- Email: [email protected]
Illegal oral care delivery
between stakeholders to use them effectively. Being prepared for policy windows is essential because a quick reaction is usually needed. Discussion.—The 4-point analysis indicates shortcomings and weaknesses in all the areas. These range from the basics to more complex, multi-level issues. This sets a baseline from which a roadmap for improvement in some or all of these areas can be developed.
Clinical Significance.—It will probably require a fundamentally new approach and joint efforts to provide a purposeful orientation and impetus toward improving global oral health. Details remain to be worked out among the participants. A well-formulated problem definition is an essential first step. The need to address the increasing inequities and the recognition that
the traditional division of the world into developed and developing countries no longer applies should provide a realistic starting point. The current low political priority for global oral health results from complex issues that are deeply rooted. Perhaps this analysis will provide the impetus to begin a broad, candid, international approach to better communication, financial consideration, and prioritization of oral health among all the involved parties.
Benzian H, Hobdell M, Holmgren C, et al: Political priority of global oral health: An analysis of reasons for international neglect. Int Dent J 61:124-130, 2011 Reprints available from H Benzian, The HealthBureau Ltd, Willmanndamm 8, 10827 Berlin, Germany; e-mail: [email protected]
Illegal oral care delivery Background.—Many areas in the world lack access to affordable, safe, and appropriate oral health care. To fill the gap, informal providers who are not legally recognized but who are often socially acceptable and considered part of the culture provide care. The concern with these providers is not just their illegal status but also the poor quality of care provided and related health risks for patients. Guyana was cited as an illustration, with a differential view of how to address the illegal practice offered. Definitions.—Illegal dental practice can refer to various practices, including ‘‘street doctors’’ who have no qualifications, immigrant providers who do not obtain licensure in their new country, and providers of alternative medicine with no proven health benefit. Illegal dental practice is defined as the provision of oral care by providers who have no legal permission to practice or no training to provide the services they pretend to offer. Case Study.—Guyana is on the northeast coast of South America and has a population of 780,000. It is among the poorest nations in the United States and culturally and politically is part of the Caribbean region. The delivery of health services in the public sector is based on a model with 5 levels, from health posts to national referral (which has not functioned well in practice) and specialist hospitals. The private sector was growing and taking on expanded functions. A major problem was the lack of
human resources at all levels of care. Staff vacancy rates range from 40% to 50% because of migration. The existing Dental Council offered no further applicable regulations or code of practice outside of identifying minimal registration needs for the dental profession. A dental school opened in 2007 lacked sufficient academic and teaching staff and operated on a somewhat basic level. The dentist/population ratio was 1:36,900, with 33 resident dentists. An additional 150 illegal providers offered services ranging from emergency care and simple dentures to complex restorative procedures. The Ministry of Health and professional association decided to develop a comprehensive strategy to address the illegal oral care problem. They began by renewing and strengthening legislation to improve quality of care for all citizens. All professions related to oral care were clearly defined. The existing workforce was scaled up with clear definitions of their roles and responsibilities. Minimum standards were set for clinical settings, including infection control, and a framework of sanctions for noncompliance was developed. Training for all related professions was offered as an incentive, focusing on the goal of integrating as many providers as possible into the formal sector. Career paths, personal development, and social acceptance plans were also developed. Physicians and pharmacists contributed to areas of continuing professional development and mandatory relicensing, creating positive synergies and
Volume 57
Issue 2
2012
71
Fig 1.—Types of illegal dental practice. (Courtesy of Benzian H, Jean J, van Palenstein Helderman W: Illegal oral care: More than a legal issue. Int Dent J 60:399-406, 2010.)
momentum toward change. A dental school was established and 20 more public dental clinics were opened to improve access to care. The expectation was that more numbers of registered dentists would help mitigate the problems of illegal providers. Analysis.—Illegal oral care can be identified as a public health problem, a legal problem, an economic problem, a professional problem, an ethical problem, and having a social dimension. Providers may not be formally trained to provide oral care and not registered (Fig 1). Fixing this requires enforcing existing regulations; strengthening administration, governance, and civil society awareness; providing communities with the appropriate oral healthcare services; and educating the public about the availability of services and the risks associated with using unlicensed, untrained providers. Traditional medicine practitioners present a special case that must be handled with discretion. There are also providers with health-related training (not in dentistry) who are not registered for oral healthcare provision. This aspect of illegal oral care can be addressed by providing all communities with appropriate oral health services; educating the public about what is available and why the use of unlicensed providers presents risks to their health; ensuring proper supervision, training, and payment for health personnel; providing skills-based training for health professionals, including basic emergency oral care;
72
Dental Abstracts
and developing laws and regulations so that medical health workers can be delegated oral care after they receive appropriate training and education. Some more advanced oral care is delivered by providers with basic oral health training only, making the practice unlicensed and therefore illegal. This requires the appropriate supervision, training, and remuneration of all health personnel; the construction of career paths and opportunities for personal and professional development; the inclusion of all members of the dental team in professional legislation, where they share a common framework of rights, responsibilities, and sanctions; making licensing regulations transparent and ensuring consistency of the process, thereby facilitating the legalization of previously unregistered providers; offering additional qualification and training incentives so previously informal providers can enter the formal care system; and ensuring that nongovernmental organizations that employ expatriate dentists and dental students comply with professional registration regulations. Finally, some providers with basic oral healthcare training overstep their responsibilities, making their actions illegal. Countering this problem requires the provision of proper training, supervision, and continuous control for such individuals; renewing the motivation of professionals; and providing the same actions as for the preceding group of illegal oral care providers.
Clinical Significance.—The illegal provision of oral care is a serious public health problem in some countries of the world. The result is low-quality care and increased risks for patients who seek the help of unqualified practitioners. This is a symptom of the underlying healthcare system. As shown in Guyana, steps can be taken to counteract the situation. Rather than confrontational, this approach is more inclusive, seeking to integrate formerly illegal providers into the formal system through the use of incentive programs, additional training, and
expanded opportunities. All parties who are stakeholders in the process should be involved in creating a better way to deliver oral health care.
Benzian H, Jean J, van Palenstein Helderman W: Illegal oral care: More than a legal issue. Int Dent J 60:399-406, 2010 Reprints available from H Benzian, The Health Bureau Ltd, Willmanndamm 8, 10827 Berlin, Germany; e-mail: [email protected]
Reforming the dental workforce Background.—Increasingly, the available evidence indicates that the dental profession is not meeting the expectations of society with respect to access to oral health care, particularly among children. Influential policy leaders are demanding change. The situation rests on what it means to be a profession, how societal expectations interact with professions, and what reforms may be needed in the dental workforce. Nature of a Profession.—The criteria traditionally accepted for a profession are as follows: (1) the work is primarily intellectual; (2) the work is based in science and learning; (3) the work is practical; (4) the work can be taught and learned through education beyond usual levels; (5) professionals organize into democratic and collegial units; and (6) professions exist to achieve goals set by society rather than by the self-interest of their members. The concept of covenant is applicable to the relationship between a profession and society. Covenants involve a pledge or promise, an exchange of gifts, and a change of being. Society has promised dentistry the right to care for oral health, and dentistry has promised to provide that care faithfully and well. Society gives self-regulation, dental education, and tax-subsidized student loans, and dentists offer society their knowledge and skills. As a result, dentistry is considered a profession, and society becomes the patient. Historically, dentistry has focused on serving the oral health needs of patients, deriving a financial gain as a natural and appropriate consequence of the service provided. However, dentists today are increasingly viewing themselves as practicing in the marketplace, as a business enterprise rather than a profession. However, health is a human good that should not be relegated to the marketplace. Human well-being, specifically oral health for both individuals
and society itself, is the goal served by dentistry. Seeing dental practice as merely a business means that patients are just a means toward achieving the end of financial gain. This view undermines the idea of a profession. Dentistry is only a business in the sense that it must adhere to good business principles in support of its professional practices. Societal Expectations.—Society is beginning to conclude that it is not being fairly treated through its social covenant because dentistry as a profession is failing to care for the public’s oral health. Ethics are being violated. All ethics are based on people cooperating with one another and treating one another fairly in the process. Society is seeing that the relationship with dentistry is out of balance. It is giving more than it is receiving because significant numbers of society’s members are not able to access oral health care. Society is frustrated by the profession’s specific inability to care for poor and minority children, a population that cannot be held personally responsible for their lack of oral health care. A fair provision of basic health care should redistribute health care more favorably to children because of the effect health care has on equality of opportunity for children. Poor and minority children have the highest prevalence of disease, the poorest access to care, and the poorest overall oral health. Justice demands that they have equal opportunity to do well, so the dental profession must address the dramatic inequities that exist in the oral health care and health care delivery for children. The character of society is evaluated on the basis of its concern for and care of its children’s health. Dentistry that fails to fulfill its social covenant cannot call itself a profession but is simply a trade association.
Volume 57
Issue 2
2012
73
Clinical Significance.—It will probably require a fundamentally new approach and joint efforts to provide a purposeful orientation and impetus toward improving global oral health. Details remain to be worked out among the participants. A well-formulated problem definition is an essential first step. The need to address the increasing inequities and the recognition that
the traditional division of the world into developed and developing countries no longer applies should provide a realistic starting point. The current low political priority for global oral health results from complex issues that are deeply rooted. Perhaps this analysis will provide the impetus to begin a broad, candid, international approach to better communication, financial consideration, and prioritization of oral health among all the involved parties.
Benzian H, Hobdell M, Holmgren C, et al: Political priority of global oral health: An analysis of reasons for international neglect. Int Dent J 61:124-130, 2011 Reprints available from H Benzian, The HealthBureau Ltd, Willmanndamm 8, 10827 Berlin, Germany; e-mail: [email protected]
Illegal oral care delivery Background.—Many areas in the world lack access to affordable, safe, and appropriate oral health care. To fill the gap, informal providers who are not legally recognized but who are often socially acceptable and considered part of the culture provide care. The concern with these providers is not just their illegal status but also the poor quality of care provided and related health risks for patients. Guyana was cited as an illustration, with a differential view of how to address the illegal practice offered. Definitions.—Illegal dental practice can refer to various practices, including ‘‘street doctors’’ who have no qualifications, immigrant providers who do not obtain licensure in their new country, and providers of alternative medicine with no proven health benefit. Illegal dental practice is defined as the provision of oral care by providers who have no legal permission to practice or no training to provide the services they pretend to offer. Case Study.—Guyana is on the northeast coast of South America and has a population of 780,000. It is among the poorest nations in the United States and culturally and politically is part of the Caribbean region. The delivery of health services in the public sector is based on a model with 5 levels, from health posts to national referral (which has not functioned well in practice) and specialist hospitals. The private sector was growing and taking on expanded functions. A major problem was the lack of
human resources at all levels of care. Staff vacancy rates range from 40% to 50% because of migration. The existing Dental Council offered no further applicable regulations or code of practice outside of identifying minimal registration needs for the dental profession. A dental school opened in 2007 lacked sufficient academic and teaching staff and operated on a somewhat basic level. The dentist/population ratio was 1:36,900, with 33 resident dentists. An additional 150 illegal providers offered services ranging from emergency care and simple dentures to complex restorative procedures. The Ministry of Health and professional association decided to develop a comprehensive strategy to address the illegal oral care problem. They began by renewing and strengthening legislation to improve quality of care for all citizens. All professions related to oral care were clearly defined. The existing workforce was scaled up with clear definitions of their roles and responsibilities. Minimum standards were set for clinical settings, including infection control, and a framework of sanctions for noncompliance was developed. Training for all related professions was offered as an incentive, focusing on the goal of integrating as many providers as possible into the formal sector. Career paths, personal development, and social acceptance plans were also developed. Physicians and pharmacists contributed to areas of continuing professional development and mandatory relicensing, creating positive synergies and
Volume 57
Issue 2
2012
71
Fig 1.—Types of illegal dental practice. (Courtesy of Benzian H, Jean J, van Palenstein Helderman W: Illegal oral care: More than a legal issue. Int Dent J 60:399-406, 2010.)
momentum toward change. A dental school was established and 20 more public dental clinics were opened to improve access to care. The expectation was that more numbers of registered dentists would help mitigate the problems of illegal providers. Analysis.—Illegal oral care can be identified as a public health problem, a legal problem, an economic problem, a professional problem, an ethical problem, and having a social dimension. Providers may not be formally trained to provide oral care and not registered (Fig 1). Fixing this requires enforcing existing regulations; strengthening administration, governance, and civil society awareness; providing communities with the appropriate oral healthcare services; and educating the public about the availability of services and the risks associated with using unlicensed, untrained providers. Traditional medicine practitioners present a special case that must be handled with discretion. There are also providers with health-related training (not in dentistry) who are not registered for oral healthcare provision. This aspect of illegal oral care can be addressed by providing all communities with appropriate oral health services; educating the public about what is available and why the use of unlicensed providers presents risks to their health; ensuring proper supervision, training, and payment for health personnel; providing skills-based training for health professionals, including basic emergency oral care;
72
Dental Abstracts
and developing laws and regulations so that medical health workers can be delegated oral care after they receive appropriate training and education. Some more advanced oral care is delivered by providers with basic oral health training only, making the practice unlicensed and therefore illegal. This requires the appropriate supervision, training, and remuneration of all health personnel; the construction of career paths and opportunities for personal and professional development; the inclusion of all members of the dental team in professional legislation, where they share a common framework of rights, responsibilities, and sanctions; making licensing regulations transparent and ensuring consistency of the process, thereby facilitating the legalization of previously unregistered providers; offering additional qualification and training incentives so previously informal providers can enter the formal care system; and ensuring that nongovernmental organizations that employ expatriate dentists and dental students comply with professional registration regulations. Finally, some providers with basic oral healthcare training overstep their responsibilities, making their actions illegal. Countering this problem requires the provision of proper training, supervision, and continuous control for such individuals; renewing the motivation of professionals; and providing the same actions as for the preceding group of illegal oral care providers.
Clinical Significance.—The illegal provision of oral care is a serious public health problem in some countries of the world. The result is low-quality care and increased risks for patients who seek the help of unqualified practitioners. This is a symptom of the underlying healthcare system. As shown in Guyana, steps can be taken to counteract the situation. Rather than confrontational, this approach is more inclusive, seeking to integrate formerly illegal providers into the formal system through the use of incentive programs, additional training, and
expanded opportunities. All parties who are stakeholders in the process should be involved in creating a better way to deliver oral health care.
Benzian H, Jean J, van Palenstein Helderman W: Illegal oral care: More than a legal issue. Int Dent J 60:399-406, 2010 Reprints available from H Benzian, The Health Bureau Ltd, Willmanndamm 8, 10827 Berlin, Germany; e-mail: [email protected]
Reforming the dental workforce Background.—Increasingly, the available evidence indicates that the dental profession is not meeting the expectations of society with respect to access to oral health care, particularly among children. Influential policy leaders are demanding change. The situation rests on what it means to be a profession, how societal expectations interact with professions, and what reforms may be needed in the dental workforce. Nature of a Profession.—The criteria traditionally accepted for a profession are as follows: (1) the work is primarily intellectual; (2) the work is based in science and learning; (3) the work is practical; (4) the work can be taught and learned through education beyond usual levels; (5) professionals organize into democratic and collegial units; and (6) professions exist to achieve goals set by society rather than by the self-interest of their members. The concept of covenant is applicable to the relationship between a profession and society. Covenants involve a pledge or promise, an exchange of gifts, and a change of being. Society has promised dentistry the right to care for oral health, and dentistry has promised to provide that care faithfully and well. Society gives self-regulation, dental education, and tax-subsidized student loans, and dentists offer society their knowledge and skills. As a result, dentistry is considered a profession, and society becomes the patient. Historically, dentistry has focused on serving the oral health needs of patients, deriving a financial gain as a natural and appropriate consequence of the service provided. However, dentists today are increasingly viewing themselves as practicing in the marketplace, as a business enterprise rather than a profession. However, health is a human good that should not be relegated to the marketplace. Human well-being, specifically oral health for both individuals
and society itself, is the goal served by dentistry. Seeing dental practice as merely a business means that patients are just a means toward achieving the end of financial gain. This view undermines the idea of a profession. Dentistry is only a business in the sense that it must adhere to good business principles in support of its professional practices. Societal Expectations.—Society is beginning to conclude that it is not being fairly treated through its social covenant because dentistry as a profession is failing to care for the public’s oral health. Ethics are being violated. All ethics are based on people cooperating with one another and treating one another fairly in the process. Society is seeing that the relationship with dentistry is out of balance. It is giving more than it is receiving because significant numbers of society’s members are not able to access oral health care. Society is frustrated by the profession’s specific inability to care for poor and minority children, a population that cannot be held personally responsible for their lack of oral health care. A fair provision of basic health care should redistribute health care more favorably to children because of the effect health care has on equality of opportunity for children. Poor and minority children have the highest prevalence of disease, the poorest access to care, and the poorest overall oral health. Justice demands that they have equal opportunity to do well, so the dental profession must address the dramatic inequities that exist in the oral health care and health care delivery for children. The character of society is evaluated on the basis of its concern for and care of its children’s health. Dentistry that fails to fulfill its social covenant cannot call itself a profession but is simply a trade association.
Volume 57
Issue 2
2012
73