Strategic Framework for Improving Oral Health in the Americas University of California, San Francisc

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Strategic Framework for Improving Oral Health
in the Americas University of California, San
Francisco, School of DentistrySpring, 2007
Dental Public Health Seminar Series
1
Pan American Health Organization

• Saskia Estupiñán-Day
• Regional Advisor for Oral Health

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GLOBAL CHANGES
Investors in global health
ENVIRONMENT
Greater strategic coherence into the
fragmented foreign aid Secure donor funding
Research into viable policies Scale up
cost-effective Interventions Best practice
models Best Buys Measurement of progress
Challenges

• Pandemic and Epidemic Threats
• Avian Flu
• Emerging and reemerging infectious diseases
• ATM
• Natural and Human Disasters
• Weather
• Large scale industrial accidents
• War
• Terrorism
• Biological attacks
• Chemical attacks
• Nuclear attacks

Fragmented foreign aid aid pours out of separate
spigots USA Policies/ transformational
democracies Dysfunctional governance in the
international system Less than 20 capita/year
on health care Average 11 capita/year Universa
l package 34 Long term donor commitments for
improving performance
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USA FOREIGN AID REFORM
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• New Strategic Framework
• 154 developing and transitional countries
  receive US aid
• 5 categories for aid
• Rebuilding Countries Afghanistan, Colombia,
  Iraq
• Developing Countries Cambodia, Pakistan,
  Egypt, Ecuador
• Transforming Countries
• Sustaining Partnership Countries Mexico,
  Russia, Kuwait
• Restrictive Countries Venezuela

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THE WORLD'S RICHEST MEN IN 32 BILLION GIVEAWAY 
-  27 JUNE 2006 The world's richest men, the
computer magnate Bill Gates and the financier
Warren Buffett, announced a 60 billion (32
billion) alliance yesterday to attack global
poverty and disease.
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FUNDING FOR INTERNATIONAL HEALTHU.S. DOLLARS
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• Gates 2006
• 1.5 billion/year
• 85 Grants
• Gates 2009
• 3.0 billion/year Gates/Buffet kick in
• USAID 2006
• 1.6 billion mostly through contracts
• IADB 2005
• 124 million loans
• 4 million Grants

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• 1990-2005 population increased by 165 million
• 2015 another 100 million will be added

• 152 million without access to safe drinking
  water and basic sanitation
• 120 million without access to health care
  poverty
• 107 million without access to health service
  geographic conditions

Source PAHO 2005
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Strategic planning
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• Where we are Old wine in new bottles?
• Where we are going Survive and thrive!
• How do we get there Marketing goals Reinvent
  yourself
• How do we know we are making progress
  Evidence Based

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Strategic Framework for Improving Oral Health
in the Americas University of California, San
Francisco, School of DentistrySpring, 2007
Dental Public Health Seminar Series
1
Pan American Health Organization

• Saskia Estupiñán-Day
• Regional Advisor for Oral Health

10
2
GLOBAL CHANGES
Investors in global health
ENVIRONMENT
Greater strategic coherence into the
fragmented foreign aid Secure donor funding
Research into viable policies Scale up
cost-effective Interventions Best practice
models Best Buys Measurement of progress
Challenges

• Pandemic and Epidemic Threats
• Avian Flu
• Emerging and reemerging infectious diseases
• ATM
• Natural and Human Disasters
• Weather
• Large scale industrial accidents
• War
• Terrorism
• Biological attacks
• Chemical attacks
• Nuclear attacks

Fragmented foreign aid aid pours out of separate
spigots USA Policies/ transformational
democracies Dysfunctional governance in the
international system Less than 20 capita/year
on health care Average 11 capita/year Universa
l package 34 Long term donor commitments for
improving performance
11
USA FOREIGN AID REFORM
3

• New Strategic Framework
• 154 developing and transitional countries
  receive US aid
• 5 categories for aid
• Rebuilding Countries Afghanistan, Colombia,
  Iraq
• Developing Countries Cambodia, Pakistan,
  Egypt, Ecuador
• Transforming Countries
• Sustaining Partnership Countries Mexico,
  Russia, Kuwait
• Restrictive Countries Venezuela

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THE WORLD'S RICHEST MEN IN 32 BILLION GIVEAWAY 
-  27 JUNE 2006 The world's richest men, the
computer magnate Bill Gates and the financier
Warren Buffett, announced a 60 billion (32
billion) alliance yesterday to attack global
poverty and disease.
4
13
FUNDING FOR INTERNATIONAL HEALTHU.S. DOLLARS
5

• Gates 2006
• 1.5 billion/year
• 85 Grants
• Gates 2009
• 3.0 billion/year Gates/Buffet kick in
• USAID 2006
• 1.6 billion mostly through contracts
• IADB 2005
• 124 million loans
• 4 million Grants

14
6

• 1990-2005 population increased by 165 million
• 2015 another 100 million will be added

• 152 million without access to safe drinking
  water and basic sanitation
• 120 million without access to health care
  poverty
• 107 million without access to health service
  geographic conditions

Source PAHO 2005
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7
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Strategic planning
8

• Where we are Old wine in new bottles?
• Where we are going Survive and thrive!
• How do we get there Marketing goals Reinvent
  yourself
• How do we know we are making progress
  Evidence Based

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Where we were
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• 1970-00
• Health-For-All and Alma Ata
• Shift from emergency care to community programs
• Lack of equity seen as a health problem
• Better understanding of prevention and
  decentralization
• DMFT-12 score introduced to gauge burden of
  disease, WHO goal DMFT-12 score lt 3 by 2000
• Surveys reported an average DMFT-12 score of 5.5
  for the Region (24 countries gt3 )

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Typology Table in Oral Health 1990 2004
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Accomplishments Trends of DMFT-12 for the Region
of the Americas 1987-2003
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Source PAHO 2005
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LESSONS LEARNED
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• Forty national oral health surveys indicate a
  marked decline between 35 to 85 in the
  prevalence of dental caries, attributed mostly to
  cost-effective salt and water fluoridation
  programs
• Burden of oral disease is severe and remains high
  in certain geographic areas and high risk
  populations
• Strong scientific evidence suggests the
  associations between oral infections, chronic
  diseases and adverse pregnancy outcomes
• Best Practice Models on prevention and delivery
  of oral care

Pan American Health Organization
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ASSOCIATIONS OF ORAL INFECTIONS AND MANY DISEASES
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CV Diseases
HIV
Trauma
Diabetes
Preterm LBW babies
Cancer
Nutritional problems
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Scientific evidence suggest that pregnant women
with periodontal disease are seven times more
likely to deliver PTLBW baby. This risk is much
higher than tobacco and alcohol.
Oral Infections and Pregnancy Outcomes
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Clinical trials suggest that treating oral
infection in pregnant women before 26 weeks of
gestation reduces the incidence of PTLBW by 28
to 82.
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Under-5 causes of death
Causes of death in Children under 5 (2000 2003)
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Neonatal causes of death
birth asphyxia,
diarrheal diseases,
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3
congenital
anomalies, 8
severe infections,
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preterm birth, 28
neonatal causes,
neonatal tetanus,
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7
other neonatal, 7
WHO The World Health Report 2005
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WHERE WE ARE GOING?
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• PAHOS PRIORITIES
• Unfinished agenda
• 8 MDGs developed in 2000 as a collective
  international responsibility to reduce poverty
• Maternal health
• Child health
• HIV and other communicable disease
• Facing new challenges
• Mounting evidence linking oral and systemic
  health
• Protect the achievements

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Strategic planning
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• LINEAR vs. 3D
• Dynamic world of doing business
• OPTIMIZATION
• Critical thinking and competitiveness
• Real market
• Real value
• SUSTAINABLE SUCCESS
• Plan, vision, mission, goals
• Provide a sense of purpose and direction
• STRATEGIC PLAN
• Respond and anticipate changes
• Business plan and implementation
• STAY FOCUS

Where there is a great complexity, there is also
a great simplicityWinston Churchill
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Framework for the strategy
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• Best Practice Model
• Best Buys
• Partnerships
• Downstream Investment
• Measurement of Progress

• Primary priority countries
• Bolivia, Haiti, Honduras, Guyana, Nicaragua
• Secondary priority countries
• Ecuador, Guatemala, and Paraguay
• Priority groups
• MCH, Children, Women in reproductive age groups,
  HIV/AIDS, Indigenous groups, Elderly

Pan American Health Organization
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.
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How do we get there?
The Road Map

• Goals
• Objectives
• Strategies
• Programs
• Marketing

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GOAL 1A Minimum Level of Oral Health
Care For All By Addressing Gaps in Care For the
Most Vulnerable Groups
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Who are most vulnerable?
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• Poor of all age groups
• Socially marginalized
• Geographically isolated
• Women and children
• HIV/AIDS

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Objectives Reduction of Oral Infections
Increasing Access to Oral Health Care

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GOAL 2The Integration of Oral Health Into PHC
Services
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• Develop mechanism to integrate oral health within
  current PHC services
• Incorporate oral health component into prenatal
  programs
• Scale up best practice models

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A different approach
Amalgam Restoration
ART Restoration
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PAHO/IADB Clinical Trials in Ecuador, Panama and
Uruguay PRAT PROBABILITY OF SUCCESS AND
FAILURE
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• Success Failure
• Dentist doing amalgam 0.943 0.057
• Dentist doing ART 0.960 0.040
• Auxiliary doing ART 0.942 0.058

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Pan American Health Organization
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Scale Up Oral Health Coverage Using
Cost-Effective and Simple Technologies, PRAT
1.50 to treat/seal a tooth
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Mexico over 10 million restorations under PRAT
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PRAT SYSTEM Best Buy
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• PRAT provided at the lowest cost service modality
  produces acceptable outcomes
• PRAT as a best practice model provides a
  framework to implement at large scale oral
  health services and will reduce the inequities
  for access to care services
• A PRAT-based strategy for expanding coverage at
  reduced cost should become a cornerstone of
  policy at the regional and country levels
• This study has produced evidence to guide
  downstream investment to improve equity and
  efficiency and quality of life in the Americas

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• GOAL 3
• Scaling-Up of Proven Cost Effective Interventions
• Salt fluoridation
• Support Bolivia, Ecuador, Haiti, Honduras,
  Nicaragua, Paraguay and Saint Lucia to reach full
  implementation of fluoridation programs
• Consolidate fluoridation programs with
  appropriate surveillance

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Sealants 21.17 FL Supplements
2.53 Water Fluoridation 0.54 Salt
Fluoridation 0.06
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PAHOs 1994Multi-Year Plan for Water-Salt
Fluoridation Programs in the Region of the
Americas
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Cuba
Haiti
Mexico
Jamaica
Belize
Guatemala
Suriname
El Salvador
Costa Rica
Colombia
Ecuador
Peru
Sao Paulo
Paraguay
Uruguay
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PAHOS MULTI-YEAR PLAN FOR SALT FLUORIDATION IN
THE AMERICAS IN 2004
Advanced Programs Mexico, Belize Costa Rica,
Jamaica Venezuela, Colombia Ecuador,
Peru Bolivia, Uruguay
Commencing Programs Cuba, Dominican
Republic, Guatemala, El Salvador, Honduras,
Nicaragua, Paraguay
Source PAHO 11/00
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SALT FLUORIDATION SYSTEMS
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• Salt fluoridation is the controlled addition of a
  fluoride compound to salt in sufficient quantity,
  so as to have an anti-cariostatic effect

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DENTAL CARIES IN COUNTRIES WITH CONSOLIDATED
NATIONAL SALT FLUORIDATION PROGRAMS
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COUNTRY
BASELINE STUDIES
FOLLOW-UP STUDIES
CARIES
YEAR DMFT-12 YEAR
DMFT-12 REDUCTION ()
Colombia Costa Rica Jamaica Mexico Uruguay
1980 1988 1984 1987 1992
4.8 8.4 6.7 4.6 4.1
1998 1999 1995 1996 1999
2.3 2.5 1.1 2.5 2.4
52.1 70.6 83.9 45.7 41.5
Source PAHO. Jan. 2001
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Protect your achievements
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• Because it works!
• Scale
• Importance
• Ability to prove and measure results
• Improved health impact
• Sustainable
• Cost effective
• Partnerships/multidisciplinary
• Information/marketing

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How do we know we are making progress?
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• Impact evaluations
• measure results
• Which interventions worked
• - look at goals
• - are beneficiaries better off in a meaningful
  and sustained way
• Solid foundations for partnerships between public
  and private sectors is critical to protect the
  established progress, ensure sustainability

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In Summary
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• Best practice model provides a framework to
  implement at large scale oral health programs
• We have the evidence and the knowledge that it
  works
• Evidence demonstrates feasibility with extreme
  cost-benefit
• Implementation requires leadership, commitment to
  guide downstream investment to improve equity and
  efficiency and quality of life in the Americas
• Action and government support for dental public
  health programs

Pan American Health Organization
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Trends of DMFT-12 for the Region of the Americas
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EVIDENCE 1987-2003
PROJECTIONS 2007-2010
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When health improves, life improves by every
measure Bill Gates