|Year : 2022 | Volume
| Issue : 3 | Page : 304-309
Status of public sector dental health-care services in Nellore District, Andhra Pradesh, India
Chandrasekhara Reddy Vuyyuru1, Manickam Ponnaiah2, Rajeshree Narayan Rangari3
1 Research Scholar in Epidemiology, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
2 Scientist F & Faculty, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
3 Tulsi Multi Speciality Hospital, Guntur, Andhra Pradesh, India
|Date of Submission||09-May-2022|
|Date of Decision||14-Jun-2022|
|Date of Acceptance||03-Aug-2022|
|Date of Web Publication||12-Sep-2022|
Chandrasekhara Reddy Vuyyuru
Research Scholar, ICMR-NIE, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background and Objectives: Primary health centers (PHCs) are the foundation of rural health services in India. The nonavailability of reports on the status of dental care services at public health-care centers in rural Andhra Pradesh prompted us to describe the status of dental care services provided at public health-care centers in the Nellore district of Andhra Pradesh. Materials and Methods: This cross-sectional study was conducted using a semi-structured interview guide, based on the Indian Public Health Standards (IPHSs) guidelines. Data were collected on the dental health workforce, equipment, and facilities available, dental care services provided in all government dental care units, and dental care services provided by PHCs without dentists in the Nellore district, from dental and medical doctors, respectively. The descriptive statistics (frequencies) were performed describing the availability of workforce, equipment, and facilities, and the type of dental care services provided. Results: Of 95 public health-care centers in the Nellore district, only 18 centers provided dental care services. No single center was furnished with the prescribed dental health workforce, equipment, and facilities to render comprehensive dental care services to an optimum level according to IPHS guidelines. There were neither oral health promotional activities nor outreach programs targeting rural children, families, and communities carried out at these PHCs as per the IPHS guidelines. Conclusion: An inadequate dental health workforce, deficient dental equipment, and facilities, and very limited dental care services were found at these public health-care centers in the Nellore district, making these services almost nonexistent to rural populations.
Keywords: Cross-sectional studies, dental care, dental equipment, Government, health workforce, India, oral health, public health, rural health services, rural population
|How to cite this article:|
Vuyyuru CR, Ponnaiah M, Rangari RN. Status of public sector dental health-care services in Nellore District, Andhra Pradesh, India. J Indian Assoc Public Health Dent 2022;20:304-9
|How to cite this URL:|
Vuyyuru CR, Ponnaiah M, Rangari RN. Status of public sector dental health-care services in Nellore District, Andhra Pradesh, India. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2022 Sep 28];20:304-9. Available from: https://www.jiaphd.org/text.asp?2022/20/3/304/355895
| Introduction|| |
Primary health centers (PHCs) are the foundation of rural health services in India. It establishes the first contact of an individual with a qualified doctor of the public health sector in rural areas. The PHCs are deemed to provide integrated curative, preventive, and promotive services to the rural population. The National Rural Health Mission has set Indian Public Health Standards (IPHS) to assess the quality of functioning of the public health centers in rural areas.
According to IPHS guidelines 2012, oral health is an essential service at PHCs, community health centers (CHCs), area hospitals (AHs), and district hospitals (DHs).,,, However, the dental care workforce is missing from the human resource requirement at PHCs. Dental care delivery is not possible without adequate dental personnel, equipment, and facilities. So far, studies from India have reported very low availability of dental care services at public health-care centers.,,
The Nellore district is located in the coastal belt of Andhra Pradesh. The primary occupation of the people in the Nellore district is agriculture. It has a population of 2,963,557 and 71% of this lives in rural areas. They are dependent on government health-care services for their health-care needs. The dentist-to-population ratio in the rural areas of Nellore district is 1:91484, which is significantly less than the World Health Organization's recommendation (1:7500).
So far, no report is available on the status of public dental care services in this part of Andhra Pradesh. To identify the provider-level issues in dental care utilization, it is important to describe the status of these services at public health centers. Hence, we conducted this study to describe the dental health workforce, dental equipment, and facilities available, the type of dental health-care services provided at dental care units (DCUs) in the public health centers, and the type of dental care services provided at PHCs without a dentist, in the Nellore district, Andhra Pradesh.
This objective was part of a cross-sectional study on the prevalence of dental diseases among rural children aged 12 years in the Nellore district, involving two study settings. The first was government rural schools (selected based on probability proportional to size (PPS) with 8th grade school strength as size), and the second was PHCs catering to those school areas and public dental care centers in the Nellore district (present study).
| Materials and Methods|| |
We conducted this cross-sectional study between September 2019 and May 2020.
Study population and study setting
We included dental doctors working in all DCUs at PHCs, CHCs, AHs, and DHs and medical doctors in all selected PHCs of the Nellore district.
Dentists working in DCUs of all public health centers and medical doctors in selected PHCs of the Nellore district were included in the study.
We designed a semi-structured interview guide, based on IPHS guidelines. The interview guide was validated and pretested on health professionals who were not a part of the study. The data on demographics, available dental health workforce, equipment and facilities, dental care services, and referral services provided in each center were collected using the interview guide by the principal investigator.
Ethics clearance and permissions
We obtained permission from the District Medical and Health Officer, Nellore district, and Andhra Pradesh Vaidya Vidhana Parishad-Office of the District Coordinator Hospital services, Nellore, Andhra Pradesh, before the study. The study protocol was approved by the Institutional Ethics Committee, before the commencement of the study (No: IEC NDCH/2019/P-22).
Data were entered into Microsoft Excel, and descriptive statistics (frequencies) were performed on (1) type of dental health workforce available, (2) facilities and dental equipment available, (3) type of dental care services provided, and (4) type of dental care services provided in PHCs without a dentist.
| Results|| |
Of 95 public health-care centers, 18 centers provided dental care services to the population of the Nellore district. These 18 centers included 1 DH, 3 AHs, 11 CHCs, and 3 PHCs. We surveyed all these 18 DCUs and found that except DH, the rest were staffed with dental graduates. Their experiences ranged from 6 to 15 years and the majority were females. Only three dental auxiliaries were available at these 18 DCUs [Table 1]. Only one DCU had a dental X-ray unit with a developer. A separate water supply facility was available at 11 DCUs and 4 DCUs with power backup [Table 1]. All the 18 DCUs provided outpatient dental (OPD) services and dental extractions. Fracture reductions, in case of accidents, were not provided by any DCU [Table 1]. These DCUs neither staffed with the required workforce nor with the required equipment and facilities as per the IPHS guidelines.
|Table 1: Details of the dental workforce, equipment, facilities available, and dental care services provided in public sector dental care centers (n=18) in Nellore District, Andhra Pradesh, India, 2020|
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Out of 77 PHCs in the Nellore district, we surveyed 20 PHCs in our study, which catered to selected government rural schools. Out of these, 17 PHCs were without dentists and did not provide any oral health promotional activities and dental checkups to either pediatric or adult dental patients, contradicting the IPHS guidelines. They neither conducted any school dental camps nor maintained any separate records for dental patients visiting them [Table 2].
|Table 2: Type of dental care services in the primary health care centers (without any dentist appointed) located within the study area, (n=17) Nellore district, Andhra Pradesh, India, 2020|
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| Discussion|| |
We observed a severe shortage of dental health workforce availability, deficient dental equipment, and inadequate facilities at public health-care centers in the Nellore district. Consequently, appropriate and prescribed dental care services were unavailable to the rural communities, particularly children, at these centers. Since no published reports are available on the status of government dental care services at the district level in the literature, we compared these study findings with the prescribed norms of IPHS guidelines and available studies.
Dental health workforce
The employment of the dental health workforce is a prime requisite of any health-care center to provide dental care services. We found that the majority of the health centers in our study were staffed with dental graduates and few dental auxiliaries. In the Haryana state study, most of the DCUs were staffed with dental graduates and many with dental auxiliaries. In another study, in Mangalore taluk, no dentist or dental auxiliaries were appointed in PHCs by the government. We found the dental specialist only at the DH, similar to that of the Mangalore taluk study.
As per IPHS guidelines, the workforce requirements at CHCs and AHs include one dentist and one dental assistant or dental hygienist or dental technician,, and for a 500-bedded DH minimum of three dental surgeons. Although CHCs, AHs, and DHs are needed to provide specialty services, the existing workforce consisted of dental graduates, instead of dental specialists.,, The National Oral Health Program, 2015 (NOHP), recommends that PHC should have a dentist and dental assistant/hygienist. However, we found no dental auxiliaries in any of the PHCs with dentists as well as without dentists.
Due to this acute shortage of dental health workforce, the provision of basic dental care services at CHCs and comprehensive dental care services at AHs and DHs appeared far-fetched. It is not possible to provide specialty services without specialist availability and required auxiliary support. These deficiencies need to be addressed at the earliest by initiating the appointment of the required number of dental personnel to provide services as per the IPHS guidelines.
We found none of the DCUs in our study with all the required dental equipment as per IPHS guidelines. A similar paucity of equipment was reported in the CHCs of Mangalore and Haryana studies., Although a prescribed list of dental equipment is required at every health center depending on their level, none of them fulfilled the stipulated requirement. These deficiencies in equipment could be either due to improper funds allocation or inadequate procurement of required instruments. In addition, a lack of priority given to dental equipment by the health authorities can also result in these deficiencies.
Despite dental surgeons' availability, deficiency of equipment had proved to be an obstacle for rendering dental care services. Thus, the provision of specialty and comprehensive care and even preventive dental procedures is not possible at these CHCs, AHs, and DHs, as prescribed by IPHS guidelines. Only with proper equipment, the provision of comprehensive dental care services will be possible at these public health-care centers.
Certain basic facilities such as electricity, water supply, and sterilization are mandatory for any health center to provide medical or dental treatment. There was neither power backup nor separate water supply in any of the PHCs. There was no power backup in the majority of CHCs, including DH. Without power backup, dental chairs and equipment become nonfunctional, hindering the basic OPD services during power failure. Even separate sterilization facilities were lacking in some of our study centers. In contrast, the Haryana study reported that most of the DCUs had a 24 h water supply. These inadequacies could be due to the lack of support given to the DCU's requirements and priority given to other areas of medical services by the concerned health center authorities. These scarce facilities hamper the provision of basic dental health-care services as per IPHS guidelines.
Dental care services
As per the IPHS guidelines, at PHCs without a dentist, medical doctors must perform oral health promotion, checkups, and appropriate referral services on identifying dental diseases. They must conduct school dental checkup camps, alongside medical camps. We observed that none of the PHCs, without a dentist, performed dental health promotional activities in this study. Only emergency medications and referral services were provided by them. They neither conducted any school dental camps nor maintained any records of dental patients referred to higher levels. The reasons could be that the medical doctors did not include dental health promotional activities into their routine medical programs because either they lacked the necessary workforce support or other priority medical issues in the community.
The PHCs with dental surgeons in our study provided limited services such as OPD services, dental extractions, and oral prophylaxis. These findings coincide with Mangalore taluk's study. Despite dental surgeons' availability in PHCs, dental services were not rendered as per the NOHP guidelines. The reason could be that the dentists were not provided with the required auxiliary support to perform their prescribed duties. In addition, the lack of equipment and facilities at PHCs yields poor dental care services.
We observed that CHCs and AHs provided only basic dental care. Services such as root canal treatment, prosthetic dentures, and minor surgical procedures were not rendered at many centers. School dental camps were not conducted by most of the CHCs and all AHs. These findings corroborate with those reported from the Mangalore taluk studies, where only basic dental procedures were performed due to a lack of resources., Similarly, DH did not provide any comprehensive procedures including preventive dental care services. The absence of dental specialists and auxiliaries, shortage of equipment, and inappropriate facilities for specialty care could be the reasons for not providing any specialist services at CHCs, AHs, and DH as per IPHS guidelines.
Because of these deficiencies, the preventive aspect of dental diseases was not given much importance. With this shortfall of health promotional activities and basic dental care services at PHCs, the rural population was severely deprived of dental health literacy and dental care utilization. Inequitable distribution of dental health workforce, denying oral health care at PHCs amounts to a contravention of the basic principles of primary health care.
It is noteworthy to mention, that the Government of India launched the “Ayushman Bharat (AB)” program in 2018 to provide Comprehensive Primary Health Care (CPHC) by transforming the existing subcenters and PHCs into AB-Health and Wellness Centers (AB-HWCs). Although basic oral health care is a part of the services offered in CPHC, there is no mention of dental health personnel employment. Because of this ambiguity in human resource requirements at AB-HWC, oral health care becomes neglected. The operationalization of AB-HWCs started in March 2020 and none of the PHCs were transformed into AB-HWCs in the Nellore district by the time of our study.
An extent of information bias can be expected in our study as the respondents may have given acceptable responses. However, the unavailability of any comprehensive dental care services, deficient equipment, and facilities at these centers the information can be considered factual.
| Conclusion|| |
The status of public sector dental health-care services in the Nellore district is poor and they did not have the prescribed dental health workforce, equipment, and facilities to render comprehensive dental care services to an optimum level prescribed by the IPHS guidelines. There were no oral health promotional activities or outreach programs targeting rural families and communities carried out, irrespective of dental surgeons' availability at the centers. The dental care services were almost nil at PHCs without dentist availability.
- The concerned district and state health authorities and policymakers need to be informed regarding the role of each dental health personnel in health-care centers so that they appoint the whole team and thus make all forms of dental care services available to the rural populations. Appointment of the dental workforce to the desired number at every level of the public health-care system is the need of the hour
- We recommend the appointment of dental doctors and dental auxiliaries at every PHC, and they should be part of the health workforce at PHCs, to reduce the health disparities and improve dental health awareness among the rural populations. Only with the support of an appropriate dental health workforce, the basic dental care services and oral health promotional activities can be integrated into the routine health services offered to the rural communities
- Proper fund allocation and procurement of dental equipment, as per the prescribed guidelines, shall improve the availability of dental equipment in these health centers. Dental equipment should be given similar priority as medical equipment, and concerned health authorities should follow IPHS guidelines strictly in procuring the same
- Facilities can be improved with the support of the concerned health center's authorities and health officials. In addition, the implementation of the IPHS guidelines in the establishment of health centers may improve the provision of facilities in these health centers
- Carrying out periodic performance assessments based on IPHS guidelines at all these public health centers will improve the quality of health services including dental care services. The establishment of “Rogi Kalyan Samiti” and prominent display of the charter of patient's rights in these public health centers, as per IPHS guidelines, can ensure the accountability of health-care services among the health authorities
- Further studies on the factors associated with the status of dental care services in government health-care centers are needed. By addressing those factors associated with poor status, optimum dental care services can be provided and also maintain the standards to the highest level possible. Thus, the rural children, families, and communities of our country can be benefitted.
We are thankful to Dr. Bhavani Shankar, Scientist B, ICMR-NIE, Dr. Ponnuraja C, Scientist E, ICMR-NIRT for their inputs and suggestions during the research. We are grateful to the DM and HO Nellore district, APPVVP-DCHS, Nellore, Andhra Pradesh, health authorities for granting us permission; and thank all Medical and Dental Health professionals for their cooperation and participation in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]