Decoding India’s national oral health program-an appraisal of the barriers to quality dental care

Abstract

Oral health is a poorly assessed and treated aspect of the health among Indians. The government continues to poorly fund oral health programs even though evidence of mounting incidence of poor oral health among Indians lingers on. Regardless of the profoundly anticipated national oral health program, oral health burden stays gazing at the nation. It could be a direct result of a fragmented policy with varying priorities regarding the possible solutions to oral health problems. Its implementation faces numerous hindrances which should be defeated for successful utilization. Thus, it is fundamental for the government of India, the policymakers, the stakeholders, and dental bodies to conquer every single barrier and define a compelling national oral health policy backed by current scientific evidence. It would guarantee oral health care to all particularly the populace from the oppressed section of the society. This paper is an endeavour to unite all the components identified with the national oral health program. Additionally, give suggestions for its viable usage.

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International Journal of Community Medicine and Public Health | January 2021 | Vol 8 | Issue 1 Page 458
International Journal of Community Medicine and Public Health
Rawat R et al. Int J Community Med Public Health. 2021 Jan;8(1):458-462
http://www.ijcmph.com
pISSN 2394-6032 | eISSN 2394-6040
Review Article
Decoding India’s national oral health program-an appraisal of the
barriers to quality dental care
Renu Rawat1*, Gunjan S. Aswal2, Dhara Dwivedi2,
Vishwanath Gurumurthy3, Soumya Vishwanath4
INTRODUCTION
India is an immensely populated country. It has an
unequal distribution of population in rural and urban
areas. Nearly 28% of the population resides in urban
areas with the remaining major bulk of 72% inhabiting
the rural areas.1 In urban areas, the dentist to population
ratio is 1:10000. On the other hand, this ratio is 1:150,000
in rural areas.2 Considering the disparity of dentists
serving the rural and urban population along with the oral
health situation in the country with an ever-expanding
burden of dental diseases in developing countries like
India; the government of India has envisaged the national
oral health programme (NOHP). It intends to deliver oral
health care in a coordinated manner leading to attainable,
accessible, and equitable oral health care for all by 2020.3
National oral health policy was conscripted by the Indian
dental association (IDA) in 1986 and was acknowledged
as a vital part of national health policy (NHP) by the
ministry of health and family welfare in one of its
conferences in the year 1995 to be included in country’s
health policy. The goals of this policy encompass-
Improving the determinants of oral health, reducing the
morbidity from oral diseases, integrating oral health
promotion and preventive services with the general health
care system, encouraging the promotion of public-private
partnerships (PPP) model for achieving better oral health.
Programmes has two components national health mission
component and tertiary component.
ABSTRACT
Oral health is a poorly assessed and treated aspect of the health among Indians. The government continues to poorly
fund oral health programs even though evidence of mounting incidence of poor oral health among Indians lingers on.
Regardless of the profoundly anticipated national oral health program, oral health burden stays gazing at the nation. It
could be a direct result of a fragmented policy with varying priorities regarding the possible solutions to oral health
problems. Its implementation faces numerous hindrances which should be defeated for successful utilization. Thus, it
is fundamental for the government of India, the policymakers, the stakeholders, and dental bodies to conquer every
single barrier and define a compelling national oral health policy backed by current scientific evidence. It would
guarantee oral health care to all particularly the populace from the oppressed section of the society. This paper is an
endeavour to unite all the components identified with the national oral health program. Additionally, give suggestions
for its viable usage.
Keywords: National oral health program, Quality dental care, Barriers, Implementation
1Department of Dental public health, University of Manchester, Manchester, United Kingdom
2Department of Dentistry, Mekelle University, Mekelle, Ethiopia
3Department of Dental technology, King Khalid University, Abha, Saudi Arabia
4All care dental centre, Bengaluru, India
Received: 24 September 2020
Accepted: 13 November 2020
*Correspondence:
Dr. Renu Rawat,
E-mail: renu.rawat@postgrad.manchestar.ac.uk
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20205736

Rawat R et al. Int J Community Med Public Health. 2021 Jan;8(1):458-462
International Journal of Community Medicine and Public Health | January 2021 | Vol 8 | Issue 1 Page 459
NATIONAL HEALTH MISSION COMPONENT
Providing support to states to set up dental care units at
district hospitals.
Support is provided for the following components:
manpower support (dentist, dental hygienist, dental
assistant), equipment’s which include dental chair and
others and consumable material for dental procedures.
TERTIARY COMPONENT
For central level activities such as-Designing IEC
materials like posters, TV, Radio spots, and training
modules, organizing national and/or regional nodal
officers training program to enhance the program
management skills, review the status of the program,
preparing state/district level trainers by conducting
national, regional workshops to train the paramedical
health functionaries associated with health care delivery.4
QUALITY DENTAL CARE
Definition of quality in dentistry according to FDI “An
iterative process involving dental professionals, patients,
and other stakeholders to develop and maintain goals and
measures to achieve optimal health outcomes.”5 Quality
in dental care is multifaceted and is difficult for any
single measure to encapsulate all various components
which should be tended to. Methods or measuring
instruments to assess quality need to be valid,
corroborated, acceptable to the investigators and the one’s
already investigated, have to be reliable, should be
completely able to address all forms or fields in which
quality needs to be addressed, must be easy to use.
We need to gauge the quality in dental care at three
levels.6 Individual patient level, practice level and
population-level. For surveying quality dental care, the
patient’s point of view towards the services they are
receiving and, the dental professional’s perspective, both
have to be considered.
From the patient’s standpoint, objective and subjective
parameters should be taken into account. Objective
outlook on the quality of dental care incorporates
technical quality of the treatment and the management
(organization and administration experienced) in terms of
treatment. Subjective perspective involves four
components-empathy, responsiveness, reliability, and
capability. From the dentist’s perspective-the outcome of
the treatment along with the treatment quality are areas of
concern.7,8
ASSESSMENT OF QUALITY OF DENTAL CARE
IN THE RURAL SETTING
To assess the quality of dental care in these rural settings,
it is essential to examine and evaluate the attributes of the
populace. This could be accomplished by epidemiological
surveys.9
It is of tremendous use when incorporating questionnaires
addressing the specific needs of this population,
educational status, and awareness regarding the
importance of sound oral health amongst the rural group,
occupational status of the people or source of income.
Examination of the existing service provider, the distance
of the setup from the residence of the community, the
time consumed in covering that stretch, mode of
transportation available to get benefitted from the service
and thus making it accessible.
Study of incidence and prevalence of the disease in
specific groups, and geographical locations, specific
diseases in the group.
Study of existing dental services, their shortcomings and
difficulties they face in providing much-needed care.
Cost of the treatments provided in the existing centre and
evaluation of the financial burden it poses on the masses
(affordability).
Addressing all the fore-mentioned factors could help in
assessing the quality of care in the population selected.
BARRIERS TO ITS IMPLEMENTATION
During the implementation of the NOHP in the pilot
phase, it was perceived that oral health is mostly given
the least importance by our policymakers. Sloppy
communication between researchers and policymakers
leads policymakers inadequately informed about the
burden of oro-dental problems and its simultaneous effect
on systemic health. All in all, it appears to people that
oral condition can pose minimal threat to life. As
recommended by WHO, health for all is viable only when
every country spends 5% of gross national product for
health care. As per available data, India is spending only
3%. Moreover, until today there is no separate budget
allocation for oral health in the national or most state’s
health budget in India.10
Another barrier to the implementation of health policy is
the unequal distribution of dental schools across the
nation. The planning commission of government
proposed the multiplication of dental colleges following
anticipation of the need for more dental workforce,
resulting in an increased number of dentists but could not
achieve their uniform distribution amongst rural and
urban masses. Most of the dental services/practitioners
are clustered in urban markets following high treatment
costs unaffordable by the rural population. The
government proposed plan to set up new dental colleges
in rural areas is only partially achieved. The planning
commission of the program could recognize the necessity
of training and incorporation of a vast number of dental

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International Journal of Community Medicine and Public Health | January 2021 | Vol 8 | Issue 1 Page 460
auxiliaries comprising of dental hygienists, dental nurses,
dental technicians and, dental assistants but could not
make any successive efforts to incorporate professional
courses for these auxiliaries in the dental schools. This
shortage of qualified professionals’ results in untrained
staff providing support to the dentist working in some
government set up.11,12
Inadequate supply of equipment, materials, and
machinery in district hospitals necessary to carry out
dental procedures also served as hindrances for the
successful implementation of the programme. A dearth of
efforts in educating the masses constrained in the
deprived areas with the importance and benefits of good
oral health. The unavailability of good salaried
employment upgraded with perks and incentives by the
government pose a threat for the appointment of dentists
at government setups. Moreover, the post of dental
surgeons is not present in many primary health
centres.13,14
The curriculum for graduation is outmoded with not
enough attention to the prevention of the diseases. The
dental graduates are unable to perceive the importance of
prevention of oro-dental ailments for the community and
they are not aware of their responsibilities towards the
society. Internship programmes offered at dental schools
are also underutilized and inadequately channelized. If
directed or formulated accurately they can help provide
services to the community specifically the rural masses.
Lack of organized school oral health programmes so that
children may learn right oral health practices from their
childhood. Over and above all the fastest-growing
population of India, rapid westernization and lack of
resources are increasing the burden of oral diseases in the
country.10,14,15
For dietary interventions on the prevention of caries, no
efforts are evident on part of NOHP to integrate with the
national nutrition policy of India, a policy of feeding of
infants and young children, breastfeeding, and other
supplementary nutrition which would have been much
beneficial. Contrary to national submission on control of
fluorosis which states fluorosis as endemic in 17 states of
India and prevalence of dental and skeletal fluorosis tends
to be a significant problem NOHP favours the promotion
of fluoride toothpaste and topical application of fluoride
in persons above 6 years of age.16
Increased life expectancy poses another challenge for oral
health policy due to the absence of adequate and sound
monitoring and evaluation systems leading to overlooking
the oral health needs of the geriatric population. Progress
of implementation of this program has been very slow
and variable in different regions and states of the country.
There are no follow up activities as to what has been
accomplished. At present, there are no effective measures
available to analyse oral health outcomes following the
policy. There is an absence of surveillance of oral health
care services which can be of great help to the direct
planners.17
NOHP has not been implemented throughout the country
due to lack of commitment, as well as alignment in terms
of priority and understanding of the solutions among the
stakeholders to effectively address the burden of oral
diseases.
POSSIBLE SOLUTIONS AND RATIONALE FOR
EFFECTIVE IMPLEMENTATION
For suggesting solutions to effectively implement
national oral health policy, countries that have such
policies running in their health care system can be
regarded as an example for motivation and for possible
solutions to make such programs fruitful.18-20 One such
country is Brazil. Brazil’s national policy of oral health
care also referred to as “Smiling Brazil” was
implemented in 2004. They designated oral health as 1 of
the 4 priority areas of SUS (unified health system). The
Universal health care system is funded by federal, state,
and municipal budgets. The government is responsible for
providing health care to everyone. Nationwide surveys
such as NHS and NOHS aimed at providing information
for public health decision-making bodies acted as crucial
epidemiological indicators.21
Brazil directed funding over US$ 2.6 billion towards oral
health over a 10-year period to strengthen health care
policy. Simultaneously enhancing the job market for
health professionals by boosting the number of dentists
by 50% with about one-quarter of all dentists having ties
to public health services of Brazil. Oral health was
efficiently integrated to all levels of health care by the
institutionalization of the policy and radical improvement
in its installed capacity of oral health care services. The
introduction of mobile dental units to regions difficult to
access has also been initiated. Free medicine to users of
public and private care services through the
implementation of people’s pharmacy in Brazil.
After a brief consideration of Brazil’s initiative to
implement a NOHP following rationale can be suggested
for India.22-24
SEPARATE BUDGET
Allocation for addressing the oral health needs of people
of India and prioritizing oral health as important as
general well-being needs urgent attention from
policymakers.
STRENGTHENING DENTAL EDUCATION IN
INDIA
Immense and urgent need for intervention in the existing
dental education system. Need to introduce the latest
concepts and advanced techniques. Acceleration and
expansion of a high standard of education to the entire

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International Journal of Community Medicine and Public Health | January 2021 | Vol 8 | Issue 1 Page 461
dental education system. Enlighten students with social
values and responsibilities toward society. Uniform
distribution of colleges is inevitable. Accreditation of
dental school should be mandatory. Students should be
encouraged to serve and practice in rural settings as well.
EFFECTIVE POLICY FORMULATION
Policymakers must address important factors that hinder
structural oral health research in India. Promoting
evidence-based researches, enhancing fund support for
relevant researches, Investments toward areas that need
more and immediate attention. Analysis of cost control
and quality control methods should be prioritized. Prompt
responses addressing diseases prevalent in the country.
Formulation of strategies for early detection of disease.
Inequalities in general and oral health between and within
the population should be addressed while formulating
policies. Systematically including oral health and general
health in all policies to effectively address the problem of
health inequity. Integrating oral health with sustainable
development goals is important for registering, oral
diseases in terms of global health and development.
Formulating strategies taking account of common risk
factors and root determinants of health. Policies on
imposing low taxes on materials used in dentistry along
with oral hygiene care products to make it more
affordable. To formulate policies addressing local
manufacturing of dental products curbing the costs and
paving ways for employment.
UNIFORM DISTRIBUTION OF DENTAL MAN-
POWER
In the rural and urban setting, for equal distribution of
services. Methods incorporated by Brazil’s health system
to address this issue can be adopted. Good salary or
financial support in establishing setups in a rural area
would be motivating for the practitioners.
STRENGTHENING OF PUBLIC HEALTH SYS-
TEM IN INDIA
The need for strengthening the existing public health
system is inevitable. Regular community oral health
programs incorporating oral health education sessions in
communities can influence patient’s knowledge and
perception towards the need for dental care. Providing
oral health education at schools in rural areas can be of
immense help, introduce measures to reduce exposure to
risk factors for oral health.
ESTABLISHMENTS OF DENTAL UNITS IN INDIA
With the prime objective of providing coordinated care
with other health facilities, setting up of dental units at
primary health care centers across the country and
government hospitals. Training of local health workers
that is-Anganwadi and accredited social health activist
(ASHA) workers to train and impart information and
awareness regarding oral health care can be of immense
help.
DENTAL SAFETY NET SYSTEM
Can be defined as the facilities, providers, and payment
programs that support dental care especially for the
“underserved populations”. The need for organized dental
safety net systems specifically in rural India cannot be
overlooked. Personnel who are dedicated and committed
to providing selfless health care for the betterment of
neglected masses can be encouraged.
PUBLIC-PRIVATE PARTNERSHIPS
Cultivating public-private partnerships specifically
involving non-profit private partners to make universal
health care available to all shall be considered.
Refinement of other determinants of health like social,
economic, and political disparities can be effectively
addressed through comprehensive partnerships.
CONCLUSION
Health conditions such as oral diseases that pose low
mortality, most of the time face challenges when it comes
to political prioritization. Unfortunately, the preventive
segment is disregarded and the service-based approach is
mainstream among policymakers. In many instances,
leaders have been emphasizing the importance of oral
health, however scarce endeavours to implement the
policy.
It possibly is contemplated that the objectives set by oral
health policy remain for the most part confined on paper
and, without consistent actions these are unlikely to be
accomplished. Thus, it is imperative for the government
of India, the policymakers, the stakeholders, and dental
bodies to overcome every single hurdle through well-
organized methodologies; and formulate an effective
national oral health policy backed by current scientific
evidence. This would ensure quality oral health care for
all, especially the impoverished section of the society of
India.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
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Cite this article as: Rawat R, Aswal GS, Dwivedi D,
Gurumurthy V, Vishwanath S. Decoding India’s
national oral health program-an appraisal of the
barriers to quality dental care. Int J Community Med
Public Health 2021;8:458-62.