nepal in recent years. A question, ‘Is this because of economic differences or governance or policy?’ is always in one’s mind. Having known of the determinants of health, it can be concluded that the underlying causes of health inequalities also make equal contribution to oral health disparities.

Watt and Sheiham (2012) presented a conceptual model of oral health inequalities with structural determinants being one of the most important components. The governance and its administration also has the foremost role in improving the oral health disparities. Health policies and plans including oral health policies led by Government of Nepal are not yet successfully implemented throughout the country. Even though the community focused oral health promotion programs have been practice since decades the change in oral health behavior was short-termed and did not sustain for long. An approach to life style modification and oral health behaviors can surely bring a remarkable change over a decade. The population based programs like water fluoridation, salt fluoridation and affordable fluoridated toothpaste are still not in practice in Nepal. The concept of availability of free toothbrush and fluoridated toothpaste in primary health centers or health posts can be advocated and this could be beneficial in future. Additionally, preventive programs like application of fluoride varnishes or fissure sealants should be in more focus.

Nepalese are still deprived of affordable and quality dental treatments. The costs of the dental treatments are considered expensive and this will surely result in the economic burden to the people and country. The consequence of oral health morbidity can also have a detrimental effect on country’s economy. So, comparison between the treatment cost and the burden of morbidity should be studied. Nepal while modeling for its federal state should concentrate on distribution of adequate health including oral health for its citizen. The concept of decentralization and referral healthcare system that could improve the health of each citizen should be implemented. Implementation of health insurance based on socio-economic condition can also strengthen the healthcare system. In addition, digitalization of the health facilities and health outcomes should be maintained to have surveillance.

According to the Nepal national oral health policy 2013, the total number of dental graduates will be 650 per year from 2017. The government of Nepal is providing basic dental services in its tertiary centers with the limited workforce. While most of the workforces are being saturated within the major cities. This is the time for the authorities to have a plan to mobilize this professionally trained manpower. These future professionals should be oriented about the socio-cultural aspect of health services and should remove the constrains that might affect health improving environment. Promotion and investment in research should be focused by the government to investigate the oral health inequalities and its associated factors.

The unequal distribution of oral health care facilities and the gap in oral health seeking behaviors can aggravate the oral health disparities. Access to oral health care and bridging the gap in the dental health system between urban and rural Nepal could be a great effort on well-being of the citizen.

Reports suggest that, each year the consumption of sugar and tobacco products are increasing in Nepal (Indexmundi 2017 and The tobacco atlas 2015). These products have a deleterious effect on both general and oral health. Improved legislation and taxation acts on sugar, tobacco and alcohol products will improve both general and oral health. Strengthening the oral health policy in a broad perspective that could advocate the prevention and controlling oral diseases is essential and room of discussion for decision makers and dental societies will contribute to creating an environment for better oral health. Oral diseases should not be neglected rather joint approaches with non-communicable diseases should be advocated.

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