1. 1. DENTAL MANPOWER PLANNING IN INDIA Guided by: Dr. Girish R Shavi Dr. Mayank Agrawal Presented by: Dr. Preyas Joshi Second year postgraduate student Public health dentistry 5/4/2015 1
2. 2. Manpower The number of people working or available for work or service.1 All the people who are available to do a particular job or to work in a particular place.2 5/4/2015 2 Manpower surplus: there are more people than available jobs. Manpower deficit: available people are fewer than jobs.
3. 3. Planning A detailed scheme, method, etc, for attaining an objective. a proposed, usually tentative idea for doing something.3 5/4/2015 3
4. 4. MANPOWER PLANNING Thomas H. Patten(1971) defines manpower planning as "the process by which an organisation ensures that it has the right number of people and the right kind of people at the right place at the right time, doing things for which they are economically most useful.4 In the words of Filppo(1976), "A manpower planning programme can be defined as an appraisal of an organisation's ability to perpetuate itself with respect to its management as a determination of measures necessary to provide the essential talent.5 5/4/2015 4
5. 5. H E A LT H M A N P O W E R P L A N N I N G Health manpower planning is the process of estimating the number of persons and the kind of knowledge, skills and attitudes they need to achieve predetermined health targets and ultimately health status objectives. Such planning also involves specifying who is going to do what, when, how and with what resources for populations, groups and individuals. It must be a continuing and not a sporadic process, and it requires continuous monitoring and evaluation. - Mejia and Flp (1978) 5/4/2015 5
6. 6. T H E P R I N C I P L E S O F O R G A N I S AT I O N A N D M O D E L S O F D E L I V E RY O F O R A L H E A LT H C A R E 6 Oral health care system includes: Health policies to promote oral health. Resources including personnel and facilities. Strategies that organise those resources to provide services. (Andersen et al, 1995) There are no definitive models of different types of oral health care delivery and various countries have developed a range of systems. 5/4/2015 6
7. 7. T H E S Y S T E M S C O N C E P T A P P L I E D T O O R A L H E A LT H A system is a set of elements, actively interrelated which operates in a bounded unit. A systems approach is valuable for examining the organisation of oral health care delivery. (Andersen et al,1995; Edelstein, 2002) Oral health care systems usually have a goal to attain freedom from diseases and impairments for the population served. (Baker, 1970; Scott, 1987) Systems are influenced by society structure and cross-cutting social policies. (Thomson et al,2002) Generally, oral health care systems seek to improve the quality of life of the population through research, education, provision of services, and through the promotion of policies such as fluoridation.they are made up of health policies, resources and strategies available to provide care. 5/4/2015 7
8. 8. Oral health care systems respond to: Changes in population demographics. Changes in patterns of oral diseases. Impact of oral diseases in relation to other systemic diseases. Social, political or economic structure and societal norms as reflected in national policies, legislation, regulations, and payment system. Characteristically, system analysis includes: Who provides What service/functions For whom In what location With what resources. By what payment mechanisms With what effects 5/4/2015 8
9. 9. C H A R A C T E R I S T I C S O F T H E O R A L H E A LT H C A R E S Y S T E M Oral health care systems worldwide can be described by: Policy Organisation Payment mechanisms Outcomes Oral health care systems respond to specific oral diseases and policies that focus on identified populations such as age groups. (andersen et al, 1995; boerma et al, 1998) A different system will develop in a nation that has stated objectives for school age children than in a country that targets infants or no specific age group. 5/4/2015 9
10. 10. Worldwide, systems differ in the focus placed on the range of functions. The appropriateness of organisations to carry out system functions varies. Universities and governments are logical components of the system to carry out functions of administration, policy, and research. Often oral health care systems have been described on the basis of only one or two characteristics, perhaps reflecting what is more unique to that country: New Zealand School-based system employing dental nurses British National health service U.S.A Fee-for-service private practice system Each system should be understood for all its characteristics, since systems are not unidimensional, and most have adapted over the years. (Hancock et al, 1999; Wang et al, 1998) 5/4/2015 10
11. 11. 5/4/2015 11 TA X O N O M Y F O R S Y S T E M AT I C C R O S S - N AT I O N A L C O M PA R AT I V E A N A LY S I S O F O R A L H E A LT H C A R E S Y S T E M S Personnel Dentist Dental hygienist Dental therapist Expanded-duty assistant Dental assistant Oral health community worker Community worker Other health care and social work professionals (e.g., physicians, nurses) Structure/Location Government facilities Universities Worksites Hospitals, institutions Schools Health/dental clinics Mobile units Individual dental offices General community facilities Financing General government revenue Specific taxation Compulsory insurance Insurance or prepayment supported by employer or individual Direct payment, private income Reimbursement Fee-for-service Capitation Contract salary Target population Infants Preschool children School-age children Young adults Adults Older adults Special care populations Identified occupational groups Functions Policy development & implementation Administration Quality control Research Professional education Public oral health education Preventive services Emergency services With what effect(examples) Appropriate dental care Improved knowledge, values, opinions and behaviors regarding oral health Less dental caries among adults Reduced tooth loss Improved oral health
12. 12. O V E R V I E W O F T H E O R A L H E A LT H C A R E D E L I V E R Y S Y S T E M SOCIO-POLITICAL AND ECONOMIC ISSUES AT SOCIETAL LEVEL POLICIES ORAL HEALTH CARE DELIVERY SYSTEM Personnel Target population(s) Financing Functions Structure Reimbursement ORAL HEALTH OF POPULATION 5/4/2015 12
13. 13. P O L I C I E S A N D O B J E C T I V E S Goals & objectives: Some countries have neither clearly articulated oral health objectives nor a well defined system of care (or have one but not the other). Other countries have oral health objectives that appear to have been developed independentaly of the organisation of care, with a system that is unresponsive to those objectives. Yet others have clearly stated objectives and a system designed to response to those objectives, both of which are outdated. At the very basis of the system of oral health care are the goals and objectives the purposes and expected outcomes of care (WHO, 2003) 5/4/2015 13
14. 14. Oral health systems may have one or any combination of the following objectives: Management and elimination of dental emergencies Treatment of existing diseases Elimination of progression of diseases Prevention of future diseases Finding new ways of preventing and treating diseases (research) Improved use of new and existing preventive and treatment approaches (education) Often uncoordinated programs and appearances of ambivalence about oral health care as a social good result when there is no clearly articulated policy. WHO has developed conceptual models and strategies to facilitate evaluation of and planning of system performance. (WHO, 2003) 5/4/2015 14
15. 15. Systems of oral health care are influenced by societal policies and have policies of their own that affect the organisation of the system and services provided. Policies,set for meeting the objectives of the oral health system, provide guidelines for securing and organising resources and may be either explicit or implicit. Policies might be represented by national nutrition guidelines or mandated governmental sponsored research, provision of care, or school education and service programmes, among others. the facilities, numbers, types and distribution of personnel, sources of revenue, and reimbursement procedures are representative of resources in the oral health care system that are influenced by policy (Gift, 1993;Boerma, 1998; kallestal et al,1999) 5/4/2015 15
16. 16. National policies influence: Who is entitled to care Which age group are emphasised What type of care are received Who provides the care Where the care is provided Recognising the complexity of the many combined issues, the world health organisation(WHO) and other organisations are increasingly encouraging evaluations. (WHO, 2003) Major evaluations have been undertaken in many countries during the past decade. (Neenan et al, 1993; IOM, 1998; Hancock et al, 1999; Seldin, 2001; Seldin and brown, 2002; Van Palenstein Heldermann, 2002) 5/4/2015 16
17. 17. O R G A N I S AT I O N Generally, the organisation of the delivery system has been described using a medical model, limited to the oral health care professionals associated with dental schools, clinics, individual dental practices, and government components directly associated with policy, remuneration, or delivery of oral health care. More recently, comprehensive community/public health models have gained favour over the medical model (Andersen et al, 1995; Chen et al, 1997) Using this expanded model, pharmacists, physicians, nurses, school teachers, and water work supervisors become part of the oral health care delivery system. Similarly, worksites, hospitals, nursing homes, and institutions are appropriate facilities for care. 5/4/2015 17
18. 18. The following description focuses on more traditional oral health care facilities and personnel. Structure a) National level At the national level, oral health care may be: Entirely centrally organised Partly decentralised Completely decentralised. Oral health care may also be: Well identified with defined structures and leadership Integrated with other medical services Not acknowledged as part of a national agenda at all. b) Practice level The most frequently observed structures for delivery of oral health care are independent practices with one or more dentist (owner or employed associates), clinics (public or private), and community outreach programmes in mobile units or any available and convenient facility. (Arnljot et al,1985; Neenan et al,1993; Andersen et al, 1995) 5/4/2015 18
19. 19. S T R U C T U R E O F O R A L H E A LT H C A R E S RV I C E S Much of the current oral health care approach has developed from The demands of treating caries in children and Providing restorations for dental caries and treatment for periodontal diseases of healthy, mobile young adults However, the traditional structure of dental practices may be less suitable for case of Older adults Individuals in remote locations Provision of many health promotion and disease prevention initiatives, particularly for people who do not routinely visit a dentist (Boerman et al, 1998; Mertz and ONeil, 2002; Pacza et al, 2001) 5/4/2015 19
20. 20. O R A L H E A LT H C A R E P E R S O N N E L EDUCATION AND TRAINING: The education and training of oral health care personnel set the stage for the organisation of the oral health care delivery system. (Weaver et al,2000) The time devoted to education and training of dentists usually is more than that for other oral health personnel, and the system is organised through licensing and credentialing to produce competent professionals. (Jeffcoat and clark, 1995; Kress, 1995; Tedesco, 1995) There has been continued pressure to increase training of dentists for preventive approaches and care of specific groups such as young children and medically compromised patients. (Atchison et al, 2002; Crall, 2002; Valachovic, 2002) 5/4/2015 20
21. 21. F I N A N C I N G , R E I M B U R S E M E N T, A N D R E M U N E R AT I O N Financing reflects how money gets into the system The most common approaches being General government revenues Specific taxation Insurance or prepayment premiums paid by individuals and/or employers Out-of-pocket direct payment by individuals. Reimbursement, including remuneration, is the mechanism for payment for services, e.g. fee-for- service, capitation, contract, or salary 5/4/2015 21
22. 22. Dental Manpower7 DENTIST - A dentist is a person licensed to practice dentistry under the law of the appropriate state province territory or nation. These laws ensure that to become licensed, a prospective dentist must satisfy certain qualifications. Dentist are concerned with the prevention and control of diseases of the oral cavity and the treatment of unfavorable conditions resulting from these diseases, from trauma or from inherent malformations. They are legally entitled to treat patients independently, to prescribe certain drugs and to employ and supervise auxiliary personnel. Dentists must be registered. Dentist must satisfy, Completion of an approved period of professional education in an approved institution. Demonstration of competence. Evidence of satisfactory personal qualities. 5/4/2015 22
23. 23. D E N TA L A U X I L I A RY / A N C I L I A RY A dental auxiliary is a person who is given responsibility by a dentist so that he or she can help the dentist render dental care,but who is not himself or herself qualified with a dental degree. The duties undertaken range from simple tasks such as sorting instruments to relatively complex procedures. CLASSIFICATION(WHO, 1967) Non-operating auxiliaries: 1) Clinical: This is a person who assists the dentist in clinical work but does not carry out any independent procedures. 2) Laboratory: A person who assists the dentist by carrying out certain technical laboratory procedures. 5/4/2015 23
24. 24. Operating auxiliary: person who not being a professional can carry out procedures under the supervision of a professional. REVISED CLASSIFICATION Non operating auxiliaries: dental surgery assistant dental receptionist dental laboratory technician dental health educator 5/4/2015 24
25. 25. Operating ancillaries: school dental nurse dental therapist dental hygienist expanded function dental ancillaries 5/4/2015 25
26. 26. DENTAL SURGERY ASSISTANT Dental assistant is a non operating auxiliary who assists the dentist and the dental hygienist in treating patients, but who is not legally permitted to treat patients independently. Dental assistant may work under the supervision of a licensed dentist, carrying out duties prescribed by the dentist or by a dental hygienist employed by the dentist. 5/4/2015 26
27. 27. D E N TA L S E C R E TA RY / R E C E P T I O N I S T 5/4/2015 27 This is a person who assists the dentist with his secretarial work and patient reception duties.
28. 28. D E N TA L L A B O R AT O R Y T E C H N I C I A N A dental laboratory technician is a non operating auxiliary who fullfills the prescription provided by dentist regarding the extra oral construction and repair of oral appliances and bridge-work. This category of personnels have also been known as dental mechanics. As per the dentist act of 1948, dental mechanic is a person who makes or repairs dentures and dental appliances. 5/4/2015 28
29. 29. D E N T U R I S T 5/4/2015 29 Those dental laboratory technicians who are permitted to fabricate dentures directly for the patients without a dentists prescription. they may be licenced or registered.
30. 30. T H E D E N TA L H E A LT H E D U C AT O R This is a person who instructs in the prevention of dental disease and who may also be permitted to apply preventive agents intraorally. In sweden, two additional weeks of training is given, after which ancillaries are allowed to conduct fluoride mouth rinsing programmes. 5/4/2015 30
31. 31. T H E S C H O O L D E N TA L N U R S E 5/4/2015 31 This is a person,who is permitted to diagnose dental disease and to plan and carry out certain specified preventive and treatment measures, including some operative procedures in treatment of dental caries and periodontal disease in defined group of people, usually school children. dental nurses are presumed to provide care more cheaply than dentist.They are less expensive to train unlike dentist and their salaries are similar to those of physical therapist and school teachers.
32. 32. T H E D E N TA L T H E R A P I S T 5/4/2015 32 This is a person who is permitted to carry out to the prescription of a supervising dentist, certain specified preventive and treatment measures including the preparation of cavities and restoration of teeth. The training of the therapist is about 2 yrs involving both reversible and irreversible procedures. Their duties include, clinical caries diagnosis. Cavity preparation in deciduous and permanent teeth. vital pulpotomies using rubber dam in deciduous teeth. Extraction of deciduous teeth under local anaesthesia.
33. 33. T H E D E N TA L H Y G I E N I S T 5/4/2015 33 The dental hygienist is a person licensed and registered to practice oral hygiene under the laws of appropriate state, province, territory or nation. The dental hygienist works under the supervision of the dentist. Who does oral prophylaxis, gives instructions in oral hygiene and preventive dentistry, assists the dental surgeon in chairside work and manages the office. As per the Indian dentist act of 1948, a dental hygienist means a person not being a dentist or a medical practitioner, who scales, cleans or polishes teeth, or gives instruction on dental hygiene.
34. 34. 5/4/2015 34 Dental council of Indias norms for dental hygienists: 1) The course of studies should extend over a period of two academic years and lead to the qualification of dental hygienist certificate. 2) The candidate should be at least 15 years of age at the time of admission or within 3 months of it and should be medically fit. 3) the candidate must have passed at least matriculation examination of a recognized university taking science subject or an equivalent recognized qualification.
35. 35. E X PA N D E D F U N C T I O N D E N TA L A U X I L I A RY ( E F D A ) 5/4/2015 35 An EFDA is a dental assistant or a dental hygienist in some cases, who had received further training in duties related to direct treatment of patients, though still working under the direct supervision of a dentist. They take reversible procedures i.e which can be corrected or redone without any undue harm to the patient. They do not prepare cavities or make decisions as to pulp protection after caries has been excavated, but work along side dentist and take over routine restorative procedures, as soon as cavity preparation and base have been completed.
36. 36. 5/4/2015 36 They Perform following Duties: placing and removing rubber dams. Placing and removing temporary restorations. placing and removing matrix bands. condensing and carving amalgam restorations. placing of acrylic restoration in previously prepared teeth. Applying the final finish and polish to the previously listed restorations.
37. 37. F R O N T I E R A U X I L I A R I E S In developed countries, dentists remain in urban centers and a large number of areas are too distant from public or private dental offices for the inhabitants to receive regular comprehensive care or emergency pain relief. Nurses and former dental assistants can in such areas, provide valuable service with minimum amount of training. Functions: Simple dental prophylaxis. Basic dental health education. Dental first aid can be rendered in cases with pain and patients can be referred to the nearest dentist more intelligently than would be possible by untrained people. They can also organize fluoride rinse programs. Simple denture repairs. 5/4/2015 37
38. 38. N E W A U X I L I A RY T Y P E S The expert committee on auxiliary dental personnel of the WHO(1959) has suggested two new types of dental auxiliaries: 1) The dental licentiate - He is a semi-independent operator, trained for two yrs to perform dental prophylaxis, cavity preparations and filling of deciduous and permanent teeth, extrations under L.A, drainage of abscess, treatment of most prevalent diseases of supporting tissues, early recognition of more serious dental conditions. 2) The dental aide - The duties performed are extraction of teeth under local anaesthesia, control of haemorrhage, recognition of dental disease which is important enough to justify transportation of the patient to a center where proper dental care is available. 5/4/2015 38
39. 39. H E A LT H W O R K F O R C E I N I N D I A 8 5/4/2015 39
40. 40. Health-worker availability Table 1 shows the absolute numbers and category-wise density (per 1000 population) of doctors, dentists and nurses including midwives at the national and state levels. In 2009, India had 761 806 doctors, 104 603 dentists and 1 650 180 nurses and midwives. At the national level, the aggregate density of doctors, nurses and midwives was 2.08 per 1000 population, which was lower than WHOs critical shortage threshold of 2.28.[9] There were gross inequalities in the availability of these health workers at the subnational level. For example, states such as Bihar, Uttar Pradesh, Uttarakhand, Jharkhand and Chhattisgarh had especially severe shortages of health workers [less than 1 per 1000 population]. 5/4/2015 40
41. 41. D E N TA L H E A LT H W O R K F O R C E I N I N D I A 5/4/2015 41 [Table/Fig-1] shows the absolute numbers and category- wise density (per 1000 population) of dentists at national and state levels. In 2009, India had 104603 dentists. There were gross inequalities in the availability of these health workers at the sub national level.[10]
42. 42. 5/4/2015 42 Three important developments highlighted: First is the recent rapid expansion in the training capacity of dentists. Between 1991 and 2013, the number of admissions to dental institutions expanded from 3100 to 23 800, i.e. by 66.8%[11]. There were clear inequalities in the distribution of these training institutions among states. Although the Empowered Action Group states account for almost half of the countrys population, they house approximately a quarter of the dental institutes [8]. Second, there has been a notable increase in the private sectors involvement in Dental education. Before 1991, there were only 49 dental colleges, of which 23 (47%) were government owned. As of 2013, 246 new dental institutions recognized or approved by the DCI have been added to the existing list, of which almost all (229) are in the private sector [8,11]. Third, despite the consistent increase in dentists production, posts in public health sectors/government are still questionable.
43. 43. 5/4/2015 43 [Table/Fig-3] shows an inter-state inequality among public health dentists.
44. 44. As India strives to achieve universal health coverage, improvement in oral health care delivery with skilled and motivated dental health workforce is necessary. Human resource shortages hinder scale up of health services and limit the capacity to absorb additional financial resources [12]. A clear understanding of the dental health-workforce situation is very critical to develop effective policies. Strength: In the past two decades, there has been drastic progress in increasing the training capacity [13]. This review shows that key finding regarding workforce production is the increase in training capacity because of the growth in private sector involvement in dental education. This trend seems likely to increase, since incentives and regulation relaxations have been introduced to encourage private investment in dental education. 5/4/2015 44
45. 45. Weakness: The primary data used in this review are the numbers of dental health personnel registered with the Dental Council of India & Dental Public Health Association and therefore have several limitations. These councils do not maintain live registers, except for doctors in Delhi. The information they provide may be inaccurate owing to non adjustment for deaths, migrations and retirements, or double counting of workers registered in more than one state. Furthermore, not all state councils follow the same procedure for registration, which may compromise direct comparisons. In spite of these limitations, this review is an attempt to highlight some key issues that the Government of India and development partners should consider when addressing the health human resource crisis. There is gross inadequacy in availability of the current stock of dentists [13,14] & public health dentists and significant inequalities in their distribution between the different states. Poorly performing states, in terms of health outcomes, have a greater shortfall in the number of dentists. 5/4/2015 45
46. 46. Threats: 1. Privatization of dental education has helped to overcome the shortcomings resulting from inadequate expansion of the training capacity in the public sector, but also raised questions on the quality of dental training. An example was an initiative to standardize the quality of medical & dental education by MCIs decision to introduce a single National Eligibility and Entrance Test for undergraduate admissions at all government and private dental colleges. This test has not yet been implemented and there is scepticism as to how it might be transparently and fairly applied to the 800,000 students who would take the test each year [8,15]. 2. The gross inequality in the distribution of the training institutes among the different states. These institutes are primarily clustered in states with high GDPs, where the issues related to shortages of dentists are relatively less acute. 3. Increased mismatch between dentists production and job opportunity in government hospitals/public health sector. This finding suggests that increases in the production and overall supply of dental graduates will not necessarily address the public sector shortages. Other strategies will need to be introduced to encourage dental health workers to serve in the public sector. 5/4/2015 46
47. 47. 4. Immigration & migration of dentists, changing disease pattern & treatment needs along with numerous challenges for expanding oral health care in India. The biggest challenge is the need for dental health planners with relevant qualifications and training in public health dentistry. There is a serious lack of authentic and valid data for assessment of community demands, as well as the lack of an organized system for monitoring oral health care services need to guide planners [13]. 5/4/2015 47
48. 48. The most important resource of the country is its 1027 million population (2001 census), distributed in 28 States, 7 Union Territories, 5564, tehsils/talukas, 640,000 villages and 5161 towns and cities.14 India is predominantly rural, as over 72% of people continue to live in rural areas.15 Rural health infrastructure has been well designed to cover rural population through 136815 subcentres (SCs), 26952 Primary Health Centres (PHCs) and 3708 Community Health Centres (CHCs). Oral health care of necessity has to be delivered through primary health care infrastructure, because of limited resources and manpower of dentists. Though the country is producing 7000 dentists per annum, the dentist: population ratio is 1:30000, the distribution of dentist to population requirement is grossly uneven. More than 90% of doctors are available in urban settings and only 10% available to 72% of rural population.16,17 5/4/2015 48 NATIONAL ORAL HEALTH POLICY16
49. 49. National Oral Health Policy has been formulated by the "Dental Council of India", through the inputs of two national workshops organized way back in 1991 and 1994 at Delhi and Mysore respectively. These workshops considered the recommendations of national workshops on oral health goals for India, Bombay 1984 and a draft oral health policy prepared by Indian Dental Association in 1986. As a follow up measure of these efforts, the core committee appointed by Ministry of Health and Family Welfare, could succeed to move the resolution in fourth conference of Central Council of Health and Family Welfare in the year 1995. 5/4/2015 49
50. 50. 1. There is an urgent need for an Oral Health Policy for the nation as an integral part of the National Health Policy. 2. Special, well coordinated, National Oral Health Programme be launched to provide Oral Health Care, both in the rural as well as in urban areas due to deteriorating oral health conditions in the country as revealed by various epidemiological studies. Dentist/population ratio in the rural areas is only 1:300,000. Whereas, 80% of the children and 60% of the adults suffer from dental caries, more than 90% of adult community after the age of 30 years suffer from periodontal diseases which also has its inception in childhood. In addition, 35% of all body cancers are oral cancers. Large segment of the adult population is toothless due to the crippling nature of the dental diseases and about 35% of the children suffer from malaligned teeth and jaws affecting proper functioning. In view of these facts, it is important to launch preventive, curative and educational oral health care programme integrated into the existing system utilizing the existing health and educational infrastructure in the rural, urban and deprived areas. 5/4/2015 50 Ten points resolution has been brought out by the Councill7:
51. 51. 3. A post of full time Dental Advisor at appropriate level in the Dte.G.H.S. should be created as a first step towards strengthening the technical wing of the Dte.G.H.S. 4. Studies have revealed that dental diseases have been increasing both in prevalence and severity over the last few decades. There is, therefore, an urgent need to prevent the rising trend of dental diseases in India. The method used for primary prevention of dental diseases aims at achieving primary prevention of periodontal diseases and oral cancers. 5. The council, therefore, resolves that preventive and promotive Oral Health Services be introduced from the village level onwards and accordingly a pilot project on Oral Health Care may be launched by the Ministry of Health and Family Welfare during 1995-96 in five districts, one each in five States. 6. The Council further resolves that legislative measures be adopted to ensure a statutory warning on the wrappers and advertisement of sweets, chocolates and other retentive sugar eatables TOO MUCH EATING SWEETS MAY LEAD TO DECAY OF TOOTH. Similar measures are also called for tobacco and Pan Masala related products. 5/4/2015 51
52. 52. 7. The Council recommends that a National Training Centre be established or the existing centres be strengthened for training of various categories of oral health care personnel. 8. The Council also resolves that all District Hospitals and Community Health Centres have dental clinics. All Dental Colleges should have courses on Dental Hygienists and Dental Technicians. 9. The Council further resolves that the Pilot Project may be extended to all the States at the rate of one District in every State. 10. The Council also resolves that there is an urgent need to have a National Institute for Dental Research to guide oral health research appropriate to the needs of the country. 5/4/2015 52
53. 53. Fourth Conference of Central Council of Health & Family Welfare in October 1995, New Delhi resolved that: There is an urgent need for an Oral health Policy for the nation as an integral part of the National Oral Health Care Programme Health Policy. Special, well coordinated, National Oral Health Care Programme be launched to provide Oral Health Care, both in the rural as well as urban areas due to deteriorating oral health conditions in the country as revealed by various epidemiological studies. Dentists/population ratio in the rural areas is only 1:300,000 whereas 80% of the children and 60% of the adults suffer from dental caries, more than 90% of adult community after the age of 30 years suffer from periodontal diseases which also have its inception in childhood. In addition, 35% of all body cancers are oral cancers. Large segment of the adult population is toothless due to the crippling nature of the dental diseases and about 35% of the children suffer from mal-aligned teeth and jaws affecting proper function. In view of the above facts, it is important to launch preventive, curative and educational oral health care programmes integrated into the existing system utilizing the existing health and educational infrastructure in the rural, urban and deprived areas. 5/4/2015 53
54. 54. A post of full time Dental Advisor at appropriate level in the Dte. G.H.S. (Directorate General of Health Services) should be created as a first step towards strengthening the technical wing of the Dte.GHS in this regard. Studies have revealed that dental diseases have been increasing both in prevalence and severity over the last few decades. There is, therefore, an urgent need to prevent the rising dental diseases in India. The method used for primary prevention of dental diseases aims at achieving primary prevention of periodontal diseases and oral cancers. The Council, therefore, resolves that preventive and promotive Oral Health Services be introduced from the village level onwards and accordingly a pilot project on Oral Health Care may be launched by the Ministry of Health & Family Welfare during 1995-96 in five districts, one in each in five states. The Council further resolves that legislative measures be adopted to ensure a statutory warning on the wrappers and advertisement of sweets, chocolate and other retentive sugar eatables TOO MUCH EATING SWEETS MAY LEAD TO DECAY OF TOOTH. Similar measures are also called for tobacco and Pan Masala related products. 5/4/2015 54
55. 55. The Council recommends that a National Oral Health Care Programme Training Centre be established or the existing centres be strengthened for training of various categories of Oral Health Care Personnel. The Council also resolves that all District Hospitals and Community Health Centres have dental clinics. All Dental Colleges should have courses on Dental Hygienists and Dental Technicians. The Council further resolves that the Pilot Project may be extended to all the States at the rate of one District in every State. The Council resolves that there is an urgent need to have a National Oral Health Care Programme Institute for Dental Research to guide oral health research appropriate to the needs of the country. 5/4/2015 55
56. 56. For the purpose of Implementation, the Programme is divided into three phases, Developing the Implementation Strategies: During 1999-2000, four regional and two National Workshops were organized to sensitize the dental personnel in various parts of the country. The outcome of these workshops has been compiled in the form of Implementation Strategies. Training and Re-orientation of Dental Surgeons: In order to train the Health Workers at various levels and the Schoolteachers, the Dental Surgeons from various Govt. Hospitals, Training and Re-orientation Programmes are being conducted in pilot states. So that the Dental Surgeons can act as Master Trainers for the National Oral Health Care Programme. Till now 11, workshops for the master trainers have been conducted for Delhi, Assam, Meghalaya, Maharashtra, Punjab, Arunachal Pradesh, Manipur and Tripura states and Indian Railways. 5/4/2015 56
57. 57. Training of Health Workers: As a part of background material for training of health workers, an educative video film on oral health Kripaya Muskuraiye and pictorial training manual on oral health for health workers have been produced. Till now 13 training programmes in the Delhi, Meghalaya, Punjab, Maharashtra, Arunachal Pradesh, Manipur and Tripura have been conducted for the health workers and Schoolteachers. Apart from these, symposiums are conducted in various professional workshops and conferences to involve more and more Dental Professionals in the National Oral Health Care Programme. Till now, five symposia have been conducted in Delhi, Bhubaneshwar, Allahabad, Kochi and Vijaywada. The nodal agency conducts Free Oral health Camps for the lower socio-economic population at various places. Till now, about 43 oral health camps and awareness programmes have been organized under the aegis of National Oral Health Care Programme. 5/4/2015 57
58. 58. IEC Material Publication and Distribution Following IEC aids have been produced as a part of this programme and are distributed to various Govt. Organization, State Health Education Bureau, Dental Colleges, IDA Branches and NGOs for Oral Health Awareness programmes. 1. National Oral Health Care Programme: Implementation Strategies 2001 2. Training Manual on Oral Health for Health Workers in Hindi and English in the year 2001 3. Educative video film on Oral Health entitled Kripaya Muskuraiye in Hindi and English in the year 2002 4. Single Sheet colored Oral Health Information for Health Workers in Hindi for their Ready Reference in the year 2002 5. Training Manual on Oral Health for Schoolteachers in Hindi and English in the year 2003 6. Posters on Oral Health Dant fit to Life Hit series of four posters in English and Hindi in 2003. 7. Educative Poster Series of five posters for schoolchildren Swastha Muskan Aapka Vardan in Hindi and English in 2004. 5/4/2015 58
59. 59. B A R R I E R S I N O R A L H E A LT H P R O M O T I O N I N T H E C O U N T R Y During the implementation of the National Oral Health Care Programme in the pilot phase, it was perceived that most of the times our policymakers give oral health last priority. They are inadequately informed about burden of oro-dental problems and its connection with the systemic health and possibly minimal threat to human life due to oro-dental problems makes step motherly treatment for dental public health programmes. One of the major disadvantages is that in India, health is a state subject and most of the states in the country are suffering from financial burden even for subsistence rather than providing quality health care. Mostly the health care is looked after by the private sector and individual practices including non-formal medical facilities. However, the treatment cost for oral diseases is enormously expensive and it has not been possible for any Govt. setup to provide dental services to all. 5/4/2015 59
60. 60. Moreover, our country lacks experts in dental public health. The curriculum for graduation is outmoded with very little importance to prevention. The dental graduates are unable to perceive the importance of learning prevention of oro-dental problems for the community and they are not aware of their responsibilities towards the society. The internship programme is also underutilized by the dental colleges for services to the grass root level and dental health needs of our geriatric population are overlooked. We do not have organized school oral health education programmes so that children may learn right oral health practices from the beginning. Over and above fastest growing population, rapid westernization and lack of resources are increasing the burden of oral diseases in our country. Tobacco abuse is further causing menace for not only the poor and disadvantaged but also civilized population. Early initiation of tobacco habits in children is causing havoc in terms of morbidity and mortality of our younger generations. 5/4/2015 60
61. 61. N AT I O N A L O R A L H E A LT H C A R E P R O G R A M M E [ 2 0 ] National Oral Health Care Programme a project of DGHS and Ministry of Health & Family Welfare was initiated in 1998 with aim of providing oral health care in the country through organized primary prevention and strengthening of Oral health setup as per the recommendations made in National Oral Health Policy. Later on the Department of Dental Surgery, All India Institute of Medical Sciences was chosen as the nodal agency to implement it. 5/4/2015 61
62. 62. Ministry of Health and Family Welfare, Govt. of India accepted in principle National Oral Health Policy in the year 1995 to be included in National Health Policy. In pursuance to National Oral Health Policy 'National Oral Health Care Programme' has been launched as "Pilot Project" to cover five States (Delhi, Punjab, Maharashtra, Kerala and North eastern States) for its implementation. To begin with, one district in each of these States has been chosen to test run the strategies evolved through 2 national and 4 regional workshops organized in the country, to achieve the following goals20 : 1. Oral Health for all by the year 2010. 2. To bring down the incidence of oral and dental diseases to less than 40% from the existing prevalence of 90%. 3. To bring down the DMFT in school children between 6-12 years of age to less than 2 which is approximately 4 at present. 4. To reduce high prevalence of periodontal diseases to lower prevalence. 5. At the age of 18 years, 85% should retain all their teeth. 6. To achieve 50% reduction in edentulousness between the age of 35-44 years. 7. To achieve 25% reduction in edentulousness at the age of 65 years and above. 8. To achieve 50% reduction in the present level of malocclusion and dento-facial deformities. 9. To reduce the number of new cases of Oral Cancers and precancerous lesions from the existing levels. 5/4/2015 62
63. 63. ELEVENTH FIVE-YEAR PLAN (2007-2012)21 Time-Bound Goals for the Eleventh Five Year Plan: Reducing Maternal Mortality Ratio (MMR) to 1 per 1000 live births. Reducing Infant Mortality Rate (IMR) to 28 per 1000 live births. Reducing Total Fertility Rate (TFR) to 2.1. Providing clean drinking water for all by 2009 and ensuring no slip-backs. Reducing malnutrition among children of age group 03 to half its present level. Reducing anaemia among women and girls by 50%. Raising the sex ratio for age group 06 to 935 by 201112 and 950 by 201617. 5/4/2015 63
64. 64. Expected achievements and goals (oral health related) : Establishment of national,state & district oral health cells for proper monitoring, planning of dental public health, interventional measures and research activities. Strengthening manpower and infrastructure at PHC/CHC & district hospitals and providing basic oral health care to the rural population. To reduce the prevalence and incidence of oral diseases in the country. To reduce the mortality and morbidity of oral diseases. Early detection of oral cancer from stage 3&4 to stage 1&2. 5/4/2015 64
65. 65. 1 2 t h F I V E Y E A R P L A N (2012-2017)22 Core strategies (oral health related) : 1. Promote access to improved oral healthcare 2. At PHC level, either specially trained dental hygienist or staff nurse may deliver simple preventive, interceptive and curative oral health services (like pain relief, ART, early diagnosis of oral cancer and HIV/AIDS related oral lesions and their referral) in addition to giving oral health education. 3. Strengthening existing CHCs and formulation of Indian Public Health Standards, defining personnel, equipment and management standards for oral health care provision. Supplementary strategies: 1. Promotion of public private partnerships for achieving public health goals. 2. Reorienting dental education to support rural health issue. 5/4/2015 65
66. 66. H E A LT H C A R E AT P R I M A RY H E A LT H C E N T R E ( P H C ) 2 2 PHC is the first contact point between village community and the Medical Officer. The PHCs are established and maintained by the State Governments under the Minimum needs Programme (MNP)/ Basic Minimum Services Programme (BMS). They are established on the basis of national norm of one PHC for every 30,000 rural population in the plains, and one PHC for every 20,000 population in hilly, tribal and backward areas for more effective coverage. There are 22,370 PHCs functioning as on March 2007 in the country, achieving an average coverage of 33,191 population per PHC. At present, a PHC is manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub Centres. It has 4 -6 beds for patients. The functions of the primary health center include the 8 "essential" elements of primary health care including medical care, Maternal and Child Health (MCH) including family planning, safe water supply and basic sanitation, prevention and control of locally endemic diseases, collection and reporting of vital statistics, health education, National Health Programmes, referral services, training of village health workers and basic laboratory services. 5/4/2015 66
67. 67. Primary Health Centre is the cornerstone of rural health services- a first port of call to a qualified doctor of the public sector in rural areas for the sick and those who directly report or referred from Sub-Centres for curative, preventive and promotive health care. 5/4/2015 67
68. 68. With an average prevalence of dental caries of 50% in all the age groups, approximately 15,000 people in a catchment area of a PHC would require restorations/extractions. About 45% of adults (60% of the population) i.e. 8100 persons would require oral prophylaxis. As many as 7% of the population i.e. up to 2100 people may suffer from oral premalignant and malignant lesions. Oral health care with emphasis on preventive and promotive aspects needs to be provided at PHC level. This would include oral health education, tobacco cessation counseling, oral prophylaxis, and pain relief, early identification of oral precancer/ cancer and other common oral diseases and referral. Also, a minimally invasive procedure using hand instruments Atraumatic Restorative Technique (ART) may be carried out to restore carious teeth. 5/4/2015 68 O R A L H E A LT H C A R E AT P R I M A RY H E A LT H C E N T R E ( P H C ) 2 2
69. 69. These services can be provided by an extended-duty dental hygienist. Till the time enough number of extended-duty hygienist can be produced, these services can be provided by trained nurses. Also, adoption of suitable number of PHCs (minimum 3) by each dental institution for carrying out oral health education and screening should be made mandatory. Existing PHCs need to be upgraded with respect to equipments and materials for carrying out the above procedures. The monitoring and evaluation would include process indicators such as percentage of PHCs with dental hygienist/ trained nurse and dental equipments. Outcome indicators such as number of times IEC activity and oral prophylaxis performed in a given time-period and number of referred dental patients/ dental hygienist need to be evaluated. This would require maintenance of records and its monthly submission to District HQ. Annual survey of oral health knowledge, attitude, practices and oral hygiene status of the catchment area would be useful impact indicators. 5/4/2015 69
70. 70. Service Delivery23: From Service delivery angle, PHCs may be of two types, depending upon the delivery case load Type A PHC: PHC with delivery load of less than 20 deliveries in a month, Type B PHC: PHC with delivery load of 20 or more deliveries in a month. All Minimum Assured Services or Essential Services as envisaged in the PHC should be available. The services which are indicated as desirable are for the purpose that we should aspire to achieve for this level of facility. Appropriate guidelines for each National Programme for management of routine and emergency cases are being provided to the PHC. 5/4/2015 70
71. 71. 5/4/2015 71 Dental health care services are not provided at PHC level
72. 72. I N D I A N P U B L I C H E A LT H S TA N D A R D S F O R C O M M U N I T Y H E A LT H C E N T R E S [ 2 2 , 2 4 ] The Community Health Centres (CHCs) constitute the secondary level of health care, were designed to provide referral as well as specialist health care to the rural population. Indian Public Health Standards (IPHS) for CHCs have been prescribed under National Rural Health Mission (NRHM) since early 2007 to provide optimal specialized care to the community and achieve and maintain an acceptable standard of quality of care. CHCs are being established and maintained by the State Government under MNP/BMS programme. Each CHC covers a population of 80,000 - 1.20 lakh population (one in each community development block). As on March 2007, there are 4045 CHCs functioning in the country. It is manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. 5/4/2015 72
73. 73. One anesthetist and one Medical Health Administrator are also employed on contractual basis. Recently, an Opthalmic surgeon has been added at CHC level. It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. Unfortunately, dental care has not been included under the Assured Services to be provided at CHC. However, if the oral disease burden of the population served at CHC is considered, it is tremendous. 5/4/2015 73
74. 74. O R A L H E A LT H C A R E AT C O M M U N I T Y H E A LT H C E N T R E ( C H C ) 2 2 With an average prevalence of dental caries of 50% and average DMFT of 1 in children (34% of population), 40,800 restorations would be required. With an average prevalence of dental caries of 50% and average DMFT of 3 in adults (60% of population), 2,16,000 restorations would be required. 28,800 children would require preventive therapy in the form of fluoride varnish and pit and fissure sealing, if provided to children up to 9 years of age (24%). About 45% of adults (60% of the population) i.e. 32,400 persons would require oral prophylaxis. 30% of geriatric population (8% of the population) i.e. 2880 persons would require prosthetic care. As many as 7% of the population i.e. up to 8400 people may suffer from oral premalignant and malignant lesions. 5/4/2015 74
75. 75. Therefore, there is a need to provide routine an emergency care in dental surgery at CHC level. This would include oral health education and School Health Education Programme as an outreach activity, identification of oral pre cancer/cancer and other common oral diseases, oral prophylaxis, dental extractions, biopsy of oral lesions, restorations and application of topical fluorides. 1 dental surgeon along with 1 chair-side assistant is a necessary requirement to provide the above mentioned services. Also, public-private partnership should be considered for providing removable prosthesis. 5/4/2015 75
76. 76. Service Delivery : Unlike Sub-centre and PHCs, CHCs have been envisaged as only one type and will act both as Block level health administrative unit and gatekeeper for referrals to higher level of facilities. The revised IPHS (CHC) has considered the services, infrastructure, manpower, equipment and drugs in two categories of Essential (minimum assured services) and Desirable (the ideal level services which the states and UT shall try to achieve). All essential services as envisaged in the CHC should be made available, which includes routine and emergency care in Surgery, Medicine, Obstetrics and Gynaecology, Paediatrics, Dental and AYUSH in addition to all the National Health Programmes. 5/4/2015 76
77. 77. Standards of services under existing programmes were updated and standards added for newly developed non communicable disease programmes based on the inputs from various programme divisions. Standards for Newborn stabilization unit, MTP facilities for second trimester pregnancy(desirable), The Integrated Counselling and Testing Centre (ICTC), Blood storage and link Anti Retroviral Therapy centre have been added. 5/4/2015 77
78. 78. 5/4/2015 78
79. 79. 5/4/2015 79 Basic Dental health Care Services are delivered at the CHC level
80. 80. 5/4/2015 80
81. 81. C O M M U N I T Y H E A LT H C E N T E R 5/4/2015 81
82. 82. L I S T O F E Q U I P M E N T S ( D I S T R I C T H O S P I TA L ) [ 2 2 ] 5/4/2015 82 S. No Item 1. Electrically Operated Fully Programmable Dental Chair 2. Autoclave 3. Storage Cabinet 4. Dental X-ray Unit with Day-light Manual Developer 5. Panoramic with Cephalomatric X-ray unit 6. Electro Cautery Unit 7. Digital Pulp Tester 8. Digital Apex Locator 9. Surgical Micromotor
83. 83. S U B - D I S T R I C T H O S P I TA L / C H C S.No. Item 1. Electrically Operated Fully Programmable Dental Chair 2. Autoclave 3. Storage Cabinet 4. Dental X-ray Unit with Day-light Manual Developer 5. Electro Cautery Unit 6. Surgical Micromotor 5/4/2015 83
84. 84. P H C ( if dental surgeon is appointed at phc as per recommendation) S.No. Item 1. Electrically Operated Fully Programmable Dental Chair 2. Autoclave 3. Storage Cabinet 4. Dental X-ray Unit with Day-light Manual Developer 5. Electro Cautery Unit 5/4/2015 84
85. 85. S M I L E T R A I N [ 2 5 ] Every year 35,000 children in India are born with clefts. Without corrective surgery, these children are condemned to a lifetime of isolation and suffering. The tragedy is that a cleft can be completely corrected with a simple surgical procedure that could take as little as 45 minutes and is TOTALLY FREE! Since 2000 Smile Train has sponsored over 450,000 surgeries across India. But there are still an estimated 10 lakh untreated cases of clefts in India. The goal of Smile Train is to continue providing cleft surgeries across India until we have completely eradicated the problem of clefts. 5/4/2015 85
86. 86. 5/4/2015 86 provided free cleft surgery for more than 1,000,000 children in thirteen years. provide free surgery for more than 300 children every day. provided free education and training for more than 20,000 medical professionals. Smile Train offers the following funding opportunities: Treatment Partnerships Treatment Grants Education & Training Grants
87. 87. F U N D I N G P R I N C I P L E S Smile Train funds hundreds of programs throughout the world dedicated to helping poor children with cleft lip and palate and improving the safety and quality of cleft care. General guidelines for funding: Smile Train funds programs and projects that focus exclusively on helping children with cleft lip and palate. funds treatment for poor children in developing countries through partnerships with local medical professionals, hospitals and organizations. Smile Train does not fund treatment missions unless there is no other source of treatment within the country. Smile Train funds programs that help the maximum number of children for the minimum amount of money. Smile train dont fund large capital expenses such as construction or maintenance of facilities or major equipment expenditures. Smile Train funds should not replace any other existing funding source. 5/4/2015 87
88. 88. PA RT N E R S H I P P R O G R A M S Treatment Partnerships: Smile Train has provided free cleft surgery and related treatment for more than 1,000,000 children around the world. All of these surgeries are performed by local doctors that Smile Train has empowered through various partnerships and grants. Treatment Partnerships involve an on-going relationship with Smile Train and require a long- term commitment providing free surgical treatment for children with cleft who would not otherwise be helped. Treatment Partnerships significantly increase the number of cleft surgeries performed at a qualified hospital/center. The Treatment Partner must meet and adhere to The Smile Train Safety and Quality Improvement Protocol. Treatment Partners are reimbursed based on the number of patients treated. All Treatment Partners are required to participate in Smile Train Express, an online patient record-keeping database. 5/4/2015 88
89. 89. Treatment Grants: Treatment Grants are one-time grants for medical professionals, hospitals, and organizations that provide treatment for poor children with clefts in developing countries, but who may not meet the requirements to become a treatment partner. These grants are designed to supplement care for children who would not otherwise receive help through free treatment (i.e. surgery, orthodontia, speech therapy), improving the quality of treatment or providing for related expenses such as equipment, outreach programs, and patient travel. The grants may also be designated for a specific project or need that help poor children with cleft lip and palate. Education and Training Grants: Smile Train programs come in all shapes and sizes, but the objective of every one is the same: to help the local medical community become self-sufficient. With the proper education and training, surgeons and nurses in developing countries are empowered to deliver excellent treatment and care. They are our best hope of helping the millions of children who need it. 5/4/2015 89
90. 90. Smile Train provides Education and Training Grants for doctors, hospitals and medical schools to develop and deliver advanced in-country cleft lip and palate teaching and education programs. These programs are made available to doctors, nurses, and medical professionals who could not otherwise afford them. Education and Training Grants are designed to improve the safety and quality of cleft care performed by existing cleft care professionals. They are designed to support in-country training and education, not U.S. based training. Education and Training sponsored by Smile Train should lead to improved treatment for poor children. The grants are not intended for funding individual travel needs to conferences and symposiums. Training grant applicants are chosen in accordance with their medical education, experience and ability. 5/4/2015 90
91. 91. C O N C L U S I O N It seems it is important to act now to strengthen dental health policy and planning. Up-to-date oral health data are rarely available at national level. A national oral health policy developed as a result of the processes will be both new and innovative, with the best chance of making real, sustainable improvements in the oral health of the population. A national dental health policy must ensure there is an effective monitoring system in place so you can recognize problems as they occur and find solutions for them. To provide adequate, respectable, and attractive Employment opportunities to the workforce while maintaining a balanced geographical distribution is the main challenge and the root of all the issues facing the dental profession in India. To cope with number of dentists graduating each year will require a massive infrastructure, a factor that requires the very urgent attention. This vicious cycle has to be stopped to get at the root of the problem and begin providing sufficient employment opportunities in an equitable manner. Effects of dental health burden induce health inequality on health of a society are profound. In a large, overpopulated country like India with its complex social structure and economic extremes, the effect of inequity on health system is multifold. 5/4/2015 91
92. 92. Unequal distribution of resources is a reflection of this inequality and adversely affects the health of underprivileged population. The socially underprivileged population groups are unable to access the oral healthcare due to geographical, social, economic or gender related distances. 5/4/2015 92
93. 93. B I B L I O G R A P H Y 1. Oxford English dictionary;2010; 3rd edition; Oxford University Press. 2. Michael Rundell, Macmillan English dictionary;2007; 2nd Edition; Macmillan education Publishers. 3. Stephanie Meyer; Collins English dictionary; 2009; Special edition; Collins Publisher. 4. Thomas H. Patten, Jr. Manpower planning and the development of human resources. 1971 Wiley-Interscience 5. Edwin B. Flippo. Principles of personnel management. 1976; 4 edition; McGraw-Hill. 6. Cynthia pine and Rebecca Harris, Community oral health- 2nd edition, Quintessence publishing co. ltd, 2007 7. Soben Peter. Essentials of preventive and community dentistry; fourth edition; 2011:412- 420. 8. Indrajit Hazarika. Health workforce in India: assessment of availability, production and distribution. WHO South-East Asia Journal of Public Health.2013;2(2):106-12 9. World Health Organization. The world health report 2006 Working together for health. Geneva, World Health Organization. 2006. 10. Mythri Halappa, NaveenB H et al; SWOT Analysis of Dental Health Workforce in India: A Dental alarm. Journal of Clinical and Diagnostic Research. 2014;8(11):3-5 11. Dental Council of India. Available from: http://www.dciindia.org/ 12. Anand S, Brnighausen T. Human resources and health outcomes: cross country econometric study. Lancet. 2004;364:1603-09. 5/4/2015 93
94. 94. 13. Shobha T. Challenges to the Oral Health Workforce in India. J Dent Edu. 2004;68(7):28- 33. 14. Ashish Bose. Health for the millions, Population Scan, First results of census of India, 2001, March-April 2001. 15. Bulletin on Rural Health Statistics in India March-2003. Issued by infrastructure division, Deptt. of FamilyWelfare, MOH&FW Nirman Bhavan New Delhi. 16. National Oral Health Policy: Prepared by core committee, appointed by the Ministry of Health and Family Welfare, 1995. 17. Fourth conference of Central Council of Health and Family Welfare - Proceedings and resolutions. October 11-13,1995 New Delhi. Bureau of planning, Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India, New Delhi. 18. Ramandeep SG, Prabhleen B,et al. Utilization of dental care: An Indian outlook. J Nat Sci Biol Med. 2013;4(2):29297. 5/4/2015 94
95. 95. 19. Khader seeks dentists help in implementing dental policy. The Hindu. Available fromhttp://www.thehindu.com/todays-paper/tp-national/tp-karnataka/khader-seeks-dentists- help-in-implementing-dental-policy/article5701403.ece 20. National oral health care programme implementation strategies, DGHS, MOH&FW. Govt. of India. Prepared by Dr. Hari Parkash, Project Director, Dr. Naseem Shah, Addl. Project Director, Department of Dental Surgery. AIIMS, Ansari Nagar, New Delhi. 21. Report of working group on communicable and non-communicable diseases for the 11th five year plan. September 2006 22. Prevention and control of non-communicable diseases, proposal for the 12th five year plan,2011 23. Indian Public Health Standards (IPHS) Guidelines for Primary Health Centres Revised 2012 24. Indian Public Health Standards (IPHS) Guidelines for Community Health Centres Revised 2012 25. http://www.smiletrainindia.org/ 5/4/2015 95
96. 96. 5/4/2015 96 Sometimes people just need to sleep!! ..Thanks anyways!