Management of Proactive Oral Health Services Concerning Entire Stakeholders’ Involvement
Dental Department, Sakaew Publichealth Office

The Problem

A report of the situation of oral health diseases and accessibility of oral health services in Thailand in 2007 revealed that oral health was a severe health problem among Thai people. 80.64% of children aged 3-5, 89.57% of adults aged 35-44, and 96.15% of elderly suffered from delayed teeth. Low accessibility to oral health services was considered a key determinant. It was found that less than 40% of these aforementioned three age groups could access dental care services as needed.
The statistics in the last five years showed that significant oral health problems of Thailand consisted of decayed tooth and periodontal tooth(tooth mobility due to dental calculus and bone loss) which led to tooth lose at a young age. The ignorance of this problem can cause false teeth dependence and other health problems in the long run.
In Sakaew Province, there is a governmental-agencies network of oral health services-promotion, curing, and rehabilitation composed of a provincial hospital, six district hospitals, and thirty-eight local health centers with twenty-seven dentists and sixty-four dental nurse. All those health settings serve 544,100 populations. A ratio of dentist: population is 1 : 20,152 (1:6,713, nationally); whereas, a ratio of dental nurse: population is 1 : 8,502 (1:15,732, nationally). This ratio reflects a severe shortage of dentists in Sakaew province. Although the ratio of dental nurse was better than that of the country, it is still not enough to serve patients in the area since Sakaew province is a border-line province, one third of patients are those who came from the neighboring countries. Despite of a demographic constraint, each day, at least fifty patients seek oral care from each health setting. For sophisticated treatment such as root canal treatment, denture, impacted tooth, it might take more than one month to receive the service.
The minimum wage in Sakaew province is 103 baht a day (200 bath on average, nationally). Thus, an average household income in Sakaew province is much lower than of the whole country. Household debt certainly exists. The majority of people in Sakaew province are farmers and laborers with low education and economic status (live from hand to mouth). It is not surprised that people prefer earning their living to taking care of their health especially oral health which typically is not urgent. Many people leave until the condition gets worse and it is too late to keep their teeth. The loss of teeth results in the reduction of one’s quality of life. Moreover, time and cost of treatment increase as the severity of disease increases.
Oral health problem in Sakaew province is a complex problem. There are numerous obstacles to resolve the problem. It is necessary to conduct systematic study and use existing relevant resources to achieve oral health of people. A health promotion dimension should be more emphasized than curing and rehabilitation dimensions. To eliminate a weak point regarding a dentist shortage, health network and self care promotion was taken into account.

Solution and Key Benefits

 What is the initiative about? (the solution)
Although oral health diseases especially decayed teeth are treatable, problems can reoccur again and again depending upon patients’ oral care behaviors. Sakaew’s Authorities concerned about this issue so they implemented a project called “The management of proactive oral care services based on a concept of stakeholders’ participation” in order to systematically eliminate oral health problems of Sakaew people.
Duet to the differences of oral care among people with different ages, we targeted our initiative on pregnant women and their baby, preschool children and primary school students. These age groups were important to promote accurate oral care skills because of milk teeth protruding. People should be aware to take care of their oral cavity as early as possible since the earlier promotion, the earlier protection. In concerning of cost effectiveness, the project focused on promotion and prevention rather than curing and rehabilitation. Compared to curing and rehabilitation, oral health promotion and prevention required less budget and time. Moreover, promotion and prevention activities could be carried out in a big scale. Besides, a long term outcome is much greater since it helped ones stay away from oral diseases.
A survey conducted from 2006-2011 as to oral health of 3-year-old children disclosed that Caries Free Index (CF) significantly increased from 29.93% to 40.07% as showed in the table below. The aim of Thailand was to incline CF to 40% by 2015.

Year 2006 2007 2008 2009 2010 2011
CF 29.93 34.43 36.41 35.76 37.32 40.07

The initiative was implemented mostly through knowledge management matters for example academic conferences, task supervision, and so on. Furthermore, oral care information at a district level was shared via an information technology network with the intention to synthesize the body of knowledge to develop oral health interventions that truly serve need of Sakaew people.
The initiative was beneficial for pregnant women and their baby in many ways: 1) we educated mother and children about accurate oral care, 2) we encourage mothers to brush children’s teeth until they could brush by themselves, 3) the local governor built supportive environment in daycare centers by providing school milk and promoting bottom-milk cessation.
For primary school students, the local governor built supportive environment in school such as an oral health education corner, teaching tools, oral health media, etc. We empowered school health teachers as key persons to instill proper oral health behaviors among their students through creative activities –games, songs, and the like.
We believed that our initiative would help form people’s habit and those people could be able to dissimulate this good habit to their lineage. As a result, Sakaew people would conceive good oral health. Finally, workload of dental staffs would reduce and they could provide more special oral care such as scaling, filling for pregnant women, and apply fluoride varnish for preschool and school children. This way, more than 80% of our target group could access to the service as needed.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
According to the national oral health policy, oral health promotion has been implemented to eight target groups consisting of pregnant women (and their baby), pre-school children (0-5 years old), children in daycare centers and kindergartens, primary school students, high school students, elderly, patients with chronic diseases, and disabilities. In Sakaew province, we prioritized pregnant women and their baby, pre-school children, and primary school students as target population because they are in the age groups of milk tooth and tooth and pregnant women are at risk of tooth decay. To accomplish oral health promotion in this sub-population, the National Health Security Office provided financial support to Sakaew province.
Oral health promotion projects have carried out through out Sakaew province. From project evaluation, it was found that two districts of Sakaew province showed great success in promoting oral health of target people.
The first one is Wangnamyen district where community participantion and health network approaches were used to mobilize the project aiming to promote oral health of pregnant women and their baby. Oral health care team was formed with the collaboration of dental staffs, village health volunteers, daycare staffs, local governor, community leaders, and patents’ family. Oral health promotion was executed through concrete activities: oral cavity examination, oral health education, and home visit. Lay villagers were trained and work as oral health volunteers to promote oral health of their community.
The other one is Klonghard district. This district focused on oral health of primary school students. Health promotion activities were implemented in schools. Teachers in schools were invited to participate in the project as key persons to promote students’ oral care. Community leaders and local governor also cooperated. Finally, eight schools in the district became a network of oral health promotion schools. Oral care activities have been provided in those schools continuously. As a result, the obvious reduction of decayed teeth among primary school student was evident. The report showed that 70% of students in oral health promotion schools freed from decayed teeth, compared to 32% of the whole country.
Fortunately, due to a geographic advantage, there is milk-cow cooperative that produces fluoride milk with acceptable price to serve people in Sakaew province. Moreover, there is a free-of-charge fluoride milk project in primary schools. This project is under the king’s patronage. Good-quality fluoride mild is distributed from the Royal Project Jitlada Palace to serve school children here every day.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
Our initiative was developed in accordance with the provincial policy for dental health promotion. We mobilized our initiative in regard to the management of oral care services based on a concept of stakeholders’ participation. Main strategies employed to achieve our ultimate goal included:
1. Multidisciplinary team building: we revealed the situation of oral health problem to all stakeholders in order to alarm them to work together for a common solution. This resulted in a provincial committee of oral health. Representatives form government, private, and civil sectors collaborated as a multidisciplinary team. Initially, we agreed on promoting good habit as to oral care. Thus, we focused our interventions on children of preschool age when health habit could be instilled and we needed to encourage children and their caretakers to take good care of children’s milk teeth. Good habit as to oral care contributes to one’s life-long teeth and oral health of Thai people as a whole.The multidisciplinary team conducted various oral care-related activities composed of:
a) Village health volunteers were trained to provide simple oral care for community members. They were able to educate people about accurate tooth brushing and basic oral care in daily life.
b) Supportive environment was taken into account. We promoted family, daycare center, school, and community without unfriendly food for oral health such as sweet snacks, candies, and soda. Furthermore, we increased people’s awareness of the benefits of fruit and vegetable.
c) We encouraged parents to be a good role model of oral care and build a good habit of oral care for their children. We believed that good oral health begins at home.
d) Mobile oral care clinic was established as a proactive campaign. A mobile clinic time, date, and place was scheduled annually and announce to public. The great advantage of the clinic was that it could serve people in out-reach areas and it helped reduce cost of transportation, significantly.
2. Concept of community participation: We believed that people own their health so we gave them privilege to share their voice in any intervention implemented in community. Community in our case regarded lay people, community leaders, local governor, community profession, and local wisdom. All sectors should be responsible for community’s oral health.
3. Incentive provision for oral health care team: It is important to encourage health staffs to move forward and mobilize the world. Incentive is one of good strategies to concern. In Sakaew province, the incentives were provided in two forms. a) knowledge and skill broaden: academic trainings were provided to update for our staffs’ competencies in oral care. Also, conferences were organized periodically as a stage for masterpiece presentation and discussion. b) aware presentation: awards were presented to those who were considered great oral care providers. In addition, awards were for oral care innovations. Incentive is a good approach to stimulate an oral health care team to bring good oral care to community.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
According to brainstorming, we conclude that oral health is the important issue of people in Sakaew province. People are poor; most of them try to work for their surviving more than concerning their oral health. If we leave this issue, it will be a seriously problem in future; more budgets will be used to solve the problem of no teeth for eating and infection diseases in oral cavity those are the cause of decreasing of the quality of life. We have to establish a network by coordinating with all partners or all stakeholders. We have to encourage people to take care the oral health since their children are infants so that all people in Sakaew will have a better oral health in the future.
Dental public health of Sakaew encourage people to take care their oral health in all age group continuously, especially group of new mother and children in primary school level. These groups are having first primary tooth and permanent tooth. Moreover, we are working with all stakeholder, we distribute Fluoride to people in many kinds such as toothpaste wich fluoride ,apply fluoride varnishes by dentist including encourage people to drink milk that mix with Fluoride, this project is support by local governor and Sakaew is one of seven provinces that are support by The Borrow’ foundation. This Foundation supports manufacturer to produce milk with Fluoride under the standard of Good Manufacturing Practice(GMP). This project is also under the project of the King Phumipol that encourages people to drink a good quality of milk with Fluoride. We are also implement pit and fissure sealant for student in primary continuously. From many project that we have done influence the index of children in Sakaew have DMFT (Decay Missing Filling tooth Index)decreasing, in the year 2007 = 2, 2008 = 1.78, 2009=1.26, 2010=1.16 and 2011 = 1.15 (nationally = 1.5)
Implementing dental public health project have to be done continuously. We evaluating the successful of the project by comparing the caries free index in each age group to 100% and DMFT decrease to 0%. We try to develop procedure to be easier and implement the project until people are able to take care their oral health, have a good behavior in oral health and have a good quality of life and also decreasing budget to solving oral health issue.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
In the past, we deal with oral health problems only of those who came seek services in health settings. We realized that patients who came to us mostly had severe conditions and needed complex treatment. Huge resources were utilized to treat these patients. The results of curing were not effective. The disease recurrence was evident. Also, curing was costly, time consuming, and stressful. This contributed to dissatisfaction in both patients and providers. As a final point, we agreed that prevention and promotion should be the best resolution.
Initially, we put our efforts to promote oral health of all defined age groups equally. Budget and resources were also allocated to all age groups evenly. However, the results turned out that only some age groups were obviously beneficial from the initiative. Primary school children continuously showed good results. Later on, we adjusted our target groups to mothers and children with the belief that oral health begins at home and mother would take a role of educator and care provider for their children. Mothers were considered as our working team. Their major task was to instill oral good habit to their children and other family members.
Another barrier was inappropriate workload. One staff was assigned to take care of a huge number of clients. The ratio of staff : clients were much higher than that of the country. This caused a coverage problem. Our solution in this case was a public sharing regarding oral health. We created channels for public to share and learn from each other. We also receive information from public sharing as input for an intervention design.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Oral health project in Sakaew use small budget due to limited budget from government so we have to plan and use carefully for more benefit. Budget from National Health Security Office(NHSO),Thailand that provide to encourage people to take care their oral health in every age group are support by The Borrow’s foundation. The budgets are less than one million Baht use for all people in Sakaew, more than 500,000 people a year.
The committee of oral health project in Sakaew are representative from many sector especially people in local area in order that the project can move forward. We emphasize on our target such as new mother and student in primary school level. We are make agreement together so we get a good cooperation then we can save budget, human resource, tools and equipments.
We publish the project by using government’s media such as radio advertisement, print advertisement and internet online so we save cost of advertising.
Tools and equipment we are support by many sectors; Local Area Organization, private sector such as Colgate, Oral B, and 3M
village health volunteers are the group that have an important role in this project because they are closed to people, they can check and give basic advise for people then they collect all data and information to dental staffs to make a plan and satisfy people need.
Assistant Teacher in daycare center and teacher who take care the sanitary in school are also the key officer. They check, record, collect all oral health information of their students, prepare and improve school environment so that student will familiar with oral health behavior.
Parent and all people in family must be an idol for children in take care their oral health so that student can do as their routine.
These are our aim and result of encouraging people in Sakaew to take care their oral health. It reduces the expense of pulp treatment so much. The fluoride varnish 1 bottle (2,000 Baht) will be used for 50 children and 5 minutes will be used to apply 1 children, It save time and money a lot and also dentist and their assistant can move to take care children in every area, people get more comfortable from this service. Comparing to children must be pulp treatment, there are more expense must be used, it can be more than 2,000 Baht per children and take time more than 1 hour, and dentist who take care children must be specialist and must be use a specific tools and equipment to treatment. Children must take a queue more than 1 month because of limit number of dentist. These are the reason of encouraging people to take care their oral health continuously more than leave the problem and solve it by dental treatment after defect.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The oral health project is extending from the center of Sakaew province to small unit area of Sakaew. Every area implements and integrated the project to their environment by using all involved sectors. We encourage all people and all sectors to interesting in their oral health. Encouraging prevetion and protection tooth decay use small budget than curing and rehabilitation dimensions. Encouraging people to have a good oral health so that they will have a good tooth for their all life, this is suitable for people who have less income.
Dental staffs in different area have different abilities, different performance and also resource in different area have different cost. We implement the project to all area and we got a good response such as the project that implement in Wang Nam Yen district, it is accepted by nation and it is recommended to publish as a model of oral health project in television, NBT channel, it is broadcasting in 2.00 pm. Sunday.
Klonghard district have a good performance in oral health project. Teacher who take care this project got a reward as “Excellent Teacher” in nation level and it is a model for others schools. We can extend the project from 8 schools to 23 schools under voluntary.
All district are ready to be an education learning and ready to support the oral health project continuously in order that people in their district will have a good tooth for all of their life.
Because of hard working on encouraging people to take care their oral health, dental caries free children and they have a good behavior in oral health. We hope that this project will be sustainable and reduce patient wich dental desease and reduce many treatment in the future. Our next steps are creating new networking of the project to student in secondary school, old patient, and people with disabilities. All of these groups are already implement but not emphasis because of limited resource. We hope that our strength networking will support and make the project success in future.
In Sakaew, we have many learning center for all age group to learn to take care their oral health. We have the group of people to introduce, recommend for all people. We hope that the development of the project continuously will be the model for other provinces to learn together with us and develop the oral health safely and efficiency.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
We learn that people in different age and different area have different need in oral health. We have to separate the group clearly before setting the activities of oral health project. We try to find out who will be our networking people. In the group of new mother we found that village health volunteers. is the key person who are close to people. village health volunteers. Have a basic knowledge in oral hygiene care. They have a good performance so dentists have a duty to set a group of village health volunteers and educate them in oral health. They can help to take care a basic oral health, then dentist have more time to take care a seriously issue. In the group of small children we found that assistant teacher, sanitary teacher and local governor are key persons to take care oral health for children. They can check, introduce and recommend solving oral health problem. local governor have the role to establish a good environment in school in order that children adapt themselves in good oral health.
To solving oral health, if we wait for treatment only, we will not solve all problems. It is the cost and high expend in treatment. If we aim to encourage and establish people to take care their oral health continuously, we will solve oral health problem sustainable. We have to aim that people must realize that good oral health will save time and money to treatment and if they have a strong network in community , they will reach the aim of good oral health easier.
Family is the key of oral health project successful. Family is the idol for children to have a good behavior in take care their oral health. They have to realize that they are their own oral health, it is not dentist.
Encouraging oral health for people in Srakaew, we do in various channels such as radio advertisement, brochure, billboard, internet online and educating to community leader teacher. The aim of using various channels is distributing knowledge to all target group of oral health project.

Contact Information

Institution Name:   Dental Department, Sakaew Publichealth Office
Institution Type:   Government Department  
Contact Person:   Dr.Lakkana Ouijirakul
Title:   secretray-general  
Telephone/ Fax:   +(66)37 269 009
Institution's / Project's Website:   -
Address:   48/72 praram9 road,saunloung
Postal Code:   10250
City:   saunloung
State/Province:   bangkok
Country:   Thailand

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