Abstract
Background and aim: A range of factors needs to be taken into account for an ideal oral health workforce plan. The figures related to dentists, specialists, auxiliaries, practice patterns, undergraduate and continuing dental education, laws/regulations, the attitudes of oral health-care providers and the general trends affecting the practice patterns, work conditions and preferences of oral health-care providers are among such determinants. Thus, the aim of the present study was to gather such information from a sample of World Dental Federation (FDI) member countries with different characteristics. Methods: A cross-sectional survey study was carried out among a sample of FDI member countries between March 2, 2012 and March 27, 2012. A questionnaire was developed addressing some main determinants of oral health workforce, such as its structure, involvement of the public/private sector to provide oral health-care services, specialty services, dental schools, trends in workforce and compliance with oral health needs, and a descriptive analysis was performed. The countries were classified as developed and developing countries and Mann–Whitney U-tests and chi-square tests were used to identify potential significant differences (P > 0.05) between developed and developing countries. All data were processed in SPSS v.19. Results: In the18 questionnaires processed, the median number of dentists (P = 0.005), dental practices (P = 0.002), hygienists (P = 0.005), technicians (P = 0.013) and graduates per year (P = 0.037) was higher in developed countries. Only 12.5% of developed and 22.2% of developing countries reported having optimal number of graduates per year. It was noted that 66.7% of developing countries had more regions lacking enough dentists to meet the demand (P = 0.050) and 77.8% lacked the necessary specialist care (P = 0.015). Although developing countries reported mostly an oversupply of dentists, regardless of the level of development most countries did not report an oversupply of specialists. Most developed countries did not feel that their regulations (87.5%) complied with the needs and demands of the population and most developing countries did not feel that their undergraduate dental education (62.5%) complied. Migrating to other countries was a trend seen in developing countries, while, despite increased numbers of dentists, underserved areas and communities were reported. Discussion: The cross-sectional survey study suggests that figures related to optimum or ideal oral health workforce and fair distribution of the available workforce does not seem to be achieved in many parts of the world. Further attention also needs to be dedicated to general trends that have the capacity to affect future oral health workforce.
Key words: Oral health workforce, planning, figures, trends, oral health
INTRODUCTION
Health-care systems worldwide address the needs of the people but the shortage of health professionals is an issue that both developed and developing economies have to face1. The health workforce is defined as a group of people aiming to promote, protect and improve the health of a population2 but over time it has been subjected to globalisation, provoking migration of skilled intellectual and technical labour to more highly developed countries leading to insufficient personnel to meet local health-care needs1., 3., 4.. Along with the numbers of schools and their graduates3, the implications of inappropriate numbers of health workforce personnel has brought attention to its current and future state3. Moreover, oral health inequalities still exist and affect the overall health and quality of life among populations. The International Association for Dental Research (IADR) has highlighted the limited effect of research on diminishing oral health inequalities4. Oral health workforce data are inconsistent and out of date because of a lack on emphasis on the importance of oral health and thus not being included in workforce planning strategies5.
The FDI’s Oral Health Workforce Task Team (OHWTT) seeks to provide future scenarios where National Dental Associations (NDAs) are well equipped to assess different aspects of oral health within their populations, including its status for workforce planning, and be able, and prepared, to act upon their findings. Therefore, the aim of this study was to provide a description of the oral health workforce structure, its distribution, trends, undergraduate and specialist education as well as the compliance of local regulations with oral health needs in a sample of FDI participating countries.
METHODS
A cross-sectional survey study was carried out among a convenience sample of FDI member countries which were classified according to World Bank’s data on gross national income per capita (GNI) into developed countries (over $12,276) and developing countries (<$12,275).
Participant countries were contacted via NDA representatives by the FDI Head Office and were asked to voluntarily answer a prepared questionnaire sent by e-mail between March 2, 2012 and March 27, 2012. The NDAs sent their responses and the completed questionnaires to the FDI Head Office. The data were confirmed with the NDAs, again through FDI Head Office. A total of 46 countries were contacted.
Questionnaire structure
The questionnaire aimed to analyse factors that could have an impact on the provision of oral health-care services and workforce planning, such as the oral health workforce, its composition, its involvement in the public/private sector for the provision of oral health-care services, specialty services as well as the number of dental schools, graduates and trends in workforce, and compliance with oral health needs. Population size, GNI and currency of participating countries were also assessed. An English, French and Spanish version of the questionnaire was sent to 30, eight and eight countries, respectively. The countries selected in this survey were essentially based on models of oral health-care services, demographics and levels of development. All data were gathered through the FDI head office.
Analysis
The main analysis aimed to report the frequency distribution as well as the median, minimum and maximum values of the responses received. Second, Mann–Whitney U-tests and chi-square tests were used to identify potential significant differences (P > 0.05) between developed and developing countries. All data were processed in SPSS Statistics for Windows Version 19.0 (IBM Corp, Armonk, NY, USA).
RESULTS
The response rate was 41.30%. Of the 18 questionnaires processed, 50% and 50% (n = 9) were from developed and developing countries, respectively. The population size, GNI and composition of oral health workforce, involvement of public/private sector to provision of oral health-care services, specialty services, private practices and number of dental schools are shown in Table 1.
Table 1.
Responses reported by World Dental Federation (FDI) participating countries
| Developed countries |
Developing countries |
|||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Canada | Belgium | Bahamas | Austria | United States | Germany | France | Finland | the Netherlands | Mozambique | Morocco | Cuba | Burundi | Costa Rica | Burkina Faso | Congo | Georgia | Benin | |
| Population size | 34.48 million | 11.01 million | 347,200 | 8.419 million | 311.6 million | 81.73 million | 65.44 million | 5.387 million | 16.70 million | 23.93 million | 32.27 million | 11.25 million | 8.575 million | 4.727 million | 16.97 million | 67.76 million | 4.486 million | 9.100 million |
| GNI(US) | 1.736 trillion | 513.7 billion | 7.788 billion | 417.7 billion | 14.99 trillion | 3.601 trillion | 2.773 trillion | 263.0 billion | 836.1 billion | 12.80 billion | 100.2 billion | 60.81 billion | 2.326 billion | 40.87 billion | 10.19 billion | 15.65 billion | 14.37 billion | 7.295 billion |
| Number of… | ||||||||||||||||||
| Dentists | 21,197 | 7,900 | 92 | 4,825 | 186,084 | 53,767 | 40,114 | 3,850 | 8,773 | 72 | 3,500 | 12,144 | 13 | 4,510 | 71 | 200 | 0 | 65 |
| Specialists | 2,500 | 900 | 10 | 0 | 39,027 | 6 | 2,001 | 650 | 596 | 5 | 500 | 6,043 | 1 | 586 | 4 | 10 | 8,423 | 10 |
| Dental practices | 12,000 | 6,000 | 60 | 3,866 | 127,022 | 44,571 | 22,000 | 2,000 | 5,600 | 394 | 2,500 | 1,700 | 10 | 0 | 70 | 0 | 0 | 55 |
| Dental hygienists | 26,541 | 0 | 40 | 0 | 181,800 | 550 | 0 | 1,600 | 3,200 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Dental Therapists | 291 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 123 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 |
| Dental Nurses | 0 | 2,500 | 1 | 12,200 | 0 | 211,000 | 0 | 6,100 | 19,000 | 93 | 0 | 0 | 0 | 0 | 176 | 0 | 2,000 | 21 |
| Denturists | 2,200 | 0 | 1 | 0 | 0 | 0 | 0 | 330 | 370 | 72 | 0 | 0 | 0 | 0 | 0 | 0 | 50 | 0 |
| Dental Technicians | 2,200 | 1,300 | 5 | 620 | 0 | 67 | 4,050 | 500 | 4,000 | 86 | 5 | 0 | 0 | 0 | 0 | 5 | 1,000 | 3 |
| Dental practices… | ||||||||||||||||||
| Nominally owned | + | + | + | + | NA | + | + | + | + | + | NA | − | + | + | + | NA | NA | + |
| Public Health Service agreement | + | + | − | + | NA | NA | + | + | NA | + | + | + | − | − | + | NA | NA | − |
| Insurance company agreement | − | − | + | NA | NA | + | + | − | NA | NA | + | − | + | + | NA | NA | NA | + |
| Only private practice | NA | − | + | NA | NA | + | + | + | NA | NA | + | − | + | NA | NA | NA | NA | + |
| Number of faculties… | ||||||||||||||||||
| Public | 10 | 3 | 0 | 3 | 38 | 30 | 16 | 4 | 0 | 2 | 2 | 17 | 3 | 1 | 1 | 1 | 4 | 0 |
| Private | 0 | 2 | 0 | 1 | 24 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 10 | 3 | 0 | 0 | 8 | 0 |
| Total | 10 | 5 | 0 | 4 | 62 | 31 | 16 | 4 | 3 | 3 | 2 | 17 | 13 | 4 | 1 | 1 | 12 | 0 |
| Number of graduates per year | 2,000 | 180 | 0 | 185 | 5,003 | 1,721 | 1,000 | 180 | 120 | 15 | 200 | 16 | 0 | 130 | 12 | 60 | 400 | 0 |
| Distribution of dentists | Not even | Even | Not even | Not even | Not even | Even | Not even | Not even | Even | Not even | Not even | Even | Not even | Not even | Not even | Not even | Not even | Not even |
| Regions which… | ||||||||||||||||||
| Lack the number of dentists | − | − | − | − | − | − | + | − | − | + | + | − | + | + | + | + | − | − |
| Oversupply the number of dentists | − | − | − | − | − | − | − | − | − | + | − | − | − | + | − | − | + | − |
| Lack the necessary specialist care | − | − | − | − | − | − | − | + | − | + | + | − | + | + | + | + | − | + |
| Oversupply the number of specialists | − | − | − | − | − | − | − | − | − | + | − | − | − | − | − | − | − | − |
| Lack the number of rural dentists | + | − | + | + | + | − | − | + | − | + | + | − | + | + | + | + | + | + |
| Oversupply number of rural dentists | − | − | + | + | + | − | − | + | − | + | + | − | − | + | + | + | + | − |
| Undergraduate dental education… | ||||||||||||||||||
| Complies with the workforce needs | − | + | + | + | + | + | − | + | − | − | + | + | − | − | − | − | − | + |
| Needs a reform | − | − | + | − | − | + | + | − | − | + | − | − | − | + | + | − | + | − |
| Specialist dental education… | ||||||||||||||||||
| Complies with the workforce needs | − | + | + | − | + | + | − | − | − | − | + | + | − | + | − | + | + | + |
| Needs a reform | − | + | + | − | − | − | − | + | − | + | − | − | + | + | + | − | + | − |
| Regulations/laws… | ||||||||||||||||||
| Comply with workforce needs | − | + | − | + | + | + | − | + | − | − | − | + | − | − | − | − | − | − |
| Need to be improved | − | + | + | − | + | − | + | − | − | + | + | + | + | + | + | + | + | + |
+, Available; −, Not available; NA, Not answered.
Workforce structure
The countries with the greatest number of dentists available were the USA (n = 185,084), Germany (n = 53,767), France (n = 40,114) and Canada (n = 21,197). In contrast, Mozambique, Burkina Faso, Benin, Burundi and Georgia had <75 in each country. Georgia reported not having any dentist available, as all were stomatologists and were considered as specialists. The countries with the greatest number of specialists available were the USA (n = 39,027), Cuba (n = 6,043), Canada (n = 2,500) and France (n = 2,001) whereas a group of nine countries had <10 per country. The number of dental practices was higher in the USA followed by France, Canada and the Netherlands with more than 5,500. Meanwhile, Georgia, the Democratic Republic of Congo (Congo), Costa Rica, Finland and Belgium ranked the lowest for dental practices reported.
Austria had 11,600 dental nurses while the Congo and the Bahamas had less than five. Only five developed countries had dental hygienists, among these the USA had most (n = 174,100) and the Bahamas had the least (n = 40). Dental therapist and denturist workforce models were only available in Canada, Mozambique and Burkina Faso. France and Canada had over 2,200 dental technicians while Congo, the Bahamas, Benin and Morocco had less than five. The remaining countries had no dental technicians available.
Dental practices
Based on the responses and without taking into account unanswered questions, dental professionals were sole proprietors (nominal owners) in all developed and most developing countries (Table 1). Among all countries, the Bahamas, Burundi, Costa Rica and Benin did not have practices arranged with public health services. Dental practices arranged with insurance companies were not present in Finland and Cuba. Lastly, Cuba was the only country without only-private practices.
Dental schools’ information
In total, the USA had 62 dental schools, both public and private, followed by Germany (n = 31). In contrast, a group of 10 countries had less than five. The highest numbers of public dental schools were available in the USA (n = 38), followed by Germany (n = 30), Cuba (n = 17) and France (n = 16); the lowest were the Congo, Burkina Faso and Costa Rica (n = 1) followed by Benin, the Bahamas and the Netherlands with no public dental schools available. Ten countries had no private dental schools. The USA had 24 private dental schools whereas Germany and Mozambique had only one. Germany, Canada and the USA reported over 1,700 graduates per year whereas Cuba, Mozambique, Burkina Faso, the Bahamas, Benin and Burundi had less than 16 per year.
Distribution of dentists
Regardless the economic level of development, the vast majority of participating countries considered their current distribution of dentists as uneven, while Belgium, Germany, the Netherlands and Cuba reported the opposite. France was the only developed country that reported a lack of sufficient dentists whereas Cuba, Georgia and Benin were the developing countries without this issue. All developed countries reported not having an oversupply of dentists and specialists; only Finland agreed that there was a lack of necessary specialist care. In contrast, the majority of developing countries lacked enough dentists, specialists and rural dentists. Mozambique, Costa Rica and Georgia exceeded the required numbers of dentists and only Mozambique exceeded with specialist care.
Undergraduate dental education
Canada, France and the Netherlands were the only developed countries that considered that their undergraduate dental education did not comply with their workforce needs. In contrast, Morocco, Cuba and Benin reported compliance according to needs. The Bahamas, Germany and France considered the necessity to reform current undergraduate education, as did Mozambique, Costa Rica, Burkina Faso and Georgia.
Specialist dental education
According to Belgium, the Bahamas, the USA and Germany (developed countries), their specialist dental education system complied with their workforce needs whereas Mozambique, Burundi and Burkina Faso, which are in the developing countries group, reported the opposite. Belgium, the Bahamas and Finland were the only developed countries that agreed on the importance of reform with regard to this issue, while Morocco, Cuba, the Congo and Benin in the developing countries group did not consider it.
Regulations/laws
Participating countries were also asked for their opinion about their adherence to current regulations or laws with regard to their workforce needs. The responses showed that Canada, the Bahamas, Finland and the Netherlands did not adhere to these regulations and, with the exception of Cuba, this was also reported by all developing countries. The need for an improvement in these regulations was consistent in all developing countries but only Belgium, the Bahamas, the USA and France agreed with this.
Developed and developing countries comparison
Mann–Whitney tests (Table 2) showed that for developed countries the median number of dentists was greater (P = 0.005), as were the numbers of dental practices (P = 0.002), dental hygienists (P = 0.005), technicians (P = 0.013) and graduates per year (P = 0.037). Although not significant, the number of graduates from dental faculties was considered as satisfactory by 11% of developing countries, in contrast to 63% of developed countries (data not shown). Only 12.5% of developed countries and 22.2% of developing countries reported having optimal numbers of graduates per year. Finally, 22.2% of developing countries responded as having more graduates than needed compared with 12.5% of developed countries.
Table 2.
Comparison of the structure of dental workforce among participating countries
| Number of… | Developed |
Developing |
U-statistic | P | ||||
|---|---|---|---|---|---|---|---|---|
| Median | Minimum | Maximum | Median | Minimum | Maximum | |||
| Dentists | 8,773 | 92 | 186,084 | 72 | 0 | 12,144 | 9.0 | 0.005 |
| Specialists | 600 | 0 | 39,027 | 10 | 1 | 8,423 | 30.0 | 0.353 |
| Dental practices | 6,000 | 60 | 127,022 | 55 | 0 | 2,500 | 5.0 | 0.002 |
| Dental hygienists | 550 | 0 | 181,800 | 0 | 0 | 0 | 13.5 | 0.005 |
| Dental therapists | 0 | 0 | 291 | 0 | 0 | 123 | 37 | 0.634 |
| Dental nurses | 2,500 | 0 | 21,100 | 5 | 0 | 2,000 | 26.0 | 0.187 |
| Denturists | 0 | 0 | 2,200 | 0 | 0 | 72 | 29.5 | 0.247 |
| Dental technicians | 620 | 0 | 4,050 | 0 | 0 | 1,100 | 13.0 | 0.013 |
| Total dental faculties | 5 | 0 | 62 | 3 | 0 | 17 | 27 | 0.232 |
| Public dental faculties | 4 | 0 | 38 | 2 | 0 | 17 | 25.5 | 0.182 |
| Private dental faculties | 0 | 0 | 24 | 0 | 0 | 10 | 38.5 | 0.846 |
| Graduates per year | 185 | 0 | 5,003 | 16 | 0 | 400 | 17 | 0.037 |
Chi-square tests (Table 3) showed that 66.7% of developing countries had more regions lacking enough dentists to meet the demand (P = 0.050) and 77.8% lacked the necessary specialist care (P = 0.015). In addition, 87.5% of developed countries did not think that current regulations complied with needs regarding oral health workforce (P = 0.041). Despite not being significant, 62.5% of developing countries did not think that undergraduate dental education complied with workforce needs and all of them thought that the regulations needed to be improved in order to comply with oral workforce needs.
Table 3.
Comparison between developed and developing participant countries
| Developed |
Developing |
P | |||
|---|---|---|---|---|---|
| Yes | No | Yes | No | ||
| Regions that: | |||||
| Lack the number of dentists to meet demand | 11.1 | 88.9 | 66.7 | 33.3 | 0.050 |
| Have exceeded the number of dentists demanded | 100 | 0 | 33.3 | 66.7 | 0.206 |
| Lack the necessary specialist care | 11.1 | 88.9 | 77.8 | 22.2 | 0.015 |
| Have exceeded the number of specialists demanded | 0 | 100 | 11.1 | 88.9 | 1 |
| Lack the number of necessary dentists in rural areas | 55.6 | 44.4 | 88.9 | 11.1 | 0.294 |
| Have exceeded the number of dentists demanded in big cities? | 44.4 | 55.6 | 66.7 | 33.3 | 0.637 |
| Do you think… | |||||
| UGDE complies with the workforce needs? | 85.7 | 14.3 | 37.5 | 62.5 | 0.119 |
| UGDE needs reform to comply with the workforce needs? | 42.9 | 57.1 | 50 | 50 | 1 |
| SDE complies with the workforce needs? | 66.7 | 33.3 | 66.7 | 33.3 | 1 |
| SDE needs reform to comply with the workforce needs? | 60 | 40 | 62.5 | 37.5 | 1 |
| Regulations comply with oral health workforce needs? | 71.4 | 28.6 | 12.5 | 87.5 | 0.041 |
| Regulations need improvement to comply with the needs? | 57.1 | 42.9 | 100 | 0 | 0.063 |
| As NDA do you participate to the negotiations with the authorities regarding oral health workforce planning | 57.1 | 42.9 | 50 | 50 | 0.614 |
UGDE, undergraduate education; SDE, specialist dental education.
Basic trends
Perceived trends reported by participant countries are displayed in Figure 1. Migrating to large cities within their countries was the primary trend reported among developed and developing countries (50% and 77.8%, respectively). For developed countries, the second trend was to prefer part-time jobs (37.5%) and limiting their working hours (25%). In contrast, 33.3% of developing countries reported the trend of dentists to prefer working in private practice. A third trend was that 50% of dentists in developed countries preferred to have large clinics with many dentists instead of solo practising, whereas 42.9% of developing countries preferred to work in private practice.
Figure 1.
Perceived basic trends reported by World Dental Federation (FDI) participating countries.
DISCUSSION
Human resources are considered as the basis of health systems and are important contributors to the accessibility to quality health services6. The World Health Organisation (WHO) states that: ‘We are currently facing a severe global health workforce crisis with critical shortages, imbalanced skill mix and uneven geographical distribution of health professionals, leaving millions without access to health services’7. As the oral health workforce has a vital role in promoting, maintaining and improving systemic and oral health, in order to assess its adequacy and structure and to evaluate some basic determinants and trends in workforce a cross-sectional survey was carried out among FDI participating countries to gather such information. Despite the limited number of responses, the questionnaire still provided valuable information regarding the current picture of oral health workforce and enabled a comparison between developed and developing countries.
In the present study, the number of oral health professionals varied widely regardless of the level of development and it was noteworthy that few countries, according to their own perception, reported an optimal number. However, it is important to highlight that these numbers only reflect the availability of professionals that were reported by the NDAs based on their databases and the collection methods may vary between countries. For example, for graduate students in Georgia it is mandatory to pursue a residency followed by a test in order to obtain a license as a specialist. Therefore, according to this academic scheme, all dentists in Georgia are specialists. The fact that similar discrepancies may exist with other countries reveals the need for clear descriptions for each type of oral health workforce personnel with well-defined role and tasks, together with dental practice/premise definitions and workforce conditions. After taking into account these considerations, in developed countries there were regions without sufficient dentists. In general, the reported numbers of dental practices were greater in developed countries but general dentists and specialists were also available. In many countries, national capacity and resources – human, financial and material – are still insufficient to ensure availability of and access to essential health services of high quality for individuals and populations, especially in deprived communities. The issue of oral health personnel – which categories of personnel need to be educated, their duties and the numbers of each – has, for many years, been of great concern. The importance of this matter has become evident in a number of countries where the production of dentists appears irrelevant to oral health needs and demands. The problem of inappropriate types and numbers of oral health professionals is still being faced by some countries8.
The median number of dentists, dental practices, hygienists and technicians was significantly higher in developed countries. Dental therapists and denturists were the least available workforce model. Despite the differences in the frequency of dental nurses, these were available in half of both developed and developing countries and, although not significant, all developed countries reported exceeding number of dentists required whereas most of the developing countries lacked enough dentists in rural areas. Regardless of the level of development, most countries do not have an oversupply of specialists. The presence of 2.28 health providers per 1,000 of population has been suggested as the ideal density, combining doctors, nurses and midwives9. For many years the precise measurement of the supply and demand of dentists in a population, ideal dentist to population ratio and the methodology has been of interest to researchers and the profession10, and there are many determinants (e.g. work patterns, economic conditions, availability of auxiliaries, funding of oral health care delivery, etc.). While an ideal or recommended dentist to patient ratio is debated as a simple guide, it is claimed that it cannot take into account the differing economic environments from region to region, state to state or urban to rural5. Many countries in Africa, Asia and Latin America have a shortage of oral health personnel and, largely, the capacity of the systems is limited to pain relief or emergency care. In Africa, the dentist to population ratio is approximately 1:150,000 compared with about 1:2,000 in most industrialised countries8. The basic aim of many programmes is the development of oral health services that match the needs of the country. For example, the changing pattern of oral disease and sociodemographic factors imply that adjustment of existing oral health manpower structures are needed for several developed countries. In developing countries, the challenge is to stimulate training programmes for types of personnel that would match the oral health needs and the infrastructure of the country8.
Reaching the optimal dentist to population ratio is a common health policy challenge around the world, but while many countries have too few dentists for their populations, some countries face the opposite problem11. In general, both developed and developing countries reported regions with an oversupply of dentists. A similar scenario exists for specialist care but is more prominent for developing countries. While an oversupply of dentists was reported in big cities (especially in developing countries, 66.7%), rural areas presented with significant shortages of dentists both in developed (55.6%) and in developing countries (88.9%). These figures clearly show that creating an optimal oral health workforce and having an even distribution of this workforce throughout the country is still a major issue for most countries. In Greece, it is reported that the number of dentists per 10,000 inhabitants increased significantly (P < 0.05) from 1982 (7.7) to 2007 (13.0), ranking Greece first (in 2008) among the European Union (EU) countries. The proportional increase in the number of dentists during the decade 1979–1988 (30.4%) was significant (P < 0.05), compared with the decade 1989–1998 (22.3%) and the 9-year period 1999–2007 (23.6%). In 1982 and 1992, the majority of dentists practised in the Attica Prefecture (Athens) (55.2% and 52.6%, respectively), but this situation changed significantly in 2007 (P < 0.05) (40.1% for Attica). The authors consider the problem that, even with a high dentist to population ratio, Greece has significant access problems in oral health11. This study once again highlights the fact that an increased number of dentists may not actually help in solving the unmet oral health needs if they are distributed unevenly, leading to areas left without basic- or health-care services.
When ideal workforce planning, dentist/population ratio and trends are concerned it is important to make reliable projections for the future. It is anticipated that in Taiwan an oversupply of dentists and a decrease in population will result in a surplus of dentists (dentist-to-population ratio expected to increase to 6.0 by the year 2020 or earlier), and it is suggested that to make better projections of the dental workforce, surplus dentists can be arranged to care for the aged, disabled and underserved people12. The availability of dental auxiliaries is another determinant. For example, in Hong Kong, the dentist to population ratio is about 1:3,200 and among the dental team, dental hygienists are trained in limited numbers: there are fewer than 320 dental hygienists registered, working under the supervision of dentists13. Another example may be the figures from a big city in China. It is stated that the total dental health workforce in Shanghai is relatively sufficient (the ratio of dentists to population is 1: 5,201), but its distribution is inequitable because there are fewer dental health personnel employed in the suburbs. Moreover, the structure of the dental health workforce in Shanghai is inequitable and specialists in preventive dentistry are lacking. It is suggested that the results of this study be applied to help Shanghai achieve the rational distribution and efficient utilisation of the dental health workforce available14. Factors such as demography, morbidity, technologies, policies and politics as well as social and economic developments also need to be considered for the workforce of the future15.
In recent years, when the unmet needs and global health workforce crisis is concerned, more emphasis has been placed on interprofessional and intraprofessional education and collaborative practice. The WHO recognises interprofessional collaboration in education and practice as an innovative strategy that will play an important role in mitigating the global health workforce crisis16. The health and education systems are suggested to work together to coordinate health workforce strategies. If health workforce planning and policymaking are integrated, interprofessional education and collaborative practice can be fully supported.
Migrating to other (probably more developed) countries is a trend for developing countries. This trend is seen in all health-care professionals and the reasons for emigration may include the desire for postgraduate professional development, career growth, better-enumerated job opportunities, better working conditions and better living conditions4. In addition, shifts in people’s health-care preferences, improvements in health-care delivery as well as demographic changes may contribute to this migration3. The present study revealed that dentists were not exceptions: we also have to consider dental care policies that can influence not only the education and movement of dentists, but health tourism15.
Migration of health workers has a significant effect in developing countries because of the loss of workforce, inadequate funding, lack of infrastructure and low capacity to train personnel1. Thus, health-care systems without proper investment may lead to poor payment of the professionals as well as inappropriate working environments and an overall low job satisfaction4.
Migrating to rural areas seems to be a new trend in developed countries. The reason may be the increased competition in big cities and/or the incentives provided for services in the rural areas17. However, the major trend both for the developing and the developed countries is still migrating to big cities and this is continuing to have a negative impact on the even distribution of oral health workforce throughout the country. These factors are among the priorities for research in low- and middle-income countries18. Another outcome may be increased competition among the oral health-care providers. Limiting work hours and preferring to have part-time work are also trends specifically related to the workforce in developed countries, which needs to be taken into account when compliance of the workforce with the needs and demands of individual patients and the public is concerned. One approach to reduce migration rates is to encourage health personnel to work within their own countries or regions for a period before they migrate no matter what their reasons4., 19..
One trend that seems to be similar for both the developing and the developed countries, is the preference for large dental clinics instead of solo practices. Dentists, instead of working in their practices on their own, are likely to prefer having group practices with other dentists or specialists. This seems to be one of the major changes in the provision of oral health-care services in the recent years. Although this started as a trend in the developed countries, the present study demonstrates that it is also well accepted by dentists in developing counties. In contrast, specialisation training is gaining greater interest and more and more dentists appear to receive specialised training in all countries. This is likely to be more prominent for the developed countries at present but the same trend is also observed in developing countries.
At present, the oral health workforce, despite its scattered distribution among countries, still works mainly in private practice20. In addition, it is expected that higher densities of health personnel may be related with a better population health3. Recognition and reduction of oral health inequalities is a priority for dentists15 and may require well-developed strategies in order to diminish them21. Economic disparities and government’s failure to address the social determinants of health have been suggested as contributory factors22. Further, although mostly dental caries, periodontal disease (and sometimes oral cancers) are considered as major global oral health problems, it needs to be clearly understood that, depending on the local circumstances, various competing diseases/disorders also exist (e.g. noma, human immunodeficiency virus, etc.) and such diseases/disorders need to be taken into consideration in any planning or future projections. Furthermore, quality of care, professionally accepted standards of care and safety of individual patients and the public at large are also important elements of workforce planning23.
Workforce planning ensures that ‘the right people with the right skills are in the right place at the right time’. For the oral health workforce to prosper, it needs a source of income and/or funding along with appropriate government policies where dental services are integrated within primary care, in order to enable them to diminish inequalities by fostering oral health and providing treatment to the harm derived from oral and dental diseases21., 24., 25..
Acknowledgements
The authors are grateful to all the NDAs that responded to this questionnaire, Isabelle Bourzeix for her kind assistance and members of OHWFTT members for their kind support.
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