| 4. In which ways is the initiative creative and innovative?
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Following steps were involved in development of this initiative:
1. Situation Analysis: During the latter half of the academic year 2005-2006. A detailed analysis of the existing situation was carried out. Existing problems were listed out along with the solutions. Prevalence of Dental Caries was referred from the oral health survey conducted on the school children during 2004. In short, SOHP needed to improve coverage of the children with prevention in order to control tooth decay. Conclusion from this analysis was that the tooth decay levels among these children was high and the prevention coverage done through SOHP was not upto the expected levels.
2. Literature Review: It was the responsibility of Forsyth Institute to review the available literature and find appropriate solution to this problem that was scientifically sound and acceptable to the community.
3. Decision Making: After the first two steps, a case was presented to Assistant Undersecretary, Dental Affairs and Oral Health Superintendent at MOH regarding the existing situation and the options for solutions. They were made fully aware of the problems faced and something needs to be done soon. A decision was made to utilize portable dental units to cover schools without clinics with prevention. This way SOHP would be able to increase the number of children receiving primary prevention and hence control tooth decay. Since, these services were being planned to be carried out within the school it would have so many other benefits associated with it. At the same time this method was cost-effective compared to setting up a clinic within a school, this was a big plus when it came to final decision making. Final decision was made to go for a phase-wise expansion with these portable units every year.
4. Procuring the Equipments and Materials: During 2006-2007, 10 Portable dental units from Aseptico, USA were ordered and the local dealer was kind enough to provide us one unit free. Hence, SOHP had 11 units in the first year. Also, required type and quantity of materials were ordered and procured through our central purchasing department.
5. Prevention Policy: During 2006-2007 our existing policy for prevention was revised. Detailed section was dedicated to functioning of prevention mobile teams using these portable units. Details included on types of units, method of functioning within the schools, administrative issues and job descriptions of the personnel working in these mobile teams.
6. Staff Training: The selected staffs were trained in the operation and minor maintenance of these portable units by the technical personnel belonging to the maintenance team. Clinical training was provided by our training department.
7. Identification of Schools: Schools without permanent dental clinics were identified and a plan was prepared to cover at least a part of them during 2006-2007.
8. Permission from Ministry of Education: Once the schools were identified the required permission from MOE was obtained to operate within the school premises.
9. Installation of the equipment: Once the school and the space were identified the maintenance technicians would transport the equipment to the schools and set up the equipment there and run a test when ready. Then the skilled personnel would move in with the required materials and perform prevention on school children.
10. Program Evaluation: This initiative was evaluated in terms of the process performed and the outcomes were measured qualitatively and quantitatively on regular basis.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Designing of the initiative along with policy development was the responsibility of the Oral Health Superintendent from MOH, Kuwait and the Program Director, who represents Forsyth Institute in Kuwait.
Once the policy was finalized the next step was implementation of the services. Plan was to go for phase-wise expansion every year. Required portable equipment and materials for 2006-2007 was ordered through our purchasing department.
Education department in various governorates provided SOHP the required permission to carry out this initiative. Permission was obtained from the participating schools through the school principals who provided space and other facilities to set up these portable systems within the school premises.
Maintenance technicians belonging to SOHP were responsible for transporting these portable units to the schools and setting them up in the space provided. They were also responsible for maintaining these units in good condition.
Personnel involved in carrying out the services were trained Dentists, Dental Hygienists and Dental Nurses. In each of the governorate they were supervised by Prevention Team Leaders and Health Education In charges.
Hence in each of the six governorates of Kuwait where SOHP operates it is managed by a program head who has a clinical supervisor, prevention team leader and health education in charge to manage various services offered under SOHP.
Also, these prevention mobile teams were well supported by the supplies department, providing the needed supplies on regular basis without delay and also the printing department provides health education materials to the children.
Health education department provided the needed media coverage and support for this initiative which was important for its success.
Parents and school teachers are an integral part of this initiative along with school children.
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| 6. How was the strategy implemented and what resources were mobilized?
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This initiative was designed to be a cost-effective one. SOHP received entire financial support for this initiative from Ministry of Health, Kuwait.
Main categories of the expenses involved were those related to, 1) Equipment, 2) Materials and 3) Manpower. Other than these there were other minor miscellaneous expenses involved on day to day basis. Detailed budget with the plan was presented to MOH and it was promptly accepted and approved. In short, the unit cost involved for setting up a clinic with portable dental unit was less than 1/5th of that of a full pledged dental clinic.
Type of equipment required to start this initiative was decided by SOHP. MOH was kept informed before the purchase orders were placed. Same procedures were followed for the procurement of materials.
When this initiative began in 2006, utilized the existing personnel of SOHP to operate whether it was dentists, hygienists or nurses. Later on during the years of expansion more qualified manpower was hired according to the expansion plans. As of 2013-2014 there are almost 55 dentists, 25 hygienists and 120 nurses working for this initiative alone. Each mobile team working with Type A portable unit comprises of a dentist and 2 nurses whereas the team using Type B unit has one hygienist/dentist and one nurse to carry out the services.
In order to minimize the burden of cost involved, SOHP went for year-wise expansion of this initiative. Since 2006-2007 on an average SOHP expanded the teams by almost ten every year. Today, SOHP has a fleet of more than 50 Type A units and almost 40 Type B units, auditing of these units are done on timely basis in order to avoid delay and maintain their efficiency. This has helped us to have better control over the initiative.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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Ever since this initiative was implemented, many successful outputs have come out of it. Here are the top five of them:
1. Increase in Prevention Coverage: When measured quantitatively our prevention productivity significantly increased every year since year 2006. Number of fluoride applications done under SOHP during 2006 was 184,373 which increased to 265,109 during 2012 which is almost an increase in coverage by 44% Similarly, the number of sealants that were placed on the newly erupting permanent posterior teeth during 2006 was 126,312 which increased around 145,000 during 2012, an increase in coverage by almost 15%. At the same time during this period the children with positive consents to prevention increased by almost 20-30%. In summary, post 2006 our prevention coverage increased drastically due to this initiative. The number of children benefitting from our services increased with each year.
2. Reduction in Treatment Needs: With the increase in prevention coverage and improve in our referral system as the result of this initiative the dental treatment needs among school-aged children reduced drastically. During 2006-2013, dental fillings done on tooth decay) by SOHP has reduced by more than 50%. The results of the National Survey of 2012-2013 shows that the disease-free children during 2013 is 16% which was around 8% in 2004.
3. Cost-effectiveness: Because of the cost-effectiveness of the initiative, has resulted in immense savings in material and equipment expenses to ministry of Health, Kuwait. Also, this initiative has delivered the benefits to school children. Hence, MOH never hesitated to support this initiative.
4. Parents and Children: Since all the services under this initiative is delivered within the school premises, parents are not needed to leave their work to take their children for dental treatment which is a saving for the country. At the same time, since all the services under this initiative was delivered inside the school, school hours lost by children due to dental treatment significantly reduced and these services were well accepted by them since it was delivered to them in familiar surroundings.
5. Disease Levels: Prevalence of tooth decay among 4-16 year old children in Kuwait reduced by almost 10-15% during 2004-2013. Also, during the same period the disease free children almost doubled. Only difference in the delivery of care between 2004 and 2013 was this initiative. Hence, these results have resulted in reduced dental treatment needs among children in Kuwait.
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| 8. What were the most successful outputs and why was the initiative effective?
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Since year 2006, SOHP has adopted s number of methods to measure to monitor and evaluate this initiative in terms of Quality and Quantity.
Quantitatively the productivities of the operators (Dentists and Hygienists) were measured on daily basis which was later summarized every month.
Each mobile team with Type A portable units would apply sealants to around 10-15 children per day depending on the number of teeth done on each child. On an average each operator would place sealants on 30-40 teeth in a day.
Each mobile team with Type B portable units would apply only Fluoride Varnish to around 60-70 children per day.
Quantitative Measurements:
Quantitative measurements of the procedures performed under this initiative were done on regular basis. Each team has a specified form which helped in summarizing these productivities on daily basis. At the end of the month, productivity for the entire month was calculated and later for the year. Each governorate has a prevention team leader who monitored this process and reported the same to program Director. As the result of this SOHP could maintain accurate database of preventive procedures performed under this initiative for comparison and further analysis.
Qualitative Measurements:
This initiative was evaluated qualitatively in different ways. To evaluate the outcome of our Fluoride varnish program, a clinical trial was designed in 2006.The sample was examined once every year for Dental Caries. After 3 years the results showed the children receiving biannual applications of Fluoride varnish had fewer decayed teeth.
For our Sealant program approach was slightly different. The quality of the sealants placed by mobile teams is evaluated separately for retention. Two kinds of retention checks are performed; 1) Short-term retention evaluation, 2) 1 year retention evaluation (as per the standard criteria).
Short-term evaluation is carried out within few days after the sealant is placed, on an average around 95% of the sealants placed by mobile teams are fully retained. During 1 year evaluation, on an average 80% of the sealants placed are completely retained.
Also, special prevention charts were designed to be exclusively used by the mobile teams, which helps to collect the information efficiently and also the follow-up of children every year.
The entire process is evaluated 3 times in a year, before, during and after the academic year. This also involved auditing of material and equipment involved with this initiative.
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| 9. What were the main obstacles encountered and how were they overcome?
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Following were the major obstacles encountered during the course of this initiative:
1. From the Personnel: The selected personnel were not always willing to work in a mobile team using a portable unit, because this would not give them the comfort of a fully-fledged dental clinic. Also, since the teams had to move frequently from school to school some of the staff complained of the transportation issues.
Solution: Working in prevention mobile teams with portable dental units was made mandatory to all the staff working for SOHP. They were all made aware of the existing problems facing the children in Kuwait and the only solution is to cover them with effective prevention. All the staffs were convinced to work in mobile teams. Also, the staff working in mobile teams received a monthly transportation allowance which took care of their complaints regarding transportation. Performance-based incentive for the personnel working for mobile teams introduced since last 2 years has become very popular among the staff, urging them to work for mobile teams, cover more children and also maintain high quality.
2. From School Administrations: Some of the schools were not ready to provide our mobile teams the space and facilities to work in their schools, saying that it would interfere in their day to day affairs.
Solution: Administrators belonging to SOHP would explain in detail to the management of such schools and convince them to change their minds. In most of the cases we were successful in changing their decision.
3. Data Collection and Follow-up: This was the big obstacle SOHP faced during the first year of this initiative. Since this concept was new here there was not existent data collection methods for the services provided through mobile teams, hence it was difficult to obtain standard data from all the teams in 6 governorates.
Solution: During 2006-2007, an unique data collection chart to be exclusively used by mobile teams was designed, which would help in collecting data about the services provided and also give a picture about what to expect in future for that child. This would help these mobile teams to reach that child on time to prevent tooth decay. This chart was put on trial during 2007-2008 by all the mobile teams. Some changes were done to this original chart before the final chart was put into use during 2008-2009. Now we have standard reliable information coming from all the mobile teams working in all the 6 governorates for SOHP.
These were the major obstacles that this initiative encountered which was sorted out with collective efforts from all involved. There are day today problems/obstacles which these teams encounter on day to today basis but today after more than 6 years of initiation of this initiative people know exactly how the system works and where to look for the solutions. When these obstacles are weighed with the benefits, they are very much outweighed.
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