Needs-led human resource planning for Sierra Leone in support of oral health

Abstract

Background In Sierra Leone (SL), a low-income country in West Africa, dental care is very limited, largely private, and with services focused in the capital Freetown. There is no formal dental education. Ten dentists supported by a similar number of dental care professionals (DCPs) serve a population of over 7.5 million people. The objective of this research was to estimate needs-led requirements for dental care and human resources for oral health to inform capacity building, based on a national survey of oral health in SL. Methods A dedicated operational research (OR) decision tool was constructed in Microsoft Excel to support this project. First, total treatment needs were estimated from our national epidemiological survey data for three key ages (6, 12 and 15 years), collected using the ‘International Caries Classification and Management System (ICCMS)’ tool. Second, oral health needs were extrapolated to whole population levels for each year-group, based on census demographic data. Third, full time equivalent (FTE) workforce capacity needs were estimated for mid-level providers in the form of Dental Therapists (DTs) and non-dental personnel based on current oral disease management approaches and clinical timings for treatment procedures. Fourth, informed by an expert panel, three oral disease management scenarios were explored for the national population: (1) Conventional care (CC): comprising oral health promotion (including prevention), restorations and tooth extraction; (2) Surgical and Preventive care (S5&6P and S6P): comprising oral health promotion (inc. prevention) and tooth extraction (D5 and D6 together, & at D6 level only); and (3) Prevention only (P): consisting of oral health promotion (inc. prevention). Fifth, the findings were extrapolated to the whole population based on demography, assuming similar levels of treatment need. Results To meet the needs of a single year-group of childrens’ needs, an average of 163 DTs (range: 133–188) would be required to deliver Conventional care (CC); 39 DTs (range: 30–45) to deliver basic Surgical and Preventive care (S6P); 54 DTs for more extended Surgical and Preventive care (S5&6P) (range 38–68); and 27 DTs (range: 25–32) to deliver Prevention only (P). When scaled up to the total population, an estimated 6,147 DTs (range: 5,565–6,870) would be required to deliver Conventional care (CC); 1,413 DTs (range: 1255–1438 DTs) to deliver basic Surgical and Preventive care (S6P); 2,000 DTs (range 1590–2236) for more extended Surgical and Preventive care (S5&6P) (range 1590–2236); and 1,028 DTs to deliver Prevention only (P) (range: 1016–1046). Furthermore, if oral health promotion activities, including individualised prevention, could be delivered by non-dental personnel, then the remaining surgical care could be delivered by 385 DTs (range: 251–488) for the S6P scenario which was deemed as the minimum basic baseline service involving extracting all teeth with extensive caries into dentine. More realistically, 972 DTs (range: 586–1179) would be needed for the S5&6P scenario in which all teeth with distinctive and extensive caries into dentine are extracted. Conclusion The study demonstrates the huge dental workforce needs required to deliver even minimal oral health care to the Sierra Leone population. The gap between the current workforce and the oral health needs of the population is stark and requires urgent action. The study also demonstrates the potential for contemporary epidemiological tools to predict dental treatment needs and inform workforce capacity building in a low-income country, exploring a range of solutions involving mid-level providers and non-dental personnel.

Oral health system strengthening in fragile and conflict-affected states: A systematic review

“…Studies related to oral health workforce in high-income countries such as the UK also focused on workforce retention and sustainability [70,71]. This contrasts with countries categorised as FCAS and/or low-and-middle-income countries, where the production of the oral health workforce is a priority due to its pressing scarcity while retention should also be sought after [72,73]. Fragility, often observed nationally, can manifest more severely, or be localised in specific geographic areas even with non-fragile states [11,74].…”

Caries clusters at lesion‐severity thresholds: A Sierra Leone case study

“…Utilizing school environments through education, promoting healthy environments and the application of prevention could facilitate capacity building. 29 Given that a significant proportion of caries is in enamel, where progression can be prevented through increasing fluoride availability, oral health strategy should exist alongside public policy to improve hygiene and sanitation. This will be particularly beneficial for rural areas and regions outside of the Western region, where the recruitment of health workers is difficult.…”

“…Accounting for the dearth of oral and general health facilities in SL and challenges in views and perceptions towards oral health, 6 upstream policies will need to utilize institutions outside of the healthcare environment—namely schools. Utilizing school environments through education, promoting healthy environments and the application of prevention could facilitate capacity building 29 . Given that a significant proportion of caries is in enamel, where progression can be prevented through increasing fluoride availability, oral health strategy should exist alongside public policy to improve hygiene and sanitation.…”

Unmet need in Sierra Leone: a national oral health survey of schoolchildren

“…As there were limited current data on schoolchildren, using the WHO basic pathfinder sampling method [ 21 ], was deemed appropriate for determining baseline oral needs. In addition, the study was unique in demonstrating the potential to use the ICCMS epidemiological tool in a low-resource setting which has enabled oral health workforce requirements to be estimated and published [ 58 ]. This is particularly important as urgent action is needed to develop dental workforce and strengthen the fragile dental system in line with WHO guidance on Oral health, Health workforce development and Universal Health Coverage (UHC) working in partnership with other agencies [ 59 – 62 ], and delivering ‘ Optimal Oral Health for All’ [ 63 ].…”