1. Bardach Policy Paper
Target decision maker: Health Minister of India
Problem Statement
In India, prevalence of oral diseases is very high with the 2 most common oral diseases across
age groups being dental caries (50%-80%) and periodontal diseases (50 %-80%) (5), where
chronic oral diseases have a negative impact on an individual’s general health, self-esteem and
quality of life.1
Evidence
With more than 1.12 billion people, India accommodates 17.5% of the world’s population, 70%
of whom reside in rural areas where the availability of the dentists is as low as 10%.2,3,6
Inequalities in oral health are deeply rooted in society with rich countries showing a marked
reduction in dental caries whereas there is a rise in incidence of dental caries in developing
countries due to westernized diets and increased consumption of sugar.10,12,13 Along with being a
widespread chronic condition, oral diseases are amongst the most expensive diseases to treat.
10,11 The most affected population being the poor, vulnerable and marginalized groups, with 29%
below poverty line and according to the Multidimensional Poverty Index, more than 55% are
poor.15 However, even with the grave burden of oral diseases the quantity and quality of
healthcare facilities in the rural area is not up to the mark. Unlike “Pulse Polio Policy” in India,
the oral health policy does not include local health workers (Anganwadi workers) who have
already been trained to systematically collect community health related data and have intimate
knowledge of community health history.16 The shortage of health workers along with the lack of

2. historic data, brought about by leaving out Anganwadi workers, together exacerbate the
situation.16
The growing burden of oral diseases include improper growth and development, pain, infections,
sleeping difficulties and malnutrition (48%).11,14 Given these evidences it is principal that oral
health care should be accessible, affordable, sustainable and based on needs analysis of the
population.16
Regardless of this burden, the health sector in India is not represented well in the national budget
with no specific allocation for oral health.4 In 1995, the Government of India (GoI) laid down the
foundation of The National Health Policy with the aim of achieving public health goals by 2004,
and later extended it to 2015.3 Unfortunately, not much has been done to implement or reform it,
considering the dynamic change in oral health status of the country.2,3 Evaluation of the National
Oral Health Policy was done using existing data, journals and observations using Maxwell
criteria (1992).17 The assessment criteria included.2
Access- Only about 60% of the rural population had access to a nearby primary health care
center. Existing primary health care (PHC) centers each provide for 20,000 -30,000 people with
only 1043 dentists posted in the PHC’s.2
Equity- People with the same needs do not get the same treatment as there is a lack of
consistency in treatment measures. Dental care facilities are concentrated in the urban areas and
the cost of the treatment varies greatly.
Effectiveness- The policy cannot be assessed on effectiveness as there are no standardized
measures to analyze the oral health outcomes.
Acceptability- The oral health policy lacks the uniform treatment guidelines that respects the
autonomy of the people and takes into account regional differences.

3. Relevance- The treatment may or may not meet the potential needs of the patient as the needs
assessment has not been done.
Efficiency- Cost beneficial programs like training health-workers, using teachers as the
workforce has not been established all over India.
There is ample evidence that there is a pressing need for a sustainable, affordable and a needs
based oral health policy as the burden of oral diseases is rising due to rapid increase in
population while resources are being depleted.7
Policy Alternatives
1. Strengthening the capacity and capability of the dental workforce - With around 300 dental
colleges in India, annually 25,000 dentist graduates pass out of college.18 There is plenty of
dental workforce but most of the dentists gravitate towards big cities as the return on investment
in education is low in rural areas. This causes an unequal distribution in the dental workforce
between urban and rural areas. To tackle this issue, like the oral health policy in Brazil (Smiling
Brazil), the government should allot some part of funding for curriculum change to train the
dental professionals in delivering primary health care and make them aware of their social
responsibilities, betterment of infrastructure and leadership skills which can help to create a self-
sustainable preventive oral health program.9,16 Initiatives should be taken to create job markets
for dentists by including them in the national oral health program, fostering ties with the public
health services.9 This will give the fresh crop of dentists adequate, reputed and good salaried job
opportunities devoid of any urban-rural inequalities.3
There exists a wide network of PHC’s and health workers in rural India.16 The immensely
successful public health program -“Pulse Polio program”- in India, recruited and trained

4. Anganwadi Workers who are trained to perform routine immunization, provision of healthcare
and government aid through continuous personal touch with families in the community.16 Using
the existing resources, which made the Pulse Polio program successful, and integrating an oral
health component can be a practical approach as these health workers have knowledge of the
health records of the people in the community.16 Educating the health workers and integrating
oral health tools like oral health education, tooth brushing technique, fluoride application and
preventive dental skills could be a game changer in reducing the incidence of dental diseases at
the grass root level.16 Health workers can be selected from the same/neighboring village making
them more accessible to the communities. Establishing a goal oriented network of all
stakeholders like health workers, local dentists, and neighboring dental schools is key to any
sustainable health program.16
2. Developing necessary epidemiological research which will yield comprehensive data, mirroring
the needs of the population8 - In a diverse country, like India, with urban vs rural disparity in
terms of socio economic and geographical variation, the prevalence of oral diseases is varied as
one would expect. Comprehensive epidemiological research and surveillance serve as pillars to
policy making as this evidence based research methodology provides primary data about
different trends like the magnitude of the disease in the country, distribution of health facilities
and infrastructure, and the expenditure of funds.9,8 Inferences from this essential data facilitate
discussions and planning of oral health actions.9 In Brazil and Nigeria, the success of their
respective oral health policies can be attributed to the fact that they set aside funds for needs
based analysis helping them to prioritize their interventions which ultimately led to efficient
utilization of funds at the local level.8,9

5. 3. Status Quo- The status quo did not provide any reforms in the policy which was formed in 1995
given the shifting dynamics of oral health in India.2,3 Moreover, there is no provision for strategic
allocation of funds based on needs analysis. With no equitable distribution of the gross national
product for healthcare, the GoI currently ranks among the lowest in the world in terms of
percentage of GDP spent on healthcare.1
Criterion
The 3 key interrelated aspects of the process of bringing about change in status of health care in a
population are cost of implementation, the cost effectiveness of the program in the long run and
the overall improvement of health status in the community.
1. Improvement in oral health and general health status - Most of India suffers from chronic oral
diseases. This makes the reduction of oral diseases like caries and periodontal diseases one of the
most crucial criteria for this analysis. The weightage given to this criterion is 40%.
2. Cost-effectiveness - This criterion is important as it embodies long term effects of policy
intervention. Reduction in oral diseases in children will reduce the number of days missed at
school consequently reducing work time missed by parents which in turn leads to increased
productivity. This policy intervention will also save the population a lot of money associated with
the treatment of the diseases which is significantly higher than the cost of preventive treatments
while also lightening the demand on already strained health care infrastructure. The weightage
given to this criterion is 35%.
3. Cost of implementation - The reason for including this criterion is because previously the policy
did not take up interventions which were costly as the budget allocated for health services in India
is very low. This criterion helps incorporate the necessary time critical evaluation of suitable case-

6. specific investments and how they affect health outcomes in the long run. The weightage given to
this criterion is 25%.
Projected Outcomes
Improvement in
oral and general
health (40%)
Cost-effectiveness
(35%)
Cost of implementation
(25%)
Status quo 0 0 0
Strengthening the
capacity and
capability of the
dental workforce
++ + - -
Developing
necessary
epidemiological
research
++ ++ -
“0” means no effect “+” means positive effect “-” means negative effect
Criterion 1- Improvement in oral health and general health status - is positive for all alternatives
except for the status quo which is at 0, considered as the base case for all the three criteria.
Improvement of oral health gets a positive outcome for the other two alternatives as both of them
are focused towards reducing the oral health problems in India in the long run.
Criterion 2 - Cost effectiveness - Both the alternatives are positive but not of the same
effectiveness. Strengthening the capacity and capability of health workers will be directly cost
effective due to improved diagnostic and treatment skills. The results of such an intervention can
be seen in a relatively short period of time. With epidemiological research, on the other hand, the
cost-effectiveness is indirect. Strong research can provide insight into the needs of the population,
allowing informed decisions to be made in strategic allocation of funds and providing a clearer
picture of how the dental workforce should be trained and in what capacity.

7. Criterion 3 - Cost of implementation -Both the alternatives are negative but not to the same
effect. The cost of implementation is high when it comes to oral health programs. It includes
dental chairs, dental instruments, expensive materials (perishable and nonperishable), electricity
and running water. Developing necessary epidemiological research increases the cost in the
beginning but in the long run the collected data will help in careful distribution of funds
according to the needs of the population.
Confronting the Trade offs
Based on the alternatives of the outcomes matrix, out of the 3 alternative 2 project the most
favorable results.
The first policy alternative of strengthening the capacity and capability of the dental workforce,
provides a good reform in the existing policy. It will strengthen the existing dental workforce and
better equip them to tackle oral health problems at the grass root level. The cost effectiveness of
this policy alternative shows that training dental professionals and health workers reduce the
burden of oral diseases in the country. The downside of this alternative is the cost of
implementation. As mentioned above initially setting up PHC’s and purchasing necessary
equipment will be expensive as the budget set aside for health services is less.
The second alternative of developing necessary epidemiologic research has a better impact than
the first alternative. Epidemiologic research has an initial investment which pays off in the long
run as it forms the bases for the next steps in implementation of the policy. A good research will
help in identifying the needs of the community and will help in equitable distribution of
resources.

8. Looking at the weights of the criteria, both do well in promoting the basic objectives of the
policy. (40% weightage given to improvement of oral and general health, as it objective of the
policy alternative). The second policy fairs better in terms of cost- effectiveness (weighed at
35%) and the cost of implementation is less than that of training dental professionals and health
workers (weighed at 25%)
Policy Recommendation
On evaluation the 2 policy alternatives based criteria and tradeoffs it is recommended that the
government should consider channelizing funds into evidence based research, as stated above.
The impact of the 2nd policy alternative is more far ranging than the 1st policy option in terms of
cost effectiveness at a relatively reasonable implementation cost.
Conclusion
“If the mountain won't come to Muhammad then Muhammad must go to the mountain."(Turkish
proverb), with increase in burden of oral diseases the government has an opportunity to bring
accessible and affordable oral healthcare to rural India to alleviate the communities from deep
seated oral diseases.
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