CHAPTER 2: LITERATURE REVIEW
2.6 Challenges in equitable oral health care distribution
The primary roles of nurses relate to educating cancer patients both in the active and follow up phase of cancer therapy (Kav and Bostanci, 2006). However, nurses should first be educated properly about the importance of oral health care so that they can subsequently educate patients (Kav et al., 2008; Dolce, Haber and Shelley, 2012). Further, nurses can play a significant role in improving access to oral health care provided they are equipped with adequate education on oral health (Dolce, Haber and Shelley, 2012). They can also impact significantly on reducing oral health inequalities prevalent in socially marginalised and underdeveloped regions (Dolce, 2014). On the other hand, doctors also need to be educated of the value of oral health care (Dolce, Haber and Shelley, 2012). The process of effective management of head and neck cancer is also facilitated if doctors are educated on the importance of oral health and assessment of head and neck cancer patients before oncology treatment starts and of the role they have in timely referral of patients for oral health consultation and management (Lawrence, Aleid and McKechnie, 2013; Samim et al., 2016). This aids to decrease or avoid where possible, oral complications and organ malfunctioning, which may cause interference or interruption of cancer therapy (Patel et al., 2012; Sonis, 2013; Lang et al., 2014; Saito et al., 2014; Samim et al., 2016).
2.6 Challenges in equitable oral health care distribution
Equitable delivery of oral health care is a cornerstone of oral health promotion. Growing inequality in oral health service delivery in South Africa is a reality, with the urban areas being prioritised over the rural counterpart (Ramphoma, 2016). The WHO Global Commission on Social Determinants of Health states that health inequalities exist as a result of, “unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives - their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns or cities – and their chances of leading a flourishing life” (Kamargo, 2011). Furthermore, amalgamation of “poor social policies and programmes, unfair economic arrangements, and bad politics” all contribute towards inequitable health within a country (Kamargo, 2011). The literature reports that the deficiencies to set up a rigorous oral health promotion program are probably present due to a lack of health care workers, poor health budget allocation, shortage
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of equipment and transport problems, making it difficult to reach out to those whose needs are to be met (Reddy and Singh, 2015).
Despite the significant proportion of population who utilises the public health service in the country and also KZN, there is a lack of oral health care providers (Bhayat and Chikte, 2017;
Dookie, Singh and Myburgh, 2017). Adequate workforce is critical for delivery of high quality dental care (Bhayat and Chikte, 2017). The reasons pertaining to this lack, might be attributed to an uneven distribution of oral health care workers across districts, reduced recruitment by the public service due to limited posts, and migration of oral health professionals to other countries due to improved financial stability and lifestyle choices (Thema and Singh, 2013;
Bhayat and Chikte, 2017; Dookie, Singh and Myburgh, 2017). It is estimated that around 70- 80% of the 6125 registered dentists in South Africa are in the private practice which roughly serves 20% of the country’s population, while the rest is employed by the public sector to cater for the vast majority (Bhayat and Chikte, 2017). The dentist to population ratio is estimated to be in the order of 1:8900 countrywide, while it is around 1:2000 in developed countries (Bhayat and Chikte, 2017). This reflects the gap facing the oral health care system in terms of professionals being employed when compared to other countries. Similarly, oral health care has always been inadequate in the province (Dookie, Singh and Myburgh, 2017). The province has around 54% of its residents in rural areas where there is a severe disparity in oral health service delivery (Brindle et al., 2000; KwaZulu-Natal Department of Health, 2016;
Ramphoma, 2016). Distribution of oral health services is focused on urban regions (Brindle et al., 2000; Ramphoma, 2016; Dookie, Singh and Myburgh, 2017). However, the pattern of oral health service delivery within rural areas is also unequal across the province (Dookie, Singh and Myburgh, 2017). Inadequate number and maldistribution of oral health care providers across the province impact on the availability and equitable delivery of oral health services (Dookie, Singh and Myburgh, 2017). KwaZulu-Natal has the most worrying dentist to population ratio when compared to Western Cape and Gauteng provinces (Bhayat and Chikte, 2017). The ratio of dentist to cater for the population is approximately 1:12 891 in the province as compared to 1:4536 in Western Cape and 1:5627 in Gauteng (Bhayat and Chikte, 2017). In 2012, the number of dentists employed by the public sector was 78, among whom 26 were based in the Ethekwini district (Dookie, Singh and Myburgh, 2017). Dental therapists accounted for 26 in total, of whom 8 were based in Ethekwini, while among the 32 oral hygienists who were employed, 12 were distributed across Ethekwini (Dookie, Singh and Myburgh, 2017). The reasons which might be attributed to the uneven distribution of oral
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health care personnel include a deficiency of human resource planning and inadequate funded posts in the public sector (Dookie, Singh and Myburgh, 2017). Another challenge in achieving equitable delivery of oral health services is in relation to the reduced number and uneven distribution of oral health care facilities between the urban and rural divide, as well as within the rural setting (Dookie, Singh and Myburgh, 2017). The total number of fixed dental facilities in 2012 was 60, with 52% of them being integrated in district hospitals, while 13% were located in primary health care clinics and 22% in community health centres (Dookie, Singh and Myburgh, 2017). Ethekwini had 10 fixed dental facilities and is reported to be among the three districts that had the least number (10 facilities) of dental facilities when compared to other districts with a lower population density (Dookie, Singh and Myburgh, 2017).
Besides staff shortages, the location of oral health services with respect to habitation must also be considered to improve accessibility to oral health care. According to the norm in South Africa, the walking distance from the place of residence to the nearest primary health care facility should fall within 5 kilometres radius (KwaZulu-Natal Department of Health, 2016).
However, a survey carried out in 2010 reported that 672 272 houses were outside the established norm (KwaZulu-Natal Department of Health, 2016). Moreover, dedicated funding contributes to equitable oral health distribution (Dookie, Singh and Myburgh, 2017). The HIV burden is highest in KwaZulu-Natal as compared to other provinces, while tuberculosis (TB), is the most common infection requiring hospital admissions in the province (KwaZulu-Natal Department of Health, 2016). Tuberculosis is the primary cause of death globally and the majority of TB cases coupled with HIV infections is reported to occur in developing countries like Sub Saharan Africa (Khuzwayo and Naidu, 2014). The rate of HIV-TB co-infection is around 70% (KwaZulu-Natal Department of Health, 2016). The high burden of HIV, other sexually transmitted diseases and TB represent a severe drain on the health system, affecting the financial priorities and reducing the budget allocated for oral health development and service delivery (KwaZulu-Natal Department of Health, 2016; Ramphoma, 2016). It is further reported that constant scrutiny of the outcome and effectiveness of oral health promotion program is lacking and therefore very little is known so that improvement in terms of resource allocation and oral health status is made in South Africa (Ramphoma, 2016).
The literature reports that HIV-positive/AIDS individuals have an elevated risk of squamous cell carcinoma of the head and neck region, mainly non-Hodgkin’s lymphoma and Kaposi sarcoma (McLemore et al., 2010; Purgina, Pantanowitz and Seethala, 2011; D’Souza et al., 2014). A study carried out in KwaZulu-Natal and Western Cape provinces reported that,
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patients were not given the necessary oral care needed, when dentists and oral health care workers became aware of the HIV-positive status of the patients (Turton and Naidoo, 2008). It is further reported that many patients are either denied care by their dentists or experience a feeling of discrimination and unwelcoming attitudes on the part of dental health care workers when their HIV status are revealed (Robinson and Croucher, 1993; Turton and Naidoo, 2008).
This consequently acts as a challenge for patients with HIV-related head and neck cancer to access dental care.