BPOC Chapter6

Basic Package of Oral Care

Jo E. Frencken

Christopher J. Holmgren

Wim H. van Palenstein Helderman

WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios

Chapter 6 - Recommendations for establishing and evaluating BPOC demonstration programs

The need for and effectiveness of each of the individual components that constitute the Basic Package of Oral Care (BPOC) have been discussed in previous chapters. The next step is to demonstrate the effectiveness, efficiency, acceptability and sustainability of the BPOC as a means of improving oral health within the country or community for which it is intended.

Introduction

Implementation of the BPOC depends on prevailing local factors, including available human and financial resources and existing infrastructures, local perceived needs, and treatment demands of the community and that of its leaders. The conditions in each country or community will not only influence the content of BPOC and the method by which it is applied, but also its success. In order to investigate this, demonstration projects on BPOC are recommended in different countries.

The guidelines presented below assume collaboration among local partners, local government, industry and organizations (including NGOs) providing oral health experts. It aims at highlighting aspects of preparation, planning, implementation and evaluation of demonstration projects. A summary of the essential steps to be taken in a demonstration project is given in Table 6.1.

Factors to consider before starting the program

Identifying a local partner

The local partner should be willing to accept joint responsibility for the planning and implementation of the program with the ultimate objective of taking on the ownership of the ongoing activities in a later phase. The setting up of a working group to initiate the program and to oversee its implementation is desirable.

Obtaining approval from decision makers

Approval for the program implies consultation with the authorities as early as possible. It is essential to obtain their consent for the planning of the demonstration program and for its implementation. In this context it is essential to have briefings at ministry level, since the Ministry of Health is a fundamental player in developing (oral) health services.

Probing the interest of possible parties involved

Local political, religious and community leaders, as well as the heads of medical and educational systems and other possible service providers, e.g. traditional healers, should be consulted to probe their views and interest in the BPOC program. If their interest is low and their willingness to support the program is nil, then it might be necessary to abandon the idea of starting a program for that particular community.

Understanding the local situation

The success of any oral health program, including oral health services research projects, depends on how well it meets the wishes and expectations of the community. If the program fails to meet these, then there is likely to be a problem with both acceptance and sustainability. In designing the program, many factors should be taken into consideration, including epidemiological data on the community`s oral health status and normative needs; the people's perceived needs (wishes) and treatment demands; their knowledge and habits related to oral health, existing health and educational structures; and available human and financial resources.

Before starting

•Identify local partner

•Obtain approval from decision-makers

•Consider the interests of all parties

•Understand the local situation

The process of planning

•Write project protocol

•Formulate measurable objectives

•Design evaluation

•Consult all parties involved

Implementation, process monitoring

and evaluation

•Monitor activities, maintain

communication and tackle problems

•Assess the outcomes

•Report the findings

Future options after evaluation

•Abandon the program

•Modify the program

•Continue and expand

The process of planning

Formulating measurable objectives

The collected information on the local prevailing conditions provides a basis for developing the program proposal. The next step is the formulation of appropriate objectives for the program that are consistent with the wishes and expectations of the community and its leaders. The objectives must be defined in such a way that allows for meaningful evaluation. Objectives that cannot be achieved or cannot be properly evaluated will frustrate both the providers and consumers, which could hinder continuation of the program.

Consultation among all parties involved

When the program proposal has been formulated, it should be presented to all parties involved. This consultation is important to determine whether the objectives and the chosen strategy meet their wishes and expectations. It is probable that in the light of consultation, minor modifications will be required. It is essential that all parties involved agree on the final draft of the program proposal. When the proposal has been accepted by those responsible, a protocol should be devised, which highlights the details of all parts of the program, the individuals responsible for each activity and the timeframe.

Implementation, process monitoring and evaluation

Monitoring activities, maintaining communication, tackling problems

Continuous monitoring of all activities is required during implementation. Maintaining communication with all parties involved is a prerequisite to identifying small problems, which, if not resolved can seriously threaten the success of the program. Unforeseen more serious problems may emerge that require modifications of the original proposal or may force the discontinuation of the program. Moreover, the monitoring process reduces the risk of drawing faulty conclusions from the results of the outcome evaluation; for instance, the conclusion that the program was ineffective when in reality the program was not carried out as designed.

Assessing the outcomes

The rationale for setting up a demonstration program (community trial) is to determine the feasibility, effectiveness, efficiency, social acceptability and sustainability of the BPOC under local conditions. This implies that the results of the outcome evaluation must be determined to assess whether the objectives have been met. Depending on the formulated objectives, achievements can be evaluated by assessing the concomitant outcome effects, for example:

• A reduction in the number of people with toothache.

• Utilization patterns of offered services, such as an increase in people seeking regular check-ups and in those coming to have decayed teeth filled. The utilization pattern of toothpaste and tooth-cleaning devices should also be determined.

• Oral health status, e.g., number of teeth decayed, filled or sealed.

• Consumer's satisfaction with treatment received.

• Job satisfaction of providers.

• Generated resources.

• Sales figures of toothpaste or price fluctuation of toothpaste by year.

The length of the demonstration program depends on the type of outcome effect to be assessed. Studies with the objective of controlling or reducing the level of dental caries might need to run for two to four years before results can be assessed. Ideally, process evaluation should have revealed whether the program is likely to be sustainable before a final assessment has been carried out.

Reporting the findings

The results of the evaluation process, including conclusions and recommendations, must be reported to all parties at regular intervals for subsequent discussion. The final outcome of the program should also be reported to all parties. In addition, outcomes, whether successful or unsuccessful, should be reported in the scientific literature. This will guide other countries or communities that might consider commencing a BPOC program.

Future options after evaluating a BPOC program

Abandon the program

The option of abandoning the program should be considered if it is found to be ineffective, unacceptable or unaffordable. Without adequate support from the community or government, an oral health services program cannot become sustainable. There is no reason to continue the program with external funding if all signs indicate that neither the government nor the community is willing to support the program with local resources.

Modify the program and run another demonstration project

Another option might be to modify the program in order to solve problems identified during the evaluation. For example, a reorientation of the program might be required to address the wishes of the parties involved, which emerged during the course of implementation. Initiation of a modified program may be considered in another demonstration project.

Continue and expand the program

Agreements on ownership must be made at an early stage of the demonstration program. The responsibilities regarding continuation should be formalized with the authorities at the end of the demonstration program. The decision to expand the program on a larger scale belongs to the authorities and the community. All efforts related to the implementation of the demonstration program on a larger scale must be based on self-supporting activities, which implies that no external funding should be considered.