Table 1 below shows that majority of the respondents are from public hospitals and they are mainly dentists and dental therapists. Respondents in the public hospitals comprise both tertiary and primary health center staff. The primary health center in the rural area has just one dentist. While the tertiary facility has 35 respondents.
Table 1: Provider characteristics
Variables
|
Total f (%)
|
Public facility
f (%)
|
Private facility
f (%)
|
X2 (P-value)
|
Geographical location
Urban
Rural
Total
|
15(28.8)
37(71.2)
52(100.0)
|
9(17.3)
36(67.3)
45(86.5)
|
6(11.5)
1(1.9)
7(13.5)
|
12.745(0.001)
|
Facility type
Tertiary Hospital
Rural Health Centre
Dental clinic
Total
|
35(67.3)
1 (1.9)
16(30.8)
52(100.0)
|
35(67.3)
1 (1.9)
9(17.3)
45(86.5)
|
0(0.0)
-
7(13.5)
7(13.5)
|
16.654(0.000)
|
Cadre of Respondents
Doctor
Dentist
Dental nurse
Dental Therapist
Total
|
1(1.9)
31(59.6)
4(7.7)
16(30.8)
52(100.0)
|
1(1.9)
28(53.8)
3(5.8)
13(25.0)
45(86.5)
|
0(0.0)
3(5.8)
1(1.9)
3(5.8)
7(13.5)
|
1.378(0.711)
|
Highest education level
Diploma
Bachelor of Dental Surg.
Master’s degree
Post-grad. fellowship
Total
|
20(38.5)
26(50.0)
4(7.7)
2(3.8)
52(100.0)
|
16(30.8)
24(46.2)
3(5.8)
2(3.8)
45(86.5)
|
4(7.7)
2(3.8)
1(1.9)
0(0.0)
7(13.5)
|
2.245(0.523)
|
*Public oral facility in the rural area comprises respondents in both tertiary and primary health facilities
Table 2, shows there is no significant difference in facility opening days and times across both facility types (p<0.05). Only the tertiary hospitals are open 24hrs. However private facilities are open for much longer. Average patient load is more in the public health facility than private with highest service being extraction (P>0.05). Majority of the respondents across both the public and private dental facilities indicate the existence of a referral mechanism and the patients are usually referred to the tertiary health facility.
Table 2. Availability of dental services and provision of treatment
Variables
|
Total n (%)
N=52
|
Public facility
n (%)
|
Private facility
n (%)
|
X2 (P-Value)
|
Facility opening days
Monday to Friday
Monday to Saturday
Monday to Sunday (Tertiary)
|
15(28.8) 8(15.8)
28(55.8)
|
15(28.8)
1(1.9)
29(55.8)
|
0(0.0)
7(13.5)
0(0.0)
|
44.48(0.000)
|
Facility opening times
24hrs (Tertiary)
8am-4pm
8am-6pm
9am-5pm
Others
|
34(65.4)
10(19.2)
2(3.8)
5(9.6)
1(1.9)
|
34(65.4)
8(15.4)
2(3.8)
0(0.0)
1(1.9)
|
0(0.0)
2(3.8)
0(0.0)
5(9.6)
0(0.0)
|
38.26(0.000)
|
Mean number of patients who received services:
Dental filling
Extraction
Root canal treatment
|
37.72(37.7)
132.80(190.8)
28.00(11.5)
|
39.56(40.7)
148.41(201.7)
30.52(6.2)
|
27.43(8.66)
39.14(35.10)
16.14(21.13)
|
198.13 (0.00)
0.195 (0.000)
12.12 (0.000)
|
Whether provider inform patients of procedure
Yes
No
|
51(98.1)
1(1.9)
|
45(86.5)
0(0.0)
|
6(11.5)
1(1.9)
|
6.555(0.135)
|
Referral mechanism
Yes
No
|
37(71.2)
15(28.8)
|
30(57.7)
15(28.8)
|
7(13.5)
0(0.0)
|
3.279(0.070)
|
*Where patients are usually referred to
Tertiary
Secondary
Private clinic
Total
|
29(76.3)
1(1.9)
7(21.1)
37(100.0)
|
22(57.9)
1(2.6)
8(21.1)
31(81.6)
|
7(18.4)
0(0.0)
0(0.0)
7(18.4)
|
2.663(0.264)
|
Table 3 below shows that there is a difference in availability of both disposable and reusable equipment across facility types (p<0.05). The use of infection control guideline is similar across facility type (p<0.05). A good number of respondents from both facility types indicated that they have functional equipment. All respondents from the private health facilities interviewed indicated availability of clean water, soap and personal protective equipment compared to public.
Table 3 Comparing available equipment and infection control measures in public and private dental facilities
Variables
|
Total f (%)
N=52
|
Public facility
n (%)
|
Private facility
n (%)
|
X2(P-value)
|
Equipment used in facilities
Disposable
Reusable
Auto-disable
Both Disposable and Reusable
|
6(11.5)
2(3.8)
1(1.9)
48(92.3)
|
6(11.5)
2(3.8)
1(1.9)
41(78.8)
|
0(0.0)
0(0.0)
0(0.0)
7(13.5)
|
1.055(0.580)
0.324(0.569)
0.159(1.000)
0.674(1.000)
|
Use national infection control guideline
Yes
No
Can’t say
|
42(80.8)
1(1.9)
9(17.3)
|
36(69.2)
1(1.9)
8(15.4)
|
6(11.5)
1(1.9)
0(0.0)
|
7.853(0.049)
|
Availability of functional equipment
Electric autoclave
Electric heater sterilizer
Fun health sterilizer
Electric steamer
Pot with cover
Cold sterilization
X-ray machine
Dental syringe
Light curing machine
|
51(98.1)
38(73.1)
36(69.2)
18(32.7)
14(25.0)
34(65.4)
43(82.7)
52(100.0
46(84.6)
|
44(84.6)
31(59.6)
29(55.8)
18(34.6)
12(23.1)
28(53.8)
39(75.0)
45(86.5)
39(75.0)
|
7(13.5)
7(13.5)
7(13.5)
0(0.0)
2(3.8)
6(11.5)
4(7.7)
7(13.5)
7(13.5)
|
0.159(1.000)
2.980(0.169)
3.595(0.085)
4.282(0.039)
0.011(0.916)
1.477(0.399)
3.689(0.055)
0.161(1.021)
1.055(0.580)
|
Resources for infection control
Clean water
PPE
Soap
|
50(96.2)
51()98.1)
52(100.0)
|
43(82.7)
44(84.6)
45(86.5)
|
7(13.5)
7(13.5)
7(13.5)
|
0.324(1.000)
0.159(0.690)
0.234(0.873)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Table 4 below shows the cost of dental caries treatment procedure per patient. For a complete procedure, the average amount charged for consultation per patient is N1357 and N1580 in public and private facilities respectively. The average cost for the majority of procedures is much higher in private facilities.
The data shows that the T-test for consultation, composite and GIC fillings, extraction, root canal and scaling and polishing has a p-value of <0.05, we, therefore, reject the null and accept the alternative hypothesis (H1) which states there is a significant difference in the cost of providing dental caries treatment service in the public and private dental facilities..
Table 4 Cost of dental caries treatment procedures per patient
Variables
|
Public facilities Mean (SD)
|
Private facilities
Mean (SD)
|
Levene’s test for equality of variances
|
t-test for equality of means (sig-2 tailed)
|
Total Mean (SD)
|
Registration
|
1357.1(801.8)
|
1580.7(648.5)
|
0.122
|
0.090
|
1550.0(667.0)
|
Consultation
|
571.4(534.5)
|
1113.6(644.9)
|
0.770
|
0.007
|
1039.2(653.8)
|
Drug
|
11.4(75.4)
|
571.4(534.5)
|
0.000
|
0.012
|
88.23(277.6)
|
X-ray
|
976.7(552.5)
|
1142.8(556.3)
|
0.000
|
0.311
|
1000.0(247.4)
|
Composite filling
|
6045.5(1033)
|
9714.3(955.9)
|
0.725
|
0.000
|
6549.0(1616.3)
|
GIC filling
|
5090.9(1654)
|
16714.3(1592.9)
|
0.580
|
0.000
|
6686.3(7007.1)
|
Amalgam filling
|
4193.2(947.6)
|
5333.3(877.4)
|
0.000
|
0.000
|
4265.9(966.0)
|
Extraction
|
4340.9(491.5)
|
7857.1(367.6)
|
0.657
|
0.000
|
4823.5(1599.4)
|
Root canal
|
19545.5(3015)
|
31214.3(596.1)
|
0.432
|
0.000
|
21147.1(6221.2)
|
Porcelain Crown
|
34932(2002.4)
|
40500.0(2161.4)
|
0.154
|
0.513
|
35600.0(12182.3)
|
Acrylic crown
|
11714.3(5964)
|
13238.6(4796.4)
|
0.350
|
0.077
|
13029.4(4116.3)
|
Bridge (Fixed)
|
11486.1(8392)
|
29166.7(14288.7)
|
0.058
|
0.944
|
75307.7(74713.2)
|
Partial denture
|
5261.4(7171)
|
10714.3(11455.9)
|
0.025
|
0.128
|
6009.8(7972.8)
|
Scaling and polishing
|
1666.7(1813)
|
6714.3(3309.5)
|
0.828
|
0.023
|
3526.3(3802.3)
|
Findings of qualitative interviews stated below show:
Accessibility
Location of oral health services: Some respondents stated that facility location generally influence the type of services provided, the number of patients seen in a facility and the type of patients seen. While some others, (mostly respondents in the private dental facilities) opined that location will only influence the caliber of patients that attend a dental facility and not the type of services provided. However provision of a type of service is most times tailored to the ability to pay which is a reflection on the type of patient attending. Respondents also stated that the location of their facilities also determine pricing of oral healthcare services. Below are the views of study respondents:
“We don’t get a large number of patients because the facility is far from town. When you add the transport cost with treatment cost and inconvenience of travelling to the teaching hospital, a lot of patients opt out for clinics in town. (P6)
“Because of my location, respondents in the high socio-economic strata don’t like coming to my clinic. So that is when I refer them to other dentists with dental clinics situated in upper class neighborhoods (P3). A similar view was shared by another respondent however in addition the respondents says “ I am located in the village community and as such those that have some money will not want to visit a village dental center and often prefer the private dental clinics in town”(P1)
“Unfortunately we cannot have uniform pricing for dental caries treatment services among all dental facilities in both public and private. Even in private facilities prices sometimes differ because some of us cost services provided in our clinics based on whether we are situated in a high brow or low brow area” (P4).
“My price is partially based on location and is not about the price of the materials. We all buy dental materials from the same market so I feel the cost of my services is based more on location and my target clientele. My target market is not very rich because if they are rich I can adjust my prices at any time”. (P2)
Availability
Provision of services: In response to the question about the dental caries treatment mostly provided majority of the respondents stated that tooth extraction was the most common service provided in their facilities. Most of the respondents come so late with untreated dental caries that the only options left are root canal and extraction. Because extraction is the cheapest option, they usually opt for it. However, some dentists also claim that a good percentage of patients receive dental filling. Root canal therapy, crowns and dentures which are treatment options for dental caries. Responses are shown below:
“Extraction is the one that is regular. The patients may not be able to afford to pay for other ones, they will go for extraction. It is the cheapest”. (P1) We usually provide fillings and root canal therapy for bad cases but sometimes the patients cannot afford to pay despite our insistence so we might end up doing more extractions (P4)
“Most of them cannot pay because of their economic status. Most patients will always want to go for root canal but by the time you tell them how much root canal costs, they will end up telling you to extract (P3) “They usually say, I don’t have that kind of money” please remove the tooth.(P6) In looking at the factors influencing provision of services, all the respondents state that the equipment and technological advances affect the type of treatment provided and also influences the pricing of services. The availability of electrical power source is a crucial issue in service provision because dental procedures need electricity it is difficult to provide services without adequate power supply. Majority of the respondents claim that the epileptic power supply has necessitated a rise in the cost of services to accommodate this. Only the public hospitals claim that their pricing remains the same even when there is no power.
“…One of the major challenges we have is power supply (P3). Most times we have to provide a generator (P5). If there is no power, we use our generator and then continue treatment. But of course that will now increase the cost of treatment because we now spend more providing power that government should be giving us.”(P1)
Most providers have an alternate power source which drives up cost. Respondents also claim that the type of equipment available in the facility will affect the ability to provide diverse treatment options for dental caries. Respondents in the rural public primary care facility are particularly affected by lack of equipment as most rural primary care facilities are grossly under equipped. Respondent views are show below:
“Of course type of equipment available affects cost of services. Like fillings we can’t do complex dental fillings. We do very simple fillings because the type of equipment that we have affects it. We don’t have amalgamator for preparing our amalgams, we don’t have filling equipment so it affects. We should do simple filling here as primary rural health care. We don’t have them, we don’t have hand pieces for cutting, and we don’t have bowls. So most time we just do GIC fillings or atraumatic restorative treatment which does not require us to use machines”(P7)
Some other providers complained about the fluctuating or inordinate cost of dental materials affecting cost of treatment. Dental service provision in most cases seems to be a monopoly in Enugu State and as such price fixing by individual private dental practitioners is rampant. The dental facility heads set prices based on how cheap or expensive they purchased the consumable dental materials and what they perceive their profit margin should be.
Cost of treatment is determined by cost of materials but this is not immediate unless the management sees no returns” (P6). I usually charge based on cost of material. I can be lenient at times but if I see no returns I have to increase charges a bit so I can buy more materials.(P5)
Government policies and taxes have also affected the cost of dental caries treatment services as well as every other dental service. Majority of the respondents state that the since most of the equipment and consumables used in dental caries treatment are not manufactured locally, any increase in government tariff or importation ban, will drive the cost of equipment and products up and this will affect the pricing of services. However, this view was expressed mainly by the respondents in the private dental facilities as shown below:
“Is just all these tariffs they place on importation. You know all the materials are almost imported. So it is difficult to get sometimes (P5). When government increase tariff, the price of materials increase so you are bound to increase your own treatment cost. So we do not increase price on our own but based on cost of materials”.(P2)
Let’s say it has affected negatively definitely because we have multiple taxation in Enugu State. Local government will tax you, state government will tax you, and environmental agency will tax you. All these things from one establishment and all these are still going back to government purse (P3). Multiple taxation is not encouraging. When you check how much you pay in a year plus the facility equipment and all those stuff. It is not easy and of course the patient has to bear all these costs. (P4)
Affordability
Ability of consumers to pay: Patients that present at the dental clinic mostly pay out of pocket and only a few of the facilities offer health insurance for clients. Namely the tertiary institution, and a few private dental facilities in the urban area. The majority of dental health facilities do not cater to patients on health insurance. Dental treatment services under the National Health Insurance Scheme (NHIS) is listed as secondary care and as such dental health care providers are secondary care providers. Most dentists frown at this because it means the patients do not have immediate access to the dental health care provider and as such most patients turn up late. Other respondents opined that many dental health care providers and even patients have very poor knowledge of how the insurance scheme works for dentistry.
“Well to be frank with us, NHIS has not really tried in the dental aspect. The most covered treatment choice is extraction. If a patient opts out of an extraction, then any other treatment becomes too expensive. The cheapest any practitioner would want to do a root canal treatment is twenty thousand (20,000). NHIS don’t cover it and so that means they are encouraging patients to remove their teeth. So treatment option for anybody that is under NHIS is either scaling and polishing or extraction (P4). There are other insurance types, mainly private health insurance which is better but not available to everyone (P3).
‘We have NHIS but to be honest most patients still end up paying out of pocket, because the NHIS plan does not cover most of the treatment needed and even when they cover, the process is so tedious that some patients just opt to pay”(P6)
“: More awareness is needed and the insurance agencies should review their level of operation and then the population should stop being scared because most of them have this phobia for dental treatment and anything dental. No dentist can go to people’s houses to force them out. So I think information is the key actually and then government also should review their own aspect and open more windows. (P5)
Respondents opined also that the social health insurance scheme benefit package is very poor and policies regarding dental health insurance are basically non-existent or very poorly formulated as there is minimal awareness or knowledge about dental health insurance amongst HMO’s and policymakers. This is reflected in the poor benefits package and the inability of most HMO’s to include dentistry in their health insurance plans. Only a few HMO’s have relatively robust benefits packages and they are mainly private health insurance plans.
“Well to be frank with you when it comes to dental policies most of my friends that are into health insurance and all what not that are doctors don’t really know anything about dental treatment and its policies. They usually more interested in medical insurance. I keep telling them that dental aspect is very important. They provide little or nothing and if you check very well those people that made the health financing policies are not even dentist” ( P3).
“Yes. At the policy level dentistry is important. In fact at the policy level it is very important because when you make things better, now so many people are going for the NHIS medically because they are seeing the benefit but most of them are not going in dental because they don’t see any benefit. Is either I wash my teeth or I remove it.” (P4)
On the issue of fee exemptions and subsidies, most respondents are not aware of any government policy directive on this and usually only give discounts on compassionate grounds. Each facility grants indigent clients discounts based on their assessment of poverty status. There is no scientific way of deciphering this. Neither is there any laid down protocol for this. Waiver or subsidization of fees is dependent on the dentist and the management of the facility. Some practitioners, especially in the private sector, usually give the clients a payment plan where they can pay their fees in smaller regular instalments. This is shown in respondents statements below
“Most times I do that out of empathy not that there is a discount constitution. So my giving an exemption or price waiver depends on my interaction with the patient and if I can help” (P3).
“There is nothing like fee exemption or subsidy and I don’t think there is anything in the government policy that says that. If there is I have not seen” We just give discount for some people period. Maybe the government hospital can give full waiver but how can private do that? We are struggling too in this harsh economy (P4).
“In a public center, you do not have the power to give any waiver or subsidy unless it’s an already documented protocol in the center. If not permission must be sought and the go-ahead given by management before that can be done”(P6)
Accomodation
Organization of services: Excerpts from literature show that the right number of staff and appropriate staff mix goes a long way in improving service provision in healthcare facilities [16] . In response to the question on appropriate staffing, majority of the respondents claim to have an appropriate number of staff, with the right staff cadre to provide quality dental care. We observed that the public oral health facilities had a good complement of staff except for the primary care facility in the rural area. This had only one dentist catering to the population. The private facilities claimed to each have different staff cadres in their dental team making service provision better. However on further probing we observed that the private clinics most times had one staff cadre performing multiple functions such as a dental therapist doubling as a dental surgery assistant. The human resource challenge in public dental facilities offering primary dental care in the rural areas is glaring however this challenge also exists in the private facilities though muted. Quotes from respondents are shown below.
“Another thing I face is that you know they said two good heads are better than one so I’m all alone here. If I need a second opinion I don’t have anybody to turn to. So that is another challenge I’m facing. Besides the work is too much for one person. But because I am alone and greatly short staffed. I don’t really take on too many patients and I don’t think the services provided here will ever meet the needs of the people unless the situation changes” (P7)
My staff strength is adequate I have two dental therapists and one doubles as a dental nurse and I have part time technologists. ( P4)
We have enough doctors and dental staff to meet the needs of our patients. We have the full complement. All staff cadres are ably represented. (P6)
Awareness
Communication and information about oral health services: Most of the respondents believed that the majority of members of their community had little knowledge about dental caries treatment options and treatment of dental diseases as a whole. This they believe would account for late presentation of most patients with dental caries which would have progressed so bad that the only option would be to do a root canal or extraction. As root canal is more expensive, a lot of them opt out for extraction.Majority of the oral health facilities do not carry out dental awareness or oral health education programs with the exception of the teaching hospital through its community dentistry unit. Some of the private dental clinics claim though to carry out sporadic enlightenment programs in elementary schools in their environment. Most cite funding challenges to carry out mass oral health enlightenment programs.
“Ok the challenges I face is that most of the community members are not enlightened that is they are ignorant of dental care… (P7)
“We do conduct oral health education and awareness talks in some communities around us. Our community dentistry department sees to this angle (P6)
“We try to do oral health awareness but it’s mostly for patients that we have finished treating. It’s difficult to do community enlightenment because its cost intensive, who will pay. Government hospitals can do that because government will pay or subsidize but we have to pay for everything from what we earn in the clinic-------- ah it’s difficult oh (P4)
“Schools we do go to some local schools in our area and just talk to the children, but not all the time oh, we go maybe on children’s day or world oral health day. But no special arrangement just whenever we feel like”(P3)