Muhammad Omar Niaz1, Mustafa Naseem2, Sara Nayab Siddiqui3, Zohaib Khurshid4
How to CITE:
Niaz MO, Naseem M, Siddiqui SN, Khurshid Z. An outline of the oral health challenges in “Pakistani” population and a discussion of approaches to these challenges. J Pak Dent Assoc 2013;22(3):219-226.
Oral health is defined as a standard of the oral and related tissues which enables an individual to eat, speak and socialize without active disease, discomfort or embarrassment and which contributes to general well-being. The traditional biomedical approach towards oral as well as general health is now being considered inappropriate to meet the health challenges of a population. A basic knowledge and application of social determinants of health is necessary at every level of a country’s healthcare system, so that effective preventive and efficient treatment strategies can be adopted by the various stakeholders in the healthcare system in order to meet those challenges.
This review article presents a synopsis of the oral health challenges faced by the Pakistani population in the light of the determinants of health and gives a critical appraisal of the current as well as possible future public health approaches to overcome these challenges. It is aimed to contribute towards the existing knowledge about the public health aspects of oral health for medical and dental students, professionals and policy makers.
Oral Health, challenges, Pakistani population
Oral Health: A Challenge?
Health is one of the major determinants that contribute to a nation’s development, especially in this age of globalization, where the health of a population is considered to be the key to better productivity and efficiency of a society. Even the definition of “health” has its roots deeply embedded in the holistic and social context rather than being defined as “a mere absence of disease” .1 Oral health, being an integral part of general health has likewise been defined as:A standard of health of the oral and related tissues which enables an individual to eat, speak and socialize without active disease, discomfort or embarrassment and which contributes to general well-being”.2
So, the knowledge of the “determinants” or “causes of the causes” of health3 and the fact that oral health as well as general health, is even defined in a subjective rather than an objective manner makes it a “challenge” in itself, let alone achieving it. This paper outlines the various challenges in oral health being faced by the population of Pakistan in the light of its determinants and discusses the present as well as possible future approaches to transform this challenge into an opportunity.
Pakistan: An Overview
he most significant geo-strategic regions of the modern world i.e. South Asia, as it shares borders with countries like China, India, Iran and Afghanistan. Since its independence from British rule over the Indo-Pak subcontinent in 1947, the country has on one hand been developing and has risen among the committee of nations to acquire a unique status of being the only Muslim nuclear state in the world. While on the other hand, political instability due to the repeated swings between democracy and military rule has been corrupting the state organs over the years and has been one of the most important factors due to which the Pakistani nation is still in search of a road to economic prosperity and sustainable development.
The Determinants Of Health/Oral Health In Pakistani Population
With a population of approximately 180 Million people, Pakistan is the sixth most populous country in the world, according to the official statistics.4, 5 It is a country of extremely diverse environmental, geographic, ethnic, social, religious and cultural demography. A vast majority of the population of the agriculture-based economy of Pakistan still lives in the rural areas. The data in Table 1 gives a panoramic view of the key indicators of physical, environmental and social determinants influencing the-general and oral health of the Pakistani population.4, 6-9
ORAL HEALTH CHALLENGES OF PAKISTAN
The Burden Of Oral Disease
The data in Table 2 illustrates the meaning of various indicators of oral health and disease in the Pakistani population.9-11 Majority of these data are based on the latest and most comprehensive oral epidemiological survey of the country yet.12,13 This pathfinder survey gives the prevalence, severity and age-wise distribution of the various oral conditions prevalent in the Pakistani population. The data gives an overview of the common oral conditions and the actual incidence/prevalence of many of these conditions varies widely with rural/urban population and in different provinces/geographic locations.
Major Oral/Dental Public Health Issues In Pakistan:
The data in Table 1 shows the most common oral conditions of public health interest and from these figures, it is usually inferred that Pakistan is a country of low caries prevalence, but the fact is that these inferences are based on not very high quality data. The high incidence of oral cancer, however, makes it the most important issue in the list of public health problems, followed by trauma and periodontal disease.14,15 The latter two issues seem to have been underestimated while planning the health care system of the country, despite the fact that besides being considered as oral health problems, their impact on general health is almost as much as that of cancer.
The most common cause of oral cancer in Pakistan is tobacco, which is used in a variety of forms ranging from smoking cigarettes and “bidis” to chewing betelnut/quid or “chhalia/paan” and snuff or “naswar”.16-21 Road traffic accidents are the most common cause of head and neck/facial trauma in Pakistan besides terrorism, domestic, sports and occupational injuries.22-25
Nevertheless, caries and periodontal disease still carry equal importance owing to the increasing trend of urbanization in Pakistan and the associated changes in social structure resulting in changing disease patterns and treatment needs.26 The rising western influence on lifestyles and dietary habits of the Pakistani population owing to many factors including the mushroom growth of electronic media has resulted in an increased incidence and prevalence of modern diseases like diabetes and cardiovascular disorders, which are common risk factors for caries, periodontal disease and other oral conditions too.27-30 But unfortunately, the healthcare system of Pakistan seems to have no policy basis to address these issues at population level.
The Real Challenge In Oral Healthcare For Pakistan: Demand vs. Supply
Oral health is still considered to be a luxury rather than a need for most Pakistanis because of the in-built errors in the oral healthcare system of the country that doesn’t take into account the determinants of health/oral health. The Pakistani population is burdened with many oral diseases due to a combination of the “forever limited resources”; affecting the treatment of these diseases and “mismanagement” of the available resources; influencing their prevention too.31 It seems that oral health has been the least of priorities for the governments and policy makers of Pakistan. This is evident from the embarrassingly small proportion of the annual budget allocated for health and the fact that the proportion of this budget dedicated particularly to oral healthcare is almost non-existent. 6, 32 On the other hand, a common Pakistani seems to have a virtual absence of need for oral health owing to multiple factors like poverty, unemployment, illiteracy, malnutrition, social inequity and religious/cultural dynamics.26
APPROACHES TO ORAL HEALTH CHALLENGES IN PAKISTAN AND THEIR CRITIQUE
Present Oral Healthcare System In Pakistan: The Bright Side Of The Picture!
It would be an injustice to start criticizing everything right at the outset; therefore, an overview of the present oral healthcare system is necessary to highlight the strengths of the current approaches, in order to be able to use them later as a basis for improvement. This section of the essay, therefore, gives an outline of the present status of approaches in the provision of oral healthcare to the people of Pakistan. The bright side of the picture is that at least these approaches exist and are somehow functioning too.
The federating units of the state of Pakistan are called provinces, which are administratively divided into divisions, which in turn consist of districts and “Tehsils”. At public level, healthcare is mainly a provincial subject when it comes to the financing, administration and service delivery with the Federal Ministry of Health performing the oversight and policy making role, until the recently implemented complete devolution of healthcare to the provinces.33 The infrastructure of the district health system of Pakistan is based on the framework of Primary Healthcare Approach (PHCA), with the hierarchy shown in Figure 1.34 The first level of contact between the population and healthcare system for professional dental care occurs at the RHC (primary& secondary) level, with secondary level oral/dental care available at THQ & DHQ hospitals and tertiary level or specialist care available only at teaching hospitals.12
On the other hand, the private sector is a major contributor towards provision of healthcare facilities to the population; with almost 70 % utilization rate compared to only about 30 % in case of the public sector facilities. The private healthcare facilities vary widely from modern hospitals and clinics equipped withstate of the art diagnostic and therapeutic facilities as well as highly qualified doctors and dentists practicing contemporary dentistry/allopathic medicine, to more informal structures providing alternative medicine in the form of homoeopathy, “Hikmat” (by “hakeems” = traditional healers), “Ayurveda” (herbal medicine), “Tibb-e-Yunani” (traditional Greek medicine), Chinese medicine/acupuncture and “spiritual healers”.35 Roadside denturists (also known as “quacks”) can be regarded as the crudest form of alternative dentistry available in Pakistan in this category.36 Whereas most of these private facilities are run by for-profit or ganizations/individuals, there are many non-profit NGO’s and charity organizations offering healthcare services of different sorts too; “Edhi Foundation” being the most notable of them allowing to its Guinness record-making free health and social care contributions to the most deprived and needy segments of Pakistani society.37
Problems In The Current Healthcare System: Priority & Management Crisis
Having established the existence of such an elaborate framework of the current approaches to oral health challenges in Pakistan, one wonders why they are still challenges. The answer to this question is as simple as the conventional argument of a management crisis that exists in almost all the departments of the state, including “health” and as complex as the recent analysis of reasons for neglected political priority to oral health that exists globally.38
The root cause of all the problems is the apparent dearth of conscience among the policy makers of this eternally troubled country who regard a subject as serious as health so casually,that such decision as abolishing the Federal Ministry of Health in the name of devolution are taken without any conscious thought of the possible repercussions.33 The recent incident of more than a hundred deaths in a month in one of the tertiary care cardiology hospitals of Punjab, the most populous province of Pakistan, occurring as a result of allegedly spurious medicines is probably the worst example of this crisis of management and policy.39
The effects of this apathy are true in the case of oral healthcare system too, thereby resulting in oral diseases that burden the Pakistani population, most of which are preventable. The neglect of a need for oral health and the fact that it has always been considered to be separate from issues of primary care and general health, has automatically resulted in an oral healthcare system that is purely treatment-focused rather than preventive.12 The “inverse care law” 40 naturally exists in such a system, besides issues of “access” as well as “quality”. These three essential themes of public health medicine/dentistry are compromised when considering issues of limited manpower as well as inefficient infrastructure of the present oral healthcare system in Pakistan.
Professional dentistry in Pakistan is almost entirely dentist-based and at present, very limited scope exists for the use of skill-mix and professionals complementary to dentistry. The dental workforce currently faces the following main issues12:
1. Sub-standard curriculum and absence of evidence-based approach for undergraduate teaching,
2. Deteriorating quality of training at postgraduate level, not recognizable internationally,
3. Questionable regulation and clinical governance with no incentive for continued professional development.
These problems result in the numerous vacant posts of dentists in various districts and tehsils of Pakistan. Whereas, many of the posts which are in fact occupied have limited efficiency because of the following main reasons12:
1. Redundant or non-functional equipment/dental units and
2. Inadequate dental materials/instruments
All these factors have resulted in the unfortunate fact thatpeople especially those belonging to underprivileged sections of the society are forced to seek dental treatments from more than 40,000 non-qualified dental practitioners. Although these “quacks” offer easily accessible and affordable solutions to the painful dental problems of the poor patients, but in doing so they play havoc not only with their oral health but general health too. Owing to the use of unscientific methods and unsterilized instruments, they are one of the leading perpetrators behind the transmission of communicable diseases like Hepatitis-B & C and HIV/AIDS.41
4 RECOMMENDATIONS FOR FUTURE IMPROVEMENT: THE WAY FORWARD!
The lessons learnt from these multi-sectoral challenges in oral health can be used to re-orient the existing general as well as oral healthcare system of a developing country like Pakistan according to the true spirit of the Primary Healthcare Approach (PHCA) instead of revamping the whole system based on utopian ideas which might seem good on paper but are in fact not practicable. This will helpachieve focus on prevention rather than technology-dependent treatment alone and empower the community at large to gain control over the determinants of health, thereby evolving a system that is efficient, cost-effective and successfully addresses the issues of equity, access and quality too.42
Recommendations For Policy
Although devolution of healthcare from federal to provincial level seems to be an effective way to ensure an efficient healthcare service, but certain crucial roles like policy-making, accountability and regulation (drugs,professional and research) must rest with a federal body in order to ensure that the service delivers too.43
A healthy public policy at national level alone can create a supportive environment for the communities to gain control over and improve their health. To translate such a policy intore-orienting the healthcare system for focus on prevention, effective Dental Health Education(DHE) and Oral Health Promotion(OHP)is needed. This can be achieved by harnessing the power of the booming electronic media of Pakistan by advertisement against tobacco and betel use and for implementing laws like ban on smoking at public places and under-age sale, considering the fact that it is the most common cause of oral cancer in Pakistan.16-21 Similarly, the health policy must include legislation for improving and implementing safety standards to avoid road traffic accidents; the most common cause of head & neck trauma in Pakistan.22-25 Issues like water fluoridation and fluoride concentration in toothpastes can also be addressed by policy making only.
The reason why there has been no or very little impetus for policy makers to include oral health in the national health policy that seems to emphasize a lot on PHC Approach is the fact that there is a lack of reliable and up to date data on oral health and the conventional biomedical approach towards dentistry still prevails.42 The following section enumerates the practicable steps how this approach can be changed to develop such a policy.
Recommendations For Re-orienting Oral Health-Care Services
Following evidence-based steps can be taken to incorporate oral health into the national health policy to operationalize the present oral healthcare system on the principles of PHCA12, 42, 44:
1. Proportion of the healthcare budget specifically meant for oral health must be defined and allocated separately. This should be based on a partially free service that at least caters for the cost of providing a set of basic and/or emergency dental procedures that can minimally be expected at the level of a primary care public health facility.
2. A Chief Dental Officer should be appointed at Federal level, whose provincial counterparts would be accountable to him for providing feedback on the fair distribution and utilization of these funds. This will also provide a basis for any revision of policy at national as well as provincial level based on data received from this feedback.
3. The regulatory role of Pakistan Medical & Dental Council (PM&DC) needs redefining so that the deteriorating quality of dental education due to the recent mushrooming growth of private medical/dental colleges can be improved. This will also bring the hitherto non standardized private healthcare facilities under monitoring and regulation so as to reduce in equalities in access to such facilities arising because of them.
4. The re-registration by the PM&DC and promotion of dentists in public service must be in centivized with continued professional development so as to inculcate an evidence-based approach among them, thus improving the quality of service.
5. These measures will automatically attract unemployed dentists to fill the various vacant posts for dentists in the district health system thereby improving the workforce deficit which in turn will improve availability and enable equitable distribution of oral healthcare at grass roots level.
6. The regulated use of dental auxiliaries should also be encouraged so that they are able to provide at least basic oral healthcare to people who cannot afford or don’t have access to a dentist. With adequate education and training of these auxiliaries as well as the roadside “quacks” discussed earlier, they can also be used effectively for technology-independent preventive procedures like At raumatic Restorative Technique (ART), DHE and OHP.
7. Following the multi-sectoral and common risk factor approach and to involve the community itself, oral health can be integrated into other social welfare and public health programs such as the Lady Health Workers/Visitors who can effectively provide preventive oral health advice by arranging school-based preventive programs and to the high risk groups that they regularly visit i.e. pregnant mothers. They can also be trained to collect data for epidemic logical use.
Oral health still remains a dream for a common Pakistani even in today’s modern times. To make this dream come true, the present oral healthcare system needs to be reoriented in letter and spirit on the principles of Primary Healthcare Approach through a policy decision at national level that recognizes the contribution oral health has towards general health and well-being of individuals as well as communities.
1. WHO. About WHO : Definition of Health. World Health Organization; 1946 [cited 2012 January 8]; Available from: https://apps.who.int/aboutwho/en/definition.htm
2. HEALTH DO. Choosing Better Oral Health: An Oral Health Plan for England London: Department of Health; 2005 [cited 2012 8 January]; 55]. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4123253.pdf.
3. WHO. WHO The determinants of Health. World Health Organization; [cited 2012 January 8]; Available from: http://www.who.int/hia/evidence/doh/en/
4. CIA. The World Factbook. USA: Central Intelligence Agency; 2011 [cited 2012 2 February]; Available from: https://www.cia.gov/library/publications/the-world-factbook/geos/pk.html.
5. Government of Pakistan PCO. PAKISTAN – CENSUS. Islamabad, Pakistan: Population Census Organization, Government of Pakistan; 2011 [cited2012 January 8]; Available from: http://www.census.gov.pk/.
6. Government of Pakistan MoF. Pakistan Economic Survey 2010-11. Islamabad, Pakistan: Economic Adviser’s Wing, Finance Division, Government of Pakistan; 2011 [cited 2012 2 February]; Available from: http://www.finance.gov.pk/survey/chapter_11/Economic%20Indicators.pdf.
7. WHO. Global Health Observatory Data Repository. 2011 [updated 01/02/2012; cited 2012 1 February]; Available from: http://apps.who.int/ghodata/?vid=15300&theme=country.
8. Khan H, Inamullah E, Shams K. Population, environment and poverty in Pakistan: linkages and empirical evidence. Environment, Development and Sustainability. 2009;11(2):375-92.
9. FDI. Data Mirror. GENEVA, SWITZERLAND: FDI WORLD DENTAL FEDERATION; 2007 [cited 2012 4 February]; Available from: http://www.fdi-worldental.org/data-mirror
10. WHO. Caries for 12-Year-Olds by Country/Area, WHO Region, WHO Language Recommendations. Malmö, Sweden: WHO/Malmö University; 2012 [updated November 01, 2011; cited 2012 4 February]; Country Oral Health Profiles > According to Alphabetical order > Country/Area: P]. Available from: http://www.mah.se/CAPP/Country-Oral-Health-Profiles/According-to-Alphabetical/CountryArea-P/
11. WHO. Periodontal country profiles. Geneva: WHO/Niigata University; 2012 [cited 2012 4 February]; Available from: http://www.dent.niigata-u.ac.jp/prevent/perio/perio.html.
12. Khan AA. Oral health in Pakistan: a situation analysis. Islamabad: Ministry of Health, Government of Pakistan/WHO (Pakistan office); 2004.
13. Khan AA, Ijaz S, Syed A, Qureshi A, Padhiar I, Sufia S, et al. Oral health in Pakistan: a situation analysis. Developing Dentistry. 2004;5:35–44.
14. Saman W. Global epidemiology of oral and oropharyngeal cancer. Oral Oncology. 2009;45(4–5):309-16.
15. Bhurgri Y. Cancer of the oral cavity – trends in Karachi South (1995-2002). Asian Pac J Cancer Prev. 2005;6(1):22-6. Epub 2005/03/23.
16. Basharat S, Kassim S, Croucher RE. Availability and use of Naswar: an exploratory study. J Public Health (Oxf) [Internet]. 2011. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21676923?do pt=Citation.
17. Javed F, Chotai M, Mehmood A, Almas K. Oral mucosal disorders associated with habitual gutka usage: a review. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2010;109(6):857-64.
18. Ali NS, Khuwaja AK, Ali T, Hameed R. Smokeless tobacco use among adult patients who visited family practice clinics in Karachi, Pakistan. Journal of Oral Pathology & Medicine. 2009;38(5):416-21.
19. Tanwir F, Altamash M, Gustafsson A. Influence of betel nut chewing, dental care habits and attitudes on perceived oral health among adult Pakistanis. Oral Health Prev Dent. 2008;6(2):89-94Epub 2008/07/22.
20. Mazahir S, Malik R, Maqsood M, Merchant KA, Malik F, Majeed A, et al. Socio-demographic correlates of betel, areca and smokeless tobacco use as a high risk behavior for head and neck cancers in a squattersettlement of Karachi, Pakistan. Substabuse Treat Prev Policy. 2006;1:10. Epub 006/05/26.
21. Merchant A, Husain SSM, Hosain M, Fikree FF, Pitiphat W, Siddiqui AR, et al. Paan without tobacco: An independent risk factor for oral cancer. International Journal of Cancer. 2000;86(1):128-31.
22. Khan SU, Khan M, Khan AA, Murtaza B, Maqsood A, Ibrahim W, et al. Etiology and pattern of maxill ofacial injuries in the Armed Forces of Pakistan. J Coll Physicians Surg Pak. 2007;17(2):94-7. Epub 2007/02/10.
23. Cheema SA, Amin F. Incidence and causes of maxillofacial skeletal injuries at the Mayo Hospital in Lahore, Pakistan. British Journal of Oral and Maxillofacial Surgery. 2006;44(3):232-4
24. Ghaffar A, Hyder AA, Masud TI. The burden of road traffic injuries in developing countries: the 1st national injury survey of Pakistan. Public Health. 2004;118(3):211-7.
25. Hyder AA, Ghaffar A, Masood TI. Motor vehicle crashes in Pakistan: the emerging epidemic. Injury Prevention. 2000;6(3):199-202.
26. Tanwir F. Absence of Toothache Syndrome – Oral health and Treatment needs among urban Pakistanis. Stockholm, Sweden: Institute of Odontology, Karolinska Intitutet; 2008.
27. Bokhari SA, Khan AA, Khalil M, Abubakar MM, Mustahsen UR, Azhar M. Oral health status of CHD and non-CHD adults of Lahore, Pakistan. J Indian Soc Periodontol. 2011;15(1):51-4. Epub 2011/07/21.
28. Sufia S, Chaudhry S, Izhar F, Syed A, Mirza BA, Khan AA. Dental caries experience in preschool children: is it related to a child’s place of residence and family income? Oral Health Prev Dent. 2011;9(4):375-9. Epub 2012/01/13.
29. Mirza BA, Syed A, Izhar F, Ali Khan A. Bidirectional relationship between diabetes and periodontal disease: review of evidence. J Pak Med Assoc. 2010;60(9):766-8. Epub 2011/03/09.
30. Tan WC, Tay FB, Lim LP. Diabetes as a risk factor for periodontal disease: current status and future considerations. Ann Acad Med Singapore. 2006;35(8) 571-81. Epub 2006/09/29.
31. Ahmed J, Shaikh BT. The state of affairs at primary health care facilities in Pakistan: where is the state’s stewardship? Eastern Mediterranean Health Journal. 2011;17(7):619-23.
32. Ahmed J, Shaikh BT. An all time low budget for healthcare in Pakistan. J Coll Physicians Surg Pak. 2008;18(6):388-91. Epub 2008/09/02.
33. Nishtar S, Mehboob AB. Pakistan prepares to abolish Ministry of Health. Lancet. 2011;378(9792):648-9.
34. Sabih F, Bile KM, Buehler W, Hafeez A, Nishtar S, Siddiqi S. Implementing the district health system in the framework of primary health care in Pakistan: can the evolving reforms enhance the pace towards the millennium development goals? East Mediterr Health J. 2010;16 Suppl:S132-44. Epub 2010/01/01.
35. WHO/EMRO. Health Systems Profile- Pakistan. Cairo, Egypt: World Health Organization, Eastern Mediterranean Regional Office; 2007 [cited 2012 5 February]; Available from: http://gis.emro.who.int/HealthSystemObservatory/PDF/Pakistan/Health% 20system%20organization.pdf.
36. Sabir A. Street Doctors in Pakistan. Islamabad, Pakistan: YouTube Channel: addielsabir1; 2009. p. 4 minutes 51 seconds.
37. Edhi AS. ADBUL SATTAR EDHI – NATIONAL AND INTERNATIONAL AWARDS. Karachi, Pakistan: Abdul Sattar Edhi Foundation; 2011 [cited20125 February]; Available from: http://edhi.org/awards.html.
38. Benzian H, Hobdell M, Holmgren C, Yee R, Monse B, Barnard JT, et al. Political priority of global oral health: an analysis of reasons for international neglect. Int Dent J. 2011;61(3):124-30. Epub 2011/06/23.
39. Moatasim M. Behind the disaster. The News International. 2012 Saturday, February 04, 2012;Sect. Opinion.
40. Julian TH. THE INVERSE CARE LAW. The Lancet. 1971;297(7696):405-12.
41. Ahmad K. Pakistan:a cirrhotic state? Lancet. 2004;364(9448):1843-4.
42. Khan AA. Oral Health Services in Developing Countries: A case for the Primary Health Care Approach DEVELOPING DENTISTRY 2004;5(2):1-4.
43. Nishtar S. Health and the 18th Amendment: Retaining national functions in devolution. Islamabad, Pakistan: Heart file; 2011 [cited 2012 2 February]; Available from: http://www.heartfile.org/pdf/HEALTH_18AM_FINAL.pdf
44. Shah MA, Darby ML, Bauman DB. Improving oral health in Pakistan using dental hygienists. International Journal of Dental Hygiene. 2011;9(1):43-52.