English

Albanian

DENTISTRY AND ORAL HEALTH PROMOTION

IN ALBANIA - A COUNTRY IN TRANSITION

Published at “International Dental Journal”

2003/53, pp.100-113

Abstract

In Albania, as in all the other East European countries after 1990, reforms and big changes have occurred in oral health care. Reforms consisted of privatization, decentralization, new forms of financing, planing and managing dental services. Following that, two forms of oral health care provision currently exist: a public service and a private service. Changes have also occurred in dental education. Studies on oral health status of the population show a higher prevalence of oral diseases recently when compared to that before 1990. A new oral health strategy, based on a preventive approach has been started, focused on wide and regular use of fluoridated toothpaste, dental health education and promotion, sealant application and annual oral examinations.

 Background

Albania is one of the Balkan countries, located in South East Europe. It has a surface area of 28.000 square km and a population of 3 million. Before 1990, during communist rule, Albania was the most isolated and backward country in Europe.

Until 1990, dentistry in Albania, as in all Eastern European countries, was financed by the national budget, totally public, provided free of charge for the whole population, with strong central planing and control. The role of government in planning, organizing and financing oral health care was predominant. All dentists were salaried employees and worked in state-owned clinics.

After 1990, as result of political changes, a period of transition and big changes started. Fundamental reforms, in health care system, as in all services, commenced. The two main components of health care reform were privatization and decentralization. The first health care reform was in dentistry, and started in 1993. The changes consisted of dental service privatization, the creation of new structures for service provision and the introduction of new methods for organizing, administering, financing and managing.

In order to facilitate the changes, the whole legal framework has altered, new laws, orders and regulations have been prepared and approved. A separate law on dentistry, the first of its kind, titled the law on “Oral Health Care”, was approved by Parliament in 1996. It codifies the organization and function of dentistry in Albania.

In 1997, a policy document “An Oral Health Strategy for Albania”, was written in a collaboration between the Albanian Ministry of Health and University College London, UK. It identified the oral health status of the population in Albania, set objectives for a period of 10 years and defined ways to improve the situation.

The Ministry of Health (MoH) and the regional municipalities are responsible for the planning and administration of oral health care. At a central level, in the MoH, the sector of Oral Health Care is in the Department of Primary Health Care, staffed by two people: the CDO and a dental officer. At a local level, there are 36 dental public health services within district health boards, each headed by a district dental officer.

 Dental personnel

Consist of dentists, laboratory technicians, and dental nurses (chairside assistants). There are no dental hygienists. Before 1990, the majority of dentists were women (80%), but this ratio is changing. The number of dentists has increased over the last ten years, not because of the needs, but because a higher number of students are accepted by the dental school each year. More applications are made because students consider the dental profession more profitable than previously.

Following privatization, the systems of delivery of oral health care are:

·            The public dental service

·            The private dental service

 Public Dental Service (PDS)

Compose 30% of dentists in Albania. It is financed and managed by the state. It provides free dental care for children up to 18 years of age (preventive and curative treatments, excluding orthodontics), emergency treatments for adults and maxillo-facial surgery interventions in hospitals for all.

Public dental care is delivered in school dental practices (around 300), which are mainly in cities; in public dental centers (one for each district and three in the capital); in the University Dental Clinic (for those who cannot afford private clinics), where the dental care is provided mainly by the dental students under supervision; in the University Hospital Center (the maxillo-facial ward), for surgical interventions, and to a minor extent, at 12 regional hospitals.

The public dental service is facing a lot of challenges, mainly: poor accessibility in rural areas, equipment is old fashioned and not fully functional, sanitary conditions are not of high standard (risk of cross infections) and the quality of service is generally poor. The salaries of employed dentists are very low, so they are not motivated to work efficiently for the state, and on the other hand they work privately (illegally) in their public clinics to compensate for their low incomes. For these reasons the vast majority of children are not treated or they refuse to be treated in public clinics. 

Since even the wealthiest countries cannot afford a dental service based on reparative treatment, oral health care oriented to prevention is more appropriate. In 2002, a new reform, focused on a preventive approach, started. The main components of this reform are: concentration of public dental service into large, better managed clinics and transformation of school practices into oral preventive centres.

 The private dental service

Private dental service is financed neither by the government out of taxation, nor by state or private insurance schemes, but through direct payment by patients (out of pockets), patients paying full fees to the dentists.  The dentists work in independent private practices.

The private clinics ae generally better than public ones. Most of them, especially in the capital, have up-graded equipment and have good hygienic conditions. Even though all private clinics are equipped with sterilization devices, there is still a risk of cross infection, (such as SIDA/HIV, hepatitis B), because dentists are irresponsible and poorly trained. Fees, which are set by dentists (the market), vary considerably, and the majority of the population cannot afford them, because they are high in comparison with salaries and pensions. There is a lack of proper clinical and financial record keeping. The use of auxiliary personnel is almost non-existent. (few dentists have chairside assistants). Some laboratory technicians work directly in patient’s mouths, which is prohibited by law.

Being new to Albania, the private service is facing a lot of problems. The first one is the licensing of all private practitioners. Others are: introducing unified patient clinical records; strengthening cross infection control; increasing control over imported dental materials, which influence the quality of treatment. Another very important issue is regulating the distribution of dentists. Currently there are large differences in accessibility to oral health care, especially between urban and rural areas, for example the dentist/population ratio in 2001 in Tirana was 1/850, while in Kukes it was 1/14.000. The reasons for this variation are urbanization and the free movement of workforce (previously strongly controlled). This has led to dentists moving  especially to the capital. As a result, private dentists are concentrating in cities, leaving distant small towns and villages and more especially rural areas without dental services. A distribution control policy, approved recently, has started to be implemented.

 Licensing

The institution responsible for licensing private dentists is the Ministry of Health. The license is given by the Commission of Professional Licensing, after approval of the required documents, without a licensing exam. The license is valid for 2 years, but recently a 5 year license was introduced, if applicants meet certain more demanding criteria. Newly graduated dentists can be licensed only after two years of supervised practice.

Features of oral health care system

Ken Eaton and Eeva Widstrom in their monograph “Systems for the provision of Oral Health Care, Workforce and Costs in the EU and EEA”, have categorized the provision of oral health care in Europe into four groups: Bismarkian, Beveridgian, Nordic and South European. In my opinion, the provision of oral health care in Albania is a mixture with some features of the Nordic Model; a significant involvement of the government, free dentistry for people up to 18 years old, a proportion of dentists working for public dental service in salaried employment, and some features of the South European model; the payment system in private clinics (patients paying direct, out of the pocket).

Dental Education

There is only one School of Dentistry (the Department of Stomatology in the Faculty of Medicine, Univ. of Tirana), established in 1953. It is a public school, financed entirely by the state. Dental education lasts 5 years. The number of students admitted each year is between 50 and 60. The proportions between various subjects taught, has changed dramatically. Before 1990, communist subjects composed 25% of the curriculum and dental subjects only 40%. Now 70% are dental subjects and the rest are general medicine. Subjects on prevention, such as “oral prevention”, “dental public health”, “community dentistry” etc, are not included in the dental curriculum yet, but there are efforts to introduce the teaching of prevention. The first textbook in this field entitled “Oral Prevention and Dental Public Health”, has been published.

In postgraduate dental education, fewer and fewer dentists are specializing each year inside the country. Before 1990 in the Department of Stomatology, there was specialist training of 2-4 years duration in six disciplines of dentistry. Now the only one is maxillo-facial surgery. There are no schemes of continuing professional education/development. University professors and lecturers are allowed to work their own private practices (unlike other dentists for whom such double employment is prohibited). There are two private schools for training dental technicians. There is no school for dental nurses.

The main challenges are the introduction of subjects on prevention into the curriculum, the regulation of students’ numbers in accordance with workforce requirements based on dentist/population ratio, and establishment of education/training for dental hygienists.

 Oral health status

Epidemiological surveys to monitor the changes in oral health status have not been conducted on a regular basis or by specialized institutions. Sporadic studies by the dental school or by people who are conducting research for higher degrees have been undertaken.

The data from the last study conducted in 2000 (using WHO indicators and age-groups) are:

6 years old: caries free 83.7%, gingivitis free 71.5%

12 years old: DMFT 3.02, gingivitis free 58.7%

18 years old: DMFT 4.7

The data show worse oral health status in children compared with the situation before 1990. Reasons for higher oral diseases prevalence are: increases in consumption of refined foods and fizzy drinks and of a wide variety of sweets; under utilization of fluoride supplements or sealants; the lack of widespread and regular use of toothbrushes and fluoride toothpaste’s; the lack of dental health education and promotion; the privatization of the dental services and the resultant high prices and largely ineffective public dental services.

 Preventive strategies

The new approach will be based on preventive dentistry. The main components will be:

·        Oral hygiene and plaque control: even though toothbrushes and fluoride toothpastes are available in the market, not all children use them regularly. According to a recent study, only 50.8% of 12 year olds brush their teeth every day. Reasons for this are the low level of awareness of the population about the importance of tooth-brushing with fluoride toothpaste and the inability of the population to afford these products. Solutions for that would be health promotion for children to raise their awareness, reduction of taxes on toothbrushes and toothpastes and collaboration with big companies to manufacture economic products for the Albanian market.  

·        Sealants: rarely applied and only in some private clinics. This year a sealant scheme for 6 year olds will be implemented in public dental clinics.

·        Fluoridation: before 1990, there were highly organized school based programs for NaF tablets distribution. Now there are no schemes for water, salt or milk fluoridation or any other fluoride supplements.

·        Oral examinations and charting of children: continuation of the existing well organised program, performed by the dental personnel at the beginning of each academic year in the school centres.

·        Diet and nutrition: high and/or frequent consumption of sugars and changes in the eating patterns, have characterised the diet of the Albanian population in the last ten years, especially in young people. This trend needs to be reversed, mainly through dental education and diet counselling.

·        Oral health promotion and education: will be carried out at the preventive centres, but there is a lack of promotional materials, posters and booklets. Activities will be mainly focused on the importance of regular tooth-brushing for preventing caries and gingivitis, instruction on tooth-brushing techniques, and advice about the risk of high sugar consumption.

Bibliography

·        Bogdani M: Studim epidemiologjik për sëmundshmërinë orale për fëmijët në Shqipëri (1999) dhe ndikimi i faktorëve socialë, ekonomikë dhe demografikë ne frekuencën e hasjes së tyre, Disertacion. 2001.

·        Bogdani, M. & Ministry of Health Albania: A Strategy of Oral Healh Care for Albania - A Policy Document. 1999.

·        Widstrom E, Eaton K: Systems for the provision of Oral Health Care, workforce and costs in the EU and EEA. National Research and Development Centre for Welfare and Health, STAKES (Finland) 1999.

·        Widstrom E, Eaton K, et al.: Oral healthcare in transition in Eastern Europe. Britsh Dental Journal, 2001. Vol. 190, No.11.