Project Peru

Project proposal

Training of health personnel in rural areas of Apurímac, Peru in oral health care

Background

The department of Apurimac is located in the Andes in the south-east of Peru. It belongs to the most deprived areas of Peru. It has a population of about 250000 people, most of them are of Indian origin and live in rural areas. The infrastructure is deficient, with dangerous roads, lack of electricity, drinking water and sanitation. Morbidity and child mortality is high and people do not have easy access to health services.

Dental services are low. There are only 16 publicly employed dentists for 155 health establishments. All dentists work either in hospitals or health centres of bigger communities, i.e departmental and provincial capitals.

Some provinces, such as Grau and Aymaraes count only with one dentist in the central health centre, resulting in a dentist/population ratio of less than 1:30 000. But caries prevalence is rather high. According to the latest epidemiological studies in above mentioned provinces, 12-year-old pupils have a mean DMFT of 4.65. Due to the lack of financial resources and missing manpower, only very basic services such as pain relief and dental emergency care can be offered to the population. People of rural areas have to travel for hours in order to be attended. There are few preventive programmes and health promotional activities.

Being aware of this problem, the German NGO Zahnmedizinische Entwicklungshilfe (ZME) had initiated a primary oral health care project in the departments of Cusco and Apurímac in 1986. The main components were the training of health workers in rural health centres and health posts to provide basic dental care to the rural population and an integrated preventive-promotional pilot oral health programme in schools.

From 1986 to 1992, this project was guided by a German dentist and funded by the German Agency for Technical Cooperation (GTZ) and German Development Service (DED). In 1991, the Sub-regional Health Authority of Apurimac has established an own Oral Health Programme (Programa de Salud Bucal Apurimac). From 1992 to 2002, the working group of Apurimac has trained new health workers in oral health. Outgoing from 12 health workers trained by GTZ, the number has increased to 40 trained health workers. Thus, it was possible to extend the services to more health centres. Now, nearly 60% of the health centres of Apurímac have a trained health worker who is able to provide basic dental services to the population. Availability, accessibility and affordability of dental services could be improved. A more detailed description of the project is attached to this proposal.

Close contacts remained with Dr. Mautsch, the initiator of the project. He visited the Oral Health Programme in Apurímac in 1994, 1995, 1997 and 2002 and offered continuing education courses for the dentists in the area of dental public health and preventive dentistry. Most importance he gave to the supervision of the trained health workers. In each visit, he held a one-week refresher course for health workers, organised and supported by the Sub-regional Health Authority. Together with local dentists, Dr. Mautsch supervised and evaluated the knowledge and skills of the trained health workers and he trained newcomers who recently had been included in the training programme of the Oral Health Programme Apurímac. In these courses the health workers got a theoretical update in basic knowledge on oral health and preventive-promotional activities. Diagnostic measures and treatment of simple periodontal problems as well as pain relief, mainly by extractions, have been taught and practised. These courses took place in rural health centres where there was no dentist. Part of the practical training was implemented in villages outside of the health centres.

Rationale and Aim of the project

During the last visit in July 2002, the local dentists and the health workers expressed their wish to extend their services beyond pure mutilation. They regret that very often they have to extract molars with occlusal caries in schoolchildren which could be easily saved if they were able to excavate caries and fill the teeth. Peru has changed its health insurance system and offers free dental services to people younger than 17 years. Apart from pain relief, preventive measures such as fluorization and conservative measures such as fillings and endodontics are included.

As there are no dentists in rural health centres, the majority of the people do not have any possibility to use these services. In addition, due to the bad infrastructure with lack of electricity and adequate dental equipment , traditional conservative treatment using sophisticated technology is neither possible nor recommendable. For these reasons, the application of the Atraumatic Restorative Treatment would be appropriate, a concept which is strongly recommended by WHO to improve dental treatment in deprived communities.

The Oral Health Programme Apurímac therefore intends to start an ART project for the schoolchildren in rural areas of the provinces of Grau and Aymaraes. As there are few dentists, experienced health workers should be trained in the new technique thus extending their scope of oral health skills.

Overall Goal

To improve the oral health status of schoolchildren in rural and urban areas of Apurímac

Aim of the Project

To improve knowledge and skills of health workers in oral health care

Specific Objectives

To increase the knowledge of health workers in diagnosis, prevention and management of caries and periodontal diseases.

To train health workers in the technique of Atraumatic Restorative Treatment (ART)

To provide health centres with appropriate equipment for ART

To improve the knowledge and skills of health workers concerning oral urgent treatment

To supervise and evaluate activities of health workers in their communities

Planned Activities

Training courses in oral health care and ART for 20 selected health workers

Translate manual on ART in Spanish and distribute it to dentists and health workers

Buy hand instruments and material appropriate for ART and hand them over to health centres

Organise and implement a refresher course in oral urgent treatment and preventive-promotional activities for 30 health workers

Support seminars for local schoolteachers concerning oral health promotion

Establish a monitoring system to control outcome of dental treatment activities.

Develop a questionnaire to evaluate patient and provider satisfaction

Time period:

September 2003 to December 2006 (3 1/2 years)

Project Description

1. Course on ART

20 health workers of the Department of Apurímac will be selected by the Oral Health Section to participate in these courses. All of them have already experience in basic dental care and preventive-promotional activities, as they have been trained by the Oral Health Section in at least one course on primary dental care. Only health workers of rural health centres and health posts can be trained in order to avoid political problems with the Dental Association. Health workers trained in ART can only practise after official permission and supervision by the Regional health Authority and within the premises of the health centres. They are not allowed to practice privately and charge privately.

In a preliminary course of three days, dentists of the Oral Health Section will be introduced to the ART technique. There will be given the opportunity to practise ART by themselves in the regional Hospital of Abancay. Educational material and literature will be translated and provided to the dentists, as well as later to the health workers in training.

5 sets of hand instruments will be handed to the dentists for their health centres and hospitals.

There will be two courses for each group of 10 health workers. Each course will last for two weeks and will include the following topics:

Basic knowledge on anatomy of mouth and teeth

Simple diagnosis, oral health status

Development and progression of caries and periodontal diseases

Preventive measures

Filling material

Practical training in excavation of caries and filling of single surface cavities

After the first course there will be an evaluation, the result of which is important to advance to the second course. After the second course, the passing of final exams is precondition to obtain a certificate and permission to practise ART in the health centre. They will be provided with a set of instruments which will be part of the property of the health centre they belong to.

Refresher course:

In the third year (2006) a refresher course of two weeks will be held for all trained health workers. Thus the Oral Health Section and the international adviser will have the opportunity to evaluate the skills and knowledge of the health workers in an intensive training session. Mistakes in the technique and arising problems can be discussed and corrections can be made immediately.

2. Course on OUT

All of the health workers have been trained in emergency dental care. This comprised simple extractions of decayed and periodontally involved teeth under local anaesthesia, treatment of post-extraction complications, scaling of teeth and application of drugs in case of infections. To refresh the knowledge and skills in this area, a course for all dentally trained health workers of the region is planned. There will be about 25 to 30 participants in a course of two weeks held by the dentists of the Oral Health Section and the international adviser.

The course will include the following topics:

Basic knowledge on anatomy of mouth and teeth

Simple diagnosis, oral health status

Local anaesthesia

Technique of extractions

Management of post-extraction complications

Treatment of dento-alveolar trauma

Application of drugs in case of oral infections

Referral of complicated cases

There will be a final exam to obtain the official certificate for successful participation and the renovation of the permission to attend patients in basic dental care. A set of instruments (forceps, elevators etc.) will be donated to health centres which do not have appropriate basic dental instruments.

3. Supervision/ Monitoring/ Epidemiological Surveillance

Regular supervision of the trained health workers by the local dentists and monitoring are important to control and guarantee a certain level of quality in dental care. The Oral Health Section will make a plan for supervisory visits to the different health centres. Dentist will stay at least one whole day to work with the health worker and discuss with him possible failures and problems.

In the beginning of the project, a basic epidemiological survey will be made in the schools where trained health workers will work. In addition control schools will be selected to have comparative data. At the end of the three years, a second survey will be done to control the outcome of the project. A special medical history will be developed to monitor any dental diagnosis and treatment procedure performed by the health workers. The ART fillings placed in schoolchildren during this period will be evaluated and analysed. The results of this project will be published.

Contribution of the Partner

A tentative plan of operations for the years 2003 to 2006 as well as a tentative budget plan for 2003/2004 is attached to this proposal. The budget lists the amount necessary to implement the activities. The Regional Health Authority as the partner of the donor organisations has very limited financial resources but hopes to be able to contribute partially to the financial costs of the project.

These include:

Travel costs and accommodation for participants

Transport (car, petrol) for trainer team to provincial health centre

Nevertheless, apart from direct financial contributions there are contributions of other kind, which should be taken into consideration:

Reduction of working hours for responsible dentists and health workers to implement the activities

Leave for participants of the courses and thus loss of working hours in their health centres

Use of health centres for practical courses

Provision of material for courses, such as cotton, gloves, anaesthetics

Office room and secretarial work

Free provision of lecture theatre for presentations and seminars

Lost working hours in private practices of the responsible persons for the project

Presentation of the Oral Health Section

The Oral Health Section has been established within the Regional Health Authority of Apurímac. It coordinates the activities of all dentists employed by the Regional Health Authority Apurímac of the Peruvian Government. It organises and implements the official oral health programmes issued by the Ministry of Health as well as the planning and implementation of regional and local oral health activities. Publicly employed dentists and dental health workers have to report to the section. The section is responsible for guidelines, monitoring and evaluation of governmental oral health services in Apurímac and for epidemiological surveillance.

The core of the Section consists of the regional Coordinator for the Oral Health Programme, his substitute and a senior health worker who has been trained in oral health:

Dr. Joaquin Farfan , Coordinator

Dr. Manuel Ramos, Substitute

TS Mario Paniagua Gamarra, health worker

Dr. Joaquin Farfan has done postgraduate studies in odontopediatrics and public health in Lima. He has worked in periurban health centres and has been nominated as coordinator in 1997.

Dr. Manuel Ramos Pena has 20 years of experience as dentist. Actually he is officially employed as second head of the dentists in the Regional Hospital of Abancay, Apurímac. He was coordinator of the Oral Health Programme from 1993 to 1997.

Mario Paniagua Gamarra is health worker. He has been trained in oral health by Dr. Mautsch in 1987. Since then he is responsible for the training and supervision of health workers. He is the "soul" of the project, due to his extraordinary ability to organise and to integrate. He is the constant factor of the Section, and knows very well how to motivate the health workers and dentists as well take in mind the reluctance and scepticism of dentists concerning training of non-academic personnel.

Dr. Walter Mautsch

Dr. Walter Mautsch has worked in Peru from 1986 - 1990. He is Master of Science in Dental Public Health (Univ. London) and has worked in various international oral health projects since 1986. He is a founding member of the German nongovernmental organisation „Zahnmedizinische Entwicklungshilfe" (ZME) and founder and coordinator of an international group called „The Oral Health Alliance" (OHA). He organised international seminars in Berlin, leading to the foundation of OHA and the publication of the book „Promoting Oral Health in Deprived Communities". At the time being he is adviser to an oral health promotion group in Prishtina, Kosovo which is supported by DHIN, MEDAIR and SSO.

Supervision, Accountability, Sustainability

After the training courses, health workers will have sufficient practical skills to treat minor cavities, particularly occlusal caries in molars. Thus they will contribute to less dental pain and early loss of permanent molars in schoolchildren. It is hoped that schoolchildren will change their attitude towards preventive measures and keep their teeth clean and healthy.

Main costs of the project are caused by the costs for training courses, provision with appropriate instruments and material, educational material and travel expenses.

Running costs of dental treatment for schoolchildren will be covered by the social security funds established for dental care for children and adolescents. Adult people who are not covered will have to pay by themselves. In any case, treatment provided by trained health workers in rural health centres using ART will cost much less than conventional dental treatment. Therefore, the trained health workers will be able to provide themselves with sufficient financial resources to buy dispensable material such as glass ionomer cement, cotton rolls and gloves.

As ART does not depend on electricity, plumb water, micromotors and rotating instruments, there will be nearly no maintenance costs apart from occasional replacements of broken hand instruments. According to the experience, fractures happen more often in the training phase than in the final phase when the health workers have developed and improved their skills.

Instruments and equipment will belong to the health centres. It is not property of the trained health worker! If a trained health worker leaves his job or is transferred to another health centre, the equipment remains as part of the equipment of the health centre. Thus, another trained health worker will dispose of the instruments.

Dr. Mautsch will be the mediator between donor organisations and the Oral Health Section. He will visit the project twice a year, give continuing education courses to the dentists and train the health workers in cooperation with the local dentists. He will establish a monitoring system and do the final evaluation. The Oral Health Section will report to him about the progress of the project in a 6-monthly interval and will be accountable to him concerning financial issues.

Dr. Mautsch will report to the donor organisations according to mutually agreed terms and intervals. He will transfer the funds to the Oral Health Section according to the needs and progress of the project activities and will send a financial report to the donor organisations at the end of the financial year.

It is expected that the project will be autonomous after three years. There will be a final supervision by Dr. Mautsch to evaluate the knowledge and skills of the health workers and the impact of the programme.

Draft Plan of Operations 2003 to 2006

Year/Month	Activities
2003
Aug - Sep	Literature, translation of ART manual
Oct	Selection of health workers, provision with instruments
Nov	Continuing education course for publicly employed dentists (3 days)
	Course I ART for first group of 10 health workers (2 weeks)
Dec	Interims and financial report to donor organisations

2004
Jan - March	Development study protocol, monitoring documents
April	Second course ART for already trained health workers (2 weeks), exams
	Official handover of instruments and material
May	Epidemiological survey in schools where health workers will work
	Questionnaire on sociodental indicators in schools
June- Dec	Supervision visits by local dentists
Sep - Oct	Course I ART for second group of 10 health workers (2 weeks)
Dec	Interims and financial report for donor organisations

2005
Feb	Course II ART for second group (2 weeks), exams
	Official handover of instruments and material
Mar - Dec	Supervision visits by local dentists
Aug	Course for 25 health workers on OUT (1 week) Provision with instruments for extraction, official handover
Dec	Interims and financial report for donor organisations

2006
Jan - June	Supervision visits by local dentists
Jul	Resfresher course ART for all 20 health workers (2 weeks)
Sep - Oct	Supervision, Monitoring, epidemiological survey
Nov-Dec	Final evaluation of project, statistical analysis epidemiological survey
Dec/Jan	Final report and final financial report to donors