Dental manpower planning in India: current scenario and future projections for the year 2020

Abstract

Dental manpower issues in India are discussed in this article which consists of both qualitative and quantitative research. The output of qualified dentists has increased substantially over last decade and at present there are over 117,825 dentists working in India. Although India has a dentist to population ratio of 1:10,271, the newly graduating dentists find it difficult to survive in the private sector. At present less than approximately 5% graduated dentists are working in the Government sector. If the present situation continues there will be more than one lakh dentists over supply by the year 2020. Continuation of the current situation will lead to wastage of highly trained dental manpower and create a threat to the professional integrity of the dentists. This research highlights the fact that there is an urgent need for an organised national human resource planning system to control the supply and demand of dental manpower, to ensure a uniform distribution of manpower and to give future directions to policy makers.

INTRODUCTION

India is the second most populous nation in the world with 1.2 billion population¹. Its health-care delivery system consists of both public and private health-care setups. In India, health is mostly a state issue and different states have different health-care agendas. Public health-care has been organised into primary health-care provided by primary health-care centres, secondary care by community health centres and tertiary care by referral and super specialty hospitals². Dental health-care is not integrated with general health-care in most of the public health-care setups. Dental care is not provided at primary health-care level; it is provided to some extent at secondary level but mostly at tertiary care centres. Most of the public dental health-care setups are poorly equipped, under-staffed and dental care is not a priority in budgetary allocations; all these factors force people to seek dental care at private setups³.

Until 1980, health-care workers were trained in government institutions; no private institutions existed and dental education was free for all students. Dentists were in short supply in India and in the early 1980s, policy makers realised that Government institutions were not enough to bridge this gap and could not invest heavily in training dentists. As a result, plans were implemented to increase the annual output of dentists by encouraging new dental colleges in the private sector. Currently, India’s dentist to population ratio is 1:10,271 which is more than many developed nations and few developing nations⁴, and India is the second largest producer of dental graduates with more than 24,000 new dental graduates adding to the existing numbers of dentists⁵. However, many recent reports described increased unemployment for new dental graduates⁶. Whether this current situation will create an oversupply or undersupply in the next 10 years is still unknown.

The current scenario in India may be similar to that faced by the UK and other European countries in the late 1970s and 1980s, when many dental schools took measures to curtail the number of new students and to close some dental schools to counter an overproduction of dentists⁷.

In India over the last 25 years, the dental workforce has grown in the absence of any specific design or policy planning, resulting in an oversupply of dentists. No research has been done to assess the impact of these increases in the dental workforce on the dental-care delivery system and on the oral health status of Indians. At present there is neither dental workforce planning at state or national level nor coordination between the Dental Council of India (regulatory body) and the Departments of Health and Human resources (the main employers) for dental manpower. The purpose of this study is to estimate the need for dentists in India using various manpower assessment models which would help decision-makers and policy-makers in India to plan scientifically for dental manpower training and utilisation.

MATERIALS AND METHODS

Data source

This study is a historical cross sectional study. All data used in this study were collected from the following sources:

• •A cross-sectional study with national pathfinder survey methodology was conducted with a sample size of 3,695 to collect unavailable data (i.e. demand for dental care, effective demand for dental care, etc.)
• •Epidemiological data/normative need related to oral diseases were obtained from the National Oral Health Survey⁸ and the cross-sectional study above
• •Demand for dental care was assessed from a the cross-sectional study above
• •Population parameters’ were taken from the National Census Report 2011¹.

Method of estimation: figures, assumptions and justifications

In order to forecast the future needs of dentists in India, different scenarios were tested based on the following factors:

• •The oral health status of the population
• •The percentage of the population to be covered by dental services
• •The annual working time of dentists
• •The period of replacement of dental restorations and prostheses.

Oral health status

An estimate of the future oral health status of the population was based on the following assumptions:

• •Caries treatment: the national oral health survey and Fluoride mapping performed in 2002–2003 showed that the mean decayed, missing and filled teeth (DMFT) index at 12-year and 15-year age-groups was 1.7, which is similar to the figures from the WHO/FDI methodology for developing countries9., 10.. In the absence of any preventive strategy, it can be assumed that the DMFT index for all ages would not vary in the years following the study. In the absence of data on the DMFT index for the 30- to 64-year-old cohort, values were estimated by extrapolating the theoretical curve for each level9., 10., 11.
• •In assessing the preventive, special care, surgical, orthodontic and periodontal treatment need, values were taken from WHO/FDI methodology, because the prevalences of these conditions as per National Oral Health survey and Fluoride mapping 2002–2003 were similar to assumptions made in WHO/FDI
• •Prostheses calculation: the prosthetic need for 35–44-year and 65–74-year age-groups were 29.8% and 65%, respectively, which are again similar to the values given in WHO/FDI methodology.

Percentage of the population to be covered by dental services

The percentage of the population requiring dental treatment (normative need), percentage of population demand dental treatment and effective demand among the general population of India was derived from the findings of our cross-sectional study. Table 1 shows the results the demand for and effective demand for care for different age cohorts.

Table 1.

Comparison of percentage of patient demand and effective demand for dental care per age cohort

Age group	Demand (% of patients)	Effective demand (% of patients)
0–14	50	12
15–29	50	21
30–64	30	23
65–79%	10	08

Annual working time of dentists

Data derived from the cross-sectional study revealed that the average dentist in India works 7 hours a day, 290 days a year (2030 hours/year). Except for a very few dental hygienists, no other operative dental auxiliaries are currently working in India and an assumption applied for this study is that all dental treatments are provided only by qualified dentists.

Method of estimation: WHO/FDI technique

In this technique, the projected population was divided into five age groups which were 0–5, 6–14, 15–29, 30–59 and 60 years and over. The dental service need was calculated on the basis of a lifetime of care for each age cohort. The service need also included the need for maintenance care, repeated care and replacement care.

Estimation of health personnel requirements

Two estimations of the dental health personnel requirements were done. In the first estimation, calculations were made using demand for services by different age cohorts and in the second calculation effective demand for service was used.

The calculation of dental health personnel requirement in this method was based on the need for services. The prevalence of dental diseases in each age group was calculated from the trend of the diseases, which was previously obtained from the National Oral Health Survey and the cross-sectional study. The prevalence of the diseases in the target year was converted to service needs, and the service needs were further converted to personnel requirements using the productivity norms.

The personnel requirement was also calculated from the demand for service, which was the actual number of services that the patient demanded. The percentage of the demand for service was first estimated from the cross-sectional study. The demand for service of each age group was calculated in this manner and the personnel requirements were calculated from these numbers. The procedure followed the second calculation (Table 2), which was similar to first calculation except for the use of effective demand in the place of demand for services.

Table 2.

Dentist to population ratio and minutes of treatment required based on patients effective demand

Cohort	% Demand	Minutes required	Minutes of demand × Cohort% of population	Minutes per person
0–14	22	21.2	4.73 × 36	(170 + 249 + 213 + 24)/100 = 6.5 minutes per person 1:18,738 in a 2030-hour year
15–29	41	19.5	7.8 × 32
30–64	33	25.0	8.2 × 26
65–79	08	52.3	4 × 6

All the procedures followed in this study were carried out in accordance with World Medical Association Declaration of Helsinki. The Drs SNR Siddhartha Institute of Dental Sciences Institutional Review board approved the study protocol and all participants provided informed written consent and for children parental/guardian consent as obtained in addition to their own verbal consent.

RESULTS

According to WHO recommended dentist to population ratio for developing countries (1:7,500), the number of dentists required for current Indian population is 161,359.

Table 3 gives the percentages of age cohorts among the Indian population and shows that nearly two-thirds of the Indian population are below the age of 30 years.

Table 3.

Percentage of age cohorts among Indian population¹

Age group	%
0–14	36
15–29	32
30–64	26
65–79%	6
Total population = 1,210,193,422

Tables 2 and 4 show the dentist to population ratio and minutes of treatment required according to different scenarios of patient demand and effective demand.

Table 4.

Dentist population ratio and minutes of treatment required based on patient demand

Cohort	% Demand	Minutes required	Minutes of demand × cohort% of population	Minutes per person
0–14	50	21.2	10.7 × 36	(385.2 + 310 + 195 + 31.2)/100 = 9.2 minutes per person 1:13,239 in a 2030-hour year
15–29	50	19.5	9.7 × 32
30–64	35	25.0	7.5 × 26
65–79	10	52.3	5.2 × 6

Table 4 shows the requirements according to treatment needs and demand-weighted needs. The requirements calculated from the demand for treatment in the age groups 0–14 years, 15–29 years, 30–64 years and 65–79 years are 50%, 50%, 35% and 10%, respectively, of the requirement calculated from the treatment need.

The results of this calculation show that the average minutes (of care) required per person was 9.2, the dentist population ratio was 1:13,239 in a 2030 hour year and the total number of dentists required will be 91,411.

The results of manpower requirements based on effective demand of patients are presented in Table 2. The effective demand for various age groups were 22% for the 0–14-year age group, 41% for the 15–29-year age group, 33% for the 30–64-year age group and 08% for the 65–79-year age group. According to this calculation, the average minutes (of care) required per person was 6.5, the dentist population ratio was 1:18,738 in a 2030 hour year and the total number of dentists required will be 64,592.

Current situation and future projection of the number of dentists

There were 47,204 dentists in India in 2001. According to the Dental Council of India, the total number of dentists registered by the end of 2011 was 117,825⁴ and the dentist to population ratio was 1:10,271.

The current number of new dentists graduating per year in India is approximately 24,000. In the absence of any new health strategy or policy, we can assume that the behaviour of patients and dentists within their profession will not change. Assuming a 2% loss of manpower from practice, the total number of dentists available by 2020 will be more than 309,700 for a population of 1,326,093,000 and there will be an overproduction of 100,000 of qualified dentists.

DISCUSSION

Table 5 shows the comparison between supply and requirement of dentists in the year 2020. The requirement in this Table is obtained via the FDI/WHO technique. Although India has a limited number of dental hygienists and other dental auxiliaries, the country does not have school dental nurses. The small number of dental auxiliaries is directly reflective of the large number of active dental practitioners.

Table 5.

Supply and requirements of dentists

Year	Indian population	Supply	Requirement
			Population ratio (1:7,500)	WHO/FDI method using demand for care	WHO/FDI method using effective demand for care
2001		47,204	–	–	–
2011	1,210,193,422	117,825	161,359	91,411	64,592
2020	1,326,093,000	309,700	176,812	–	–

WHO, World Health Organisation; FDI, International Federation for Dentistry.

The FDI/WHO technique also has some disadvantages. The technique is rather complicated and requires many assumptions. Most of these assumptions are still not well studied: for example, this technique uses artificial age-cohorts to calculate the need for services. However, the actual utilisation rate of dental-care services is far less than the percentage demand used in WHO/FDI method. Therefore this technique may well overestimate the personnel requirement in the target year¹⁰. The findings of our study suggest that there is a huge gap between the demand for dental service and effective demand for dental service. For example, the estimation for personnel requirement using effective demand gave a ratio of 1:18,738, while the requirement was 1:13,239 when just demand was used in calculations.

After graduation, dentists are able to choose the area in the country in which they will practise, so distribution depends entirely on their preference. For this reason, there is an uneven distribution of dentists resulting in inequalities in dental care across India. Most dentists prefer to practise in urban areas with high standards of living; hence, with 70% of the dentists practising in the cities, only 30% are providing care for the semi-urban and rural of the population⁴. Again, within in the India there are also an excess number of dentists in few states such as Karnataka, Kerala where, contrary to national estimates (1:10,271), the dentist to population ratios are 1:2,130 and 1:3,388, respectively.

In the next 10 years, there will be a huge oversupply of dentists; the country will have more than 100,000 dentists’ surplus. Moreover, the growth in numbers of dentists in India exceeds more than three times the population growth rate. Even if India joins the category of developed countries by 2020, where the recommended dentist to population ratio is 1:5,000, the total number of dentists required will be 265,218 and still there will be an oversupply of more than 50,000 dentists.

The reasons for such excess supply of dentists are poor (no) manpower planning, reliance on faulty statistics, mushrooming of dental colleges and inefficient regulatory bodies. Policy makers in India quote different statistics in different scenarios: on one hand policy makers say India is a developing country and on the other hand they quote the WHO recommended dentist to population ratio for highly developed countries for India and conclude their statement that there is a shortage of dental manpower. For example, the dentist to population ratio mentioned in a report by Central Bureau of Health Intelligence was 1:10,271 in 2011⁴ and in the same year the chairman for the planning commission of India made a statement that ‘currently India has shortage of two hundred thousand dentists’¹².The total number of dentists in India in 2011, as stated in the Central Bureau of Health Intelligence report, was 117,825; however, this is highly questionable because approximately 90,000 registered dentists were present in four states (Andhra Pradesh, Karnataka, Tamilnadu and Kerala), as per the respective state dental registries, and it is hard to believe that remaining 26 states had only 27,825.

The three estimations (Table 5) used in the requirements projection give different results in the requirements for manpower as their underlying concepts are different. However, there is a question of what ratio should be used in order to give the best estimate of personnel requirements for India. In this respect, it is worth mentioning the concepts of shortage. Normative shortage refers to the quantity of services effectively demanded, and if it is less than that required to bring the health of the population up to a professionally derived standard of health; market shortage implies that the quantity of dental services supplied is less than that effectively demanded¹³. Normative shortage is need-based manpower estimation, which is an expensive and unrealistic approach that is not suited for any population unless health care is provided free of cost to the whole population, and market shortage is a demand-based estimation and cannot identify underserved populations¹³. If need-based manpower estimation is to be considered for the Indian scenario, the question here is who is going to pay for dental care for underserved populations in a country such as India where more than 95% of dental care is provided at private set-ups with fees for service as the major payment mechanism involved.

Population-to-provider ratios have been, and continue to be, the most widely used means of identifying health professional shortages, both in India and abroad, because it is extremely easy to compute, data are readily available and ratios exist for nearly every country and have existed for decades. However, when this statistic is used to evaluate the ability of existing oral health-care resources to meet patient needs, it is being used in error13., 14..

A high population-to-provider ratio does not explicate levels of untreated disease, potential demand or effective demand; it therefore reveals little information about the criticality of intervention or the character of intervention. It is at best a general overview statistic. At worst, it is a malleable and ambiguous statistic capable of manipulating policy makers based on the values of whichever interest group is conducting the research13., 15.. This is a highly misused statistic by Indian policy makers to grant permissions for opening new dental colleges. The dentist to population ratio cannot be used in a country such as India where 95% of dental care is provided by private practitioners, there is negligible dental insurance and private fees for service are the main mode of payment involved. Possibly, we should use demand models that make use of various indicators of utilisation, such as the expected number of dental visits, which in turn function as surrogates for demand in practice¹⁶. Demand-based models compare the volume of dental visits that a given population will demand with the supply of visits available from practitioners to determine the amount of market shortage or surplus¹⁷.

When India became independent in 1947 there were just two colleges for a population of 350 million. Less than 40 years later, in 1985, there were 21 dental colleges¹⁸. There was a 10-fold increase in next 25 years and currently India has nearly 300 dental colleges for 1.2 billion population and more than 26,000 new students per year are enrolling for dental graduation programmes. Whether such an increase in the number of dental colleges has any positive impact on oral health status is highly doubtful, as India’s neighbour China, which has 102 dental schools for a population of 1.32 million and dentist to population ratio of 1:12,727, has better oral health indicators than India¹⁹.

However, although some experts may assume that an excess dental manpower would benefit the public by delivering better services at lower cost in a free market¹⁰, the imbalance in dental manpower can lead to undesirable consequences at the professional, economic, health and social levels¹⁰. Dentist oversupply may adversely affect conditions of practice and patterns of work. Dentists may experience unemployment, under-employment or reduced opportunities for employment¹⁰. There may be increasing competition between professionals and a decrease in income levels of dentists. A consequence of this may be deterioration in the quality of care¹⁰ or even a threat to ethical principles; for example, there may be a temptation to overtreat patients, introduce unnecessary services or fail to refer when indicated¹⁰.

At present, less than 5% of dentists are employed in public health-care systems and new dental graduates are facing extreme competition for employment⁶. The salaries offered for new dental graduates in the private sector ranges from Rs6000–8000 per month (US$120–150 per month) are less than any unskilled labourer or taxi driver⁶. For this reason, many newly graduated dentists are working in business process outsourcings and choosing alternative careers6., 20.. This trend, in turn, will have an adverse effect on years and money invested in education and, ultimately, a huge wastage of national resources in terms of loss of productive years and money spent on training such dentists.

Students who are enrolling into dental courses appear to be unaware of career prospects for dentists in India²⁰. The Government, Dental Council of India, Universities and non-govermental organisations (NGOs) turn a blind eye to educating students about the facts. More than three-quarters of dental colleges are run by private managements⁵, mostly with a business dictum, thus dental education in India has moved into the hands of the private sector where admissions are open to candidates with moderate scholastic ability²⁰.

The findings of this study cannot be interpreted without taking into consideration certain limitations. Principally, different estimations of the dentist to population ratio were used as a measure because of the availability of data. This limitation is not mitigated by taking into consideration the data on other clinical indices for the Indian population. It is obvious that using this measure to plan and allocate the dental workforce will result in needs remaining unmet and inequalities not being addressed¹⁰. Recently, attention has focused on more advanced and refined models for workforce distribution. Of particular interest are systems dynamic models and the socio-dental approach in determining the needs of various population groups. Most health manpower researchers use more than one model. An organised national human resource planning system is necessary to ensure the uniform distribution of manpower and to give future directions to policy makers. Planning should be a continuous process and not sporadic, and requires continuous monitoring and evaluation.

CONCLUSIONS

India continues to show a yearly increase in the number of dentists, and hence the trend towards an increase in dental manpower seems likely to continue, along with employment problems for dentists. At the same time, oral health care remains under-utilised and unavailable to large parts of the rural population. Solving all these problems will require both informed public policy makers and public policies based on the best available scientific data and proper manpower planning.

Acknowledgements

I am grateful to Dr George Paul, Oral and Maxillofacial Surgeon, Executive Trustee, HMA Trust, India and Dr Prasanna Kumar YS, Reader, Dayananda Sagar Dental College, Bangalore for their suggestions in completion of this study.

Conflict of interest

None declared.