Challenges facing improving
Oral Health
in Chile
Camila Ávila - Andrea Moller - Javiera Nazal - Renato Venturelli
Introduction
Chilean Health System
Private Sector
Public Sector
ISAPRE
FONASA
20%
80%
Health provider institution
National Health Fund
Ministry of
Health
Gattini and Alvarez, 2011.
Chile’s commitment
• The government of ex-president Ricardo Lagos adopted
the strategies proposed by WHO in the Commission of
Social Determinants of Health.
• The government accepts that social determinants are
significant causes of health outcomes.
• They propose an intersectoral approach in its national
health policy. That emphasizes the need to embrace all
key sectors of society, not just the health sector.
(World Conference on Social Determinants of Health, Rio de Janeiro, 2011)
Encouraging policies
•Banning tobacco (tobacco
law)
•Taxing soft drinks
•Taxing alcohol
UPSTREAM / HEALTHY PUBLIC POLICY
Encouraging policies
•Food guidance for nurseries
and public schools
MIDSTREAM / SUPPORTIVE ENVIRONMENT
“Give every child the best start in life”
Encouraging policies
•Fluoride varnish for preschool children
•“Chile grows with you”
(2007)
DOWNSTREAM / REORIENTATION OF HEALTH SERVICES
“Give every child the best start in life”
Current dental issues:
• Centralization of policy making
• Poor dental workforce planning
• GES programme
• High caries rates and high rates of
untreated caries
• Health surveys
Current dental issues:
•Centralization of policy
making
•Poor dental workforce
planning
•GES programme
•High caries rates and high rates
of untreated caries
•Health surveys
Centralization
Most dentists
work in Santiago
Few dental
specialists in
rural areas and
remote cities
Most decisions
taken in Santiago
No local oral
health needs
assessment
Decentralization
• More decision making in regions
• Local dental needs assessment
Current issues:
• Centralization of policy making
•Poor dental workforce
planning
• GES programme
• High caries rates and high
rates of untreated caries
• Health surveys
Dental Workforce: Problems
•CHILE: 39 Schools of Dentistry
- 2012: 1 dentist every 1.023 inhabitants
- 2016: 1 dentist every 630 inhabitants
WHO RECOMMENDATION
1 dentist every 2000
inhabitants
•Dentists mainly in private practices
•No mandatory accreditation
•Focus: Treatment not prevention.
•No regulation for immigrant dentists
Monsalves 2012 - WHO, 2013 - Cartes-Velasquez 2013
Dental Workforce: Problem. Uncontrolled
increase of dental schools
1997:
5 dental schools
2011: 34 dental schools
Number of private and traditional dental schools in Chile, 1997-2011
Cartes-Velásquez 2013
Dental Workforce: Problem. Uncontrolled
increase of dental schools
2012: 17.000 dentists
2025: 42.500 dentists
Projection of dental workforce and ratio of inhabitants per dentist
in Chile 2012-2025
Cartes-Velasquez 2013
Dental Workforce: Recommendations
•Restrict number of dental schools and ensure accreditation
• National examination
•Training and strengthening professionals: WHO guidelines
and recommendations
•Promote work in public sector and remote areas: improve
work conditions
Cartes-Velasquez 2013 - WHO 2013 - WHO 2014
Dental Workforce: Recommendations
WHO GUIDELINES
 Training
 Inter Professional Education
 Integrated work
Current issues
• Centralization of policy making
• Poor dental workforce planning
• GES programme
• High caries rates and high rates of
untreated caries
• Health surveys
GES: What is it?
Explicit Health Guarantees
• Benefits guaranteed by law.
• Good effort to improve Health
• Dental Area: Includes 5 Guarantees
• Not universal benefits
Cartes-Velasquez 2013 - Monsalves 2012
GES: Problems
Inequalities in access: visits to
dentists by income
% visits to dentists
Income quintile
Equity line
6-18 years
Elderly adults
< 5 years
Adults
Frenz et al. 2013
GES: Recommendations
 Ensure universal health coverage in oral health.
o Proportionate universalism according to level of
disease by age group and SEP
 Shift of health system: Treatment  Prevention
Monsalves 2012 - Sen 2013 - WHO 2013
Current issues
• Centralization of policy making
• Poor dental workforce
planning
• GES programme
•High caries rates and
high rates of untreated
caries
• Health surveys
dmft by age
4
3.5
3
dmft
2.5
2
dmft
1.5
1
0.5
0
2
4
Age
6
Ministry of Health, 2010. Diagnóstico de Situación de Salud Bucal (Oral Health Status Diagnosis). , pp.1–15.
DMFT by age group
25
DMFT
20
15
DMFT
10
5
0
6
12
35-44
65-74
Age Groups
Urzua, I. et al., 2012. Dental caries prevalence and tooth loss in chilean adult population: First national dental
examination survey. International Journal of Dentistry, 2012, pp.1–6.
Oral Health Status by Socioeconomic
Status
Index
Age
High SES
Middle SES
Low SES
Caries free
6
59%
28%
22%
12
68%
36%
29%
dmft
6
1.35
3.59
4.41
DMFT
12
0.66
1.96
2.22
MINSAL, Soto L, Tapia R y col. Diagnóstico Nacional de Salud Bucal de los niños de 6 años. Chile, 2007. Soto L, Tapia R y col.
Chile, 2007. Diagnóstico Nacional de Salud Bucal del Adolescente de 12 años y Evaluación del Grado de Cumplimiento de los
Objetivos Sanitarios de Salud Bucal 2000-2010. Chile 2007
Current policies
Ignores the
adult
population
Prevention
and
promotion
based on
education
Main focus on
treatment
Only
population
based policy:
water
fluoridation
Recommendations
Population
based
strategies
Common risk
factor approach
•Sugar control
policies
Fluoride policies
•Subsidies for
affordable fluoride
toothpaste
Individual
approach
Deal with
current caries
levels in ALL age
groups
Current issues:
• Centralization of policy making
• Poor dental workforce
planning
• GES programme
• High caries rates and high
rates of untreated caries
•Health surveys
Health surveys
2003
• Clinical data:
•Caries
•Periodontal diseases
•Edentulism
•Dental abnormalities
• Poor Quality of Life
Assessment
2009 – 2010
• No Clinical data: Only
General Questions
• Poor Quality of life
assessment
Health surveys: Recommendations
 Implementig a national oral health survey:
Adult/children using a sociodental approach to assess
treatment needs
 Include quality of life assessment: OHIP-14/OIDP
questionnares
 Include health behaviour measures
Future challenges for the dental profession
1.
Reduce levels of dental caries and oral health inequalities.
2.
Reorient public health practices and policy towards a social
determinants model.
3.
Health interventions with a population strategy, creation of
supportive environments and strengthening community action
that address the social determinants of health will decrease
inequalities in health and oral health.
Future challenges for the dental profession
4.
Integration of health and oral professionals into preventive and
promotional activities in non-health sectors.
5.
Adopt an integrated Common Risk Factor Approach and work closely
with other health professionals
6.
Increase resources for data collection and analysis on social
determinants for further actions.
7.
Control the number of dental schools being opened and the number
of dentists being trained.
“Don’t just mop the floor. Turn the tap off”
Burkitt DP. McCarrison Society Newsletter; 1989