Development and Implementation of the Concept of Providing Free Dental Care to the Child Population under Conditions of Predominantly Non-State Healthcare in Kazakhstan

The dissertation is devoted to the development and implementation of the concept of providing free dental care to the child population under conditions of predominantly non-state healthcare in Kazakhstan. The study is based on long-term epidemiological surveys of the child population of Karaganda city conducted in 1988, 1998, 2000, 2005, and 2007, and an organizational experiment (2002–2007) testing a model of free pediatric dental care by a private clinic using the family-based principle. The author analyzes the dynamics of dental caries prevalence, periodontal diseases, the spread of dentoalveolar anomalies, the timing of permanent tooth eruption, and the need for implantological care among young adults. Particular attention is paid to the socio-economic substantiation of the proposed model, the assessment of its effectiveness for the private clinic and for the population, as well as to the factors of staff motivation and the risk of burnout syndrome among dentists.

Relevance of the problem

In recent years, serious structural and functional transformations have taken place in the system of therapeutic and preventive care for the population of the Russian Federation (Shchepin V.O., 1997). The development of the dental service under market relations has radically changed the approaches to its organization. First of all, they gave a tangible impulse to a higher quality of dental care for the population through the re-equipment of dental institutions and organizations, as well as the introduction of the latest technologies and materials. However, with the predominant transition to paid services, serious difficulties arose in providing dental care primarily to children and the poor strata of the population (Alimskiy A.V., 2001, 2003). Similar problems affected almost all the republics of the post-Soviet space. Meanwhile, in most of them, dental care is still largely provided by state dental institutions, including partly on a paid basis. At the same time, the volume of dental care provided by private structures is constantly growing and now amounts to 5-10% (Leontʹev V.K., 2000).

Private dental organizations are increasingly gaining authority among the population due to, as a rule, the quality of dental care and the high level of service (Mchedlidze T.Sh., 1996). According to the same author (1997), it is the well-off strata of the population, mainly of working age, who most often turn to commercial medical firms. At the same time, a predominance of patients requiring labor-intensive interventions is revealed.

The works of V.M. Grinin (1993, 2007) also confirm this information, and he notes that in dental non-budgetary institutions, therapeutic care remains the most widespread. Particularly attractive for patients are the quality of equipment and materials, as well as shorter appointment times compared to budget state medical institutions.

In recent years, a number of reports have appeared on improving dental care for the child population and adolescents in modern economic conditions, as well as on the use of highly effective technologies of diagnosis, prevention and treatment (Kiselʹnikova L.P. et al., 2002; Alpatova V.G., Kiselʹnikova L.P., 2008 et al.)

A.V. Alimskiy (2008) points out the need to take into account in the current conditions primarily the motivation and level of appeal of the population for dental care, and not only the state of their dental morbidity, since the majority, for various reasons (and primarily economic ones), do not apply regularly and in a timely manner to dental institutions.

The only republic of the former Soviet Union where 85% of dental institutions have been privatized is Kazakhstan. Along with the undoubted positive results that the restructuring gave to the dental service of the republic, certain serious negative aspects also emerged (Alimskiy A.V., 1998). First of all, they concerned the defects in the provision of dental care to the child population.

The leadership of the Republic of Kazakhstan has made and is making certain efforts to solve this problem. In particular, the so-called state order for servicing children is provided, which is distributed on a competitive basis among private dental organizations. The only difficulty is that the funds allocated by the state for the rehabilitation of the child population are clearly insufficient. In particular, for the sanation of 1 child per year, the state allocates on average less than 350 tenge (about 2.2 US dollars) across the republic. Given the existing level of dental morbidity in Kazakhstan, a significant part of the child population does not receive much-needed dental care.

Taking into account the current situation and the need to solve it in the new economic conditions, as well as in order to prevent further deterioration of the oral and dental health of the child population of the republic, the problem of developing a fundamentally new concept and model for organizing dental care for the child population of Kazakhstan through the use of the resources of the private dental service has become extremely urgent.

To test its viability, an organizational experiment was carried out in 2002-2007 in one of the largest cities of Kazakhstan — Karaganda. The choice of this region was due to the fact that, firstly, it was the subject of a long-term study of the indicators of the dental status of the child population, carried out by the expeditions of TSNIIIS consistently in 1988 and 1998, and secondly, the previously existing only children's dental polyclinic in the city ceased to exist in the mid-1990s. As a result, a unique opportunity arose to compare the possibilities of organizing sanation work under the conditions of planned therapeutic and preventive reception carried out during the Soviet era, and to trace the dynamics of subsequent changes in the dental status of the child population of Karaganda after the transition to non-state forms of providing dental care to the population.

As a result of subsequent dynamic observation and implementation of the model proposed in the study for providing dental care to children by a non-state structure (the Dentist firm), factual material was obtained confirming its viability. Moreover, these data were obtained from subsequent epidemiological studies conducted in 2002-2005 and 2007.

Purpose of the study

Increasing the volume and quality of dental care for the child population through the development and implementation of a new model of organizing and providing therapeutic and preventive dental care in the conditions of predominantly non-state healthcare.

Objectives of the study:

In accordance with the stated purpose, the following tasks were set and solved:

1. To study the dynamics of dental caries indicators and dental care for the indigenous child population of Karaganda city over 20 years (1988-2007).

2. To evaluate the changes in the structure of DMF and dmf in children of Karaganda city for the entire period before and after the collapse of the state healthcare system and to identify the emerging negative trends.

3. To study the timing of eruption of permanent teeth in the modern child population in the studied region, as well as the interrelation of the level of caries, dental fluorosis and dentoalveolar anomalies, to evaluate the volumes of necessary and actually provided orthodontic care to children.

4. To determine the need for implantological dental care among young adults of Karaganda city.

5. To develop a concept, on the basis of which to create, test and implement a model for providing free dental care to the child population by a private clinic.

6. To identify the factors of motivation of the management and staff of a private clinic to provide dental care to children on a free basis according to the family principle and the changes in its personnel composition and the attitude of doctors to work that occurred in this connection.

7. To evaluate the effectiveness of the proposed model of organizing dental care through long-term monitoring of the studied contingent of the child population.

Scientific novelty

As a result of the study, for the first time:

- Over 20 years of successive (1988, 1998, 2000, 2005, 2007) epidemiological studies among the child population of Karaganda city, a significant reduction in the prevalence of dental caries among schoolchildren was established (the average prevalence of dental caries decreased from 84.61±1.11% in 1988 to 72.76±1.56% in 2007, and the intensity of the lesion, respectively, from 1.99±0.07 to 1.27±0.04 on average per 1 examined person), which is associated with the natural optimal for this region content of fluorine in drinking water (0.5-0.6 mg/l) and the expansion of the use of oral hygiene products, including those containing fluorine;

- the highest level of organization and provision of dental care to the child population of Karaganda city was recorded at the time of the first survey (in 1988), i.e. during the period of planned development of healthcare (the share of fillings in the DMF structure then reached 80-90% among schoolchildren). At the second stage of observation (1998), as a result of the collapse of the state healthcare system of Kazakhstan, it decreased to 30%;

- it was established that as a result of the cessation of the existence of the only children's dental polyclinic in the city, the share of carious teeth in need of treatment increased in the DMF structure of schoolchildren from 16.8% to 56.8%, and in the dmf structure from 13.7% to 58.9%. The share of caries complications in permanent teeth increased by more than 5 times (from 1.01% to 5.55%, respectively) and by more than 10 times in the dmf structure (from 0.76% to 7.51%), the share of permanent teeth to be extracted among schoolchildren increased by 3 times (from 0.5% to 1.51%). In 1988, in the dmf structure there were no recorded complications of caries of temporary teeth subject to extraction, and 10 years later their share was already 12.8%;

- to correct the situation, for the first time in Kazakhstan, a new model of providing dental care to children on a free basis (at the expense of financing by a private clinic) according to the family principle was proposed and applied. Their treatment is paid only by parents and other adult family members (and not higher than the current price list), and children receive dental care free of charge at the expense of gratuitous investments of the firm;

- the transition to the new service system made it possible to improve the DMF structure of schoolchildren of Karaganda city practically to the previous best level: the share of fillings among schoolchildren of the experimental bases was brought to 60-70% by 2007. At the same time, 28.2% of students aged 16-19 now receive sanation twice a year;

- an inversely proportional relationship was established between fluorosis, caries and dentoalveolar anomalies: the higher the frequency of fluorosis among the child population, the lower the prevalence of dental caries and dentoalveolar anomalies. It is shown that with a relatively high prevalence of dentoalveolar anomalies in the child population of Karaganda city (29.8% in preschoolers and 47.4% in schoolchildren), the need for orthodontic care is currently met by no more than 5-10%;

- the timing of eruption of all groups of permanent teeth in the region located near the former nuclear test site was studied. Their acceleration was established (6th teeth erupt in the child population of Karaganda city already at the age of 4), and the completion of the formation of occlusion is observed at 10-12 years. In girls, the process of eruption proceeds at a faster rate than in boys. All groups of permanent teeth (except for the 4th and 5th) erupt earlier on the lower (mobile) jaw. The earlier eruption of premolars on the upper (immobile) jaw indicates their determining role in its development, as well as in the formation of occlusion in general;

- delays in the timing of eruption of permanent teeth in adolescents and young adults of Karaganda city were established in comparison with other regions of the former Soviet Union, which is probably due to the peculiarities of the location of the city and the proximity of the former nuclear test site. They are observed in 16.7% of boys and 24.5% of girls at the age of 14 and in 14.3% and 3.3% of persons, respectively, at the age of 16-19;

- the need for implantological dental care among young adults was determined. Its highest level (17.3%) is observed among young people aged 16-19 (including 3.6% of persons with unerupted teeth and 13.6% with defects of the dentition);

- it is shown that the proposed model of providing dental care to the child population of Karaganda city on a free basis at the expense of investments of a private firm turned out to be economically beneficial for it, despite additional costs, and attractive and popular for the population. Over the years of its implementation, the number of children taken for free service increased by 117 times, and the number of adults (with a disproportionately higher level of need for dental and, above all, orthopedic care) — by more than 150 times. Due to the treatment of adults, the clinic's income increased, which many times exceeded its expenses for the free treatment of children.

Practical significance

The proposed service model gives a high medical (quality sanation of the adult and child population is ensured), social (free dental care continues to be provided to the child population) and economic effect (now parents do not need to spend their own money on providing quality dental care to their children, i.e. there is a clear saving of their budget), which is especially important in the conditions of predominantly non-state healthcare and the relatively low income level of the majority of the population of the Republic of Kazakhstan.

This model of organizing and providing free dental care to the child population has been tested, implemented and successfully functions in the conditions of Karaganda city and other regions of Kazakhstan for more than 5 years. As a result, the quality of treatment has improved and the introduction of the latest technologies has been ensured, in particular orthodontic (bracket systems) and orthopedic (dental implantation).

Scientific propositions of the thesis submitted for defense:

1. Data from a successive long-term (1988-2007) epidemiological survey of the child population of Karaganda city showed a decrease in the prevalence and intensity of caries of permanent teeth in schoolchildren, but an increase in the prevalence of caries of temporary teeth in preschoolers. At the end of the first decade (1998), it was noted that with the transition to a predominantly private dental service in the Republic of Kazakhstan, the volume of dental care provided to the child population of Karaganda city decreased many times and its quality deteriorated. The model of providing dental care to children on a free basis, developed, tested and implemented over more than 5 years, made it possible during the period of its implementation (since 2003) to significantly change the situation: the share of fillings increased among schoolchildren practically to the previous best level.

2. The accelerated eruption of permanent teeth in children as a result of the worldwide general processes of acceleration also applies to the territory located near the former nuclear test site. The earlier eruption of the 4th and 5th permanent teeth on the immobile upper jaw indicates their important role in its development and the formation of occlusion. The observed delays in eruption in adolescents and young adults are associated with the geographical features of the region, which also contribute to the development of dentoalveolar anomalies, which reached 29.8% in preschoolers and 47.4% in schoolchildren. In their structure, occlusion anomalies predominate (27.1% and 31.2%, respectively).

3. The organization of free dental care for children by a private clinic is an important socio-economic factor contributing to the improvement of the health of the population in the conditions of predominantly non-state healthcare and the introduction of new technologies, including dental implantation, the need for which is 17.3% among persons aged 16-19.

Implementation of research results:

The results of the study have been introduced into the work of dental organizations not only in Karaganda city, but also in the Semipalatinsk, Taldykurgan and a number of other regions of the Republic of Kazakhstan. The materials of the study are used in reports, lectures and practical classes in the training of dentists, as well as in the system of their postgraduate education at the Karaganda State Medical Academy. The proposed concept and program for providing free dental care to the child population were approved and included for implementation in the decisions and resolution of the IV Unifying Congress of Dentists of the Republic of Kazakhstan (Almaty, May 2008). They were transferred to the Ministry of Health of the republic for wider implementation.

Approval of the work:

The materials of the dissertation were reported at:

- the III International Congress "Dentistry of Kazakhstan, 2004" (2004);

- the IV International Conference "New Organizational Forms of the Children's Dental Service in the Republic of Kazakhstan" (2005);

- the II Regional Dental Conference (Pavlodar, 2006);

- the I Republican Dental Conference (Astana, 2007);

- the V Republican Dental Conference (Pavlodar, 2007);

- the XIX All-Russian Scientific and Practical Conference "Current Problems of Dentistry" (Moscow, April 2008);

- the IV Unifying Congress of Dentists of the Republic of Kazakhstan (Almaty, May 2008);

- the XXI All-Russian Scientific and Practical Conference "Current Problems of Dentistry" (Moscow, April 2009);

- the International Scientific and Practical Conference of Dentists of the Republic of Kazakhstan "Priorities for the Implementation of the Program for the Prevention of Dental Diseases in Children" (Almaty, May 2009).

The pre-defense discussion of the dissertation was held at a joint meeting of the staff of the departments of maxillofacial surgery, orthopedic dentistry, therapeutic dentistry, experimental implantology, orthodontics, the laboratory of methods and means of prevention, as well as the scientific and organizational department of the Federal State Institution "TSNIIS and ChLK Rosmedtekhnologiy", with the participation of staff of the Karaganda State Medical Academy.

Publications:

On the topic of the dissertation, 25 works were published, of which 9 were in central press.

Structure and scope of the dissertation:

The dissertation work is presented on 254 pages, consists of an introduction, 7 chapters, "Discussion of the results obtained", Conclusions, Practical recommendations, a List of references. The dissertation contains 39 tables and is illustrated with 18 figures. The list of references contains 198 sources, of which 159 are domestic (in Russian) and 39 are foreign authors.