Manual 21318112

Manual 21318112
THE ECONOMIC ASSESSMENT OF WATER
FLUORIDATION IN SOUTH AFRICA AND ITS IMPACT ON
HUMAN RESOURCES AND ORAL HEALTH SERVICE
DELIVERY
by
JEROEN KROON
submitted in fulfilment of the requirements for the degree
PHILOSOPHIAE DOCTOR
in the
SCHOOL OF DENTISTRY
FACULTY OF HEALTH SCIENCES
UNIVERSITY OF PRETORIA
APRIL 2008
© University of Pretoria
TABLE OF CONTENTS
TABLE OF CONTENTS ...................................................................................................... i
DECLARATION ..................................................................................................................vi
SUMMARY.........................................................................................................................vii
ACKNOWLEDGEMENTS...................................................................................................ix
LIST OF TABLES ...............................................................................................................xi
LIST OF FIGURES ............................................................................................................xv
LIST OF ABBREVIATIONS..............................................................................................xvi
CHAPTER 1: PROBLEM STATEMENT, AIMS, RESEARCH DESIGN AND
STRUCTURE .......................................................................................................................1
1.1
Problem statement ....................................................................................................1
1.2
Aims and objectives of the study ...............................................................................5
1.3
Research design .......................................................................................................5
1.4
Structure of thesis .....................................................................................................6
1.5
Summary ...................................................................................................................7
CHAPTER 2: LITERATURE REVIEW.................................................................................8
2.1
2.2
Overview of water fluoridation ...................................................................................8
2.1.1
Historical perspective ..................................................................................8
2.1.2
Caries prevention from water fluoridation..................................................13
2.1.3
Recent international reports ......................................................................14
2.1.4
Water fluoridation in South Africa..............................................................18
2.1.5
The economics of water fluoridation..........................................................23
Human resources planning......................................................................................30
2.2.1
Brief overview............................................................................................30
2.2.2
Approaches to human resources planning ................................................32
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i
2.2.3
World Health Organization/Fédération Dentaire Internationale planning
model ........................................................................................................37
2.3
2.4
2.2.4
A South African perspective on human resources planning......................39
2.2.5
Human resources distribution and trends in South Africa .........................52
South African policy documents on health and oral health service delivery ............58
2.3.1
Transformation of health services .............................................................58
2.3.2
National Oral Health Policy .......................................................................60
2.3.3
Primary oral health care package..............................................................63
Summary .................................................................................................................65
CHAPTER 3: COST EVALUATION OF THE IMPLEMENTATION OF WATER
FLUORIDATION IN SOUTH AFRICA ...............................................................................66
3.1
Introduction..............................................................................................................66
3.2
A model to calculate per capita cost, cost-effectiveness and cost-benefit of the
implementation of water fluoridation in South Africa................................................66
3.3
3.4
3.2.1
Chemical cost (Variable Group (A)) ..........................................................70
3.2.2
Labour cost (Variable Group (B)) ..............................................................75
3.2.3
Maintenance cost (Variable Group (C)).....................................................78
3.2.4
Opportunity cost (Variable Group (D)).......................................................81
3.2.5
Capital depreciation (Variable Group (E)) .................................................81
3.2.6
Operating cost (Variable Group (F))..........................................................82
3.2.7
Total cost (Variable Group (G)) .................................................................82
3.2.8
Per capita cost (Variable Group (H)) .........................................................83
3.2.9
Caries prevalence (Variable Group (I)) .....................................................84
3.2.10
Cost-effectiveness (Variable Groups (J)) ..................................................85
3.2.11
Cost- benefit (Variable Groups (K))...........................................................85
Results ....................................................................................................................86
3.3.1
Total cost of water fluoridation ..................................................................87
3.3.2
Per capita cost ..........................................................................................89
3.3.3
Cost-effectiveness.....................................................................................92
3.3.4
Cost-benefit...............................................................................................94
Discussion ...............................................................................................................97
3.4.1
Introduction ...............................................................................................97
3.4.2
Total and per capita cost of the introduction of water fluoridation .............99
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ii
3.5
3.4.3
Cost-effectiveness...................................................................................102
3.4.4
Cost-benefit.............................................................................................103
Summary ...............................................................................................................104
CHAPTER 4: COST EVALUATION OF DELIVERING THE MINIMUM PACKAGE OF
ORAL CARE TO SOUTH AFRICAN CHILDREN............................................................106
4.1
Introduction............................................................................................................106
4.2
A model to calculate the per capita cost of delivering the minimum package of
oral care ................................................................................................................106
4.2.1
Population size (Variable [1]) ..................................................................107
4.2.2
Treatment need (Variable [2]) .................................................................107
4.2.3
Treatment fees (Variable [3])...................................................................114
4.2.4
Monetary value for each treatment need type (Variable [4]) ...................119
4.2.5
Total expense to address treatment need (Variable [5]) .........................120
4.2.6
Total per capita cost to address treatment need (Variable [6])................120
4.2.7
Percentage of total cost for each treatment need type (Variable [7]) ......120
4.2.8
Per capita cost of each treatment need type (Variable [8]) .....................120
4.3
Results ..................................................................................................................120
4.4
Discussion .............................................................................................................126
4.4.1
Introduction .............................................................................................126
4.4.2
Per capita cost of delivering the minimum package or oral care to South
African children .......................................................................................128
4.5
Summary ...............................................................................................................130
CHAPTER 5: ORAL HEALTH HUMAN RESOURCES NEEDS FOR SOUTH AFRICAN
CHILDREN.......................................................................................................................131
5.1
Introduction............................................................................................................131
5.2
World Health Organization/Fédération Dentaire Internationale human resources
planning model ......................................................................................................131
5.3
5.2.1
Restorative care, arresting care and extractions (Variable Group (A))....134
5.2.2
Treatment time requirements (Variable Group (B)) .................................136
5.2.3
Human resources calculations (Variable Group (C))...............................141
5.2.4
Impact of the implementation of water fluoridation ..................................142
A “Service Targets Method” model to calculate human resources ........................142
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iii
5.4
5.5
5.6
5.3.1
Minutes of need (Variable Group (A)) .....................................................144
5.3.2
Minutes of demand (Variable Group (B)) ................................................148
5.3.3
Human resources calculations (Variable Group (C))...............................148
5.3.4
Impact of the implementation of water fluoridation ..................................149
Results ..................................................................................................................149
5.4.1
Background information ..........................................................................149
5.4.2
Total human resources ...........................................................................150
5.4.3
Oral hygienists ........................................................................................155
5.4.4
Dental therapists and dentists .................................................................155
Discussion .............................................................................................................158
5.5.1
Introduction .............................................................................................158
5.5.2
Oral health human resources required on a national level ......................160
5.5.3
Oral health human resources required on a provincial level ...................162
Summary ...............................................................................................................163
CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS .........................................165
6.1
Conclusions...........................................................................................................165
6.1.1
Cost evaluation of the implementation of water fluoridation in South
Africa.......................................................................................................165
6.1.2
Cost evaluation of delivering the minimum package of oral care to South
African children .......................................................................................167
6.1.3
6.2
Oral health human resources needs for South African children ..............169
Recommendations ................................................................................................173
BIBLIOGRAPHY..............................................................................................................177
ANNEXURES...................................................................................................................187
ANNEXURE 1: PER CAPITA COST, COST-EFFECTIVENESS AND COST-BENEFIT
OF THE IMPLEMENTATION OF WATER FLUORIDATION FOR THE CITY OF
TSHWANE METROPOLITAN MUNICIPALITY (PRETORIA)................................187
ANNEXURE 2: DETAILED INFORMATION ON WATER PROVIDERS ..........................189
ANNEXURE 3: PER CAPITA COST OF DELIVERING THE MINIMUM PACKAGE OF
ORAL CARE TO THE 15-YEAR-OLD AGE COHORT ..........................................195
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ANNEXURE 4: THE WORLD HEALTH ORGANIZATION/FéDéRATION DENTAIRE
INTERNATIONAL HUMAN RESOURCES PLANNING MODEL: NATIONAL
REQUIREMENTS TO DELIVER THE MINIMUM PACKAGE OF ORAL CARE TO
4- TO 15-YEAR-OLD SOUTH AFRICAN CHILDREN ...........................................205
ANNEXURE
5:
A
“SERVICE
TARGETS
METHOD”
MODEL
FOR
HUMAN
RESOURCES PLANNING: REQUIREMENTS TO DELIVER THE MINIMUM
PACKAGE OF ORAL CARE TO 4- TO 15-YEAR-OLD SOUTH AFRICAN
CHILDREN ............................................................................................................207
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v
DECLARATION
I, Jeroen Kroon, declare that the thesis, “THE ECONOMIC ASSESSMENT OF
WATER FLUORIDATION IN SOUTH AFRICA AND ITS IMPACT ON HUMAN
RESOURCES AND ORAL HEALTH SERVICE DELIVERY”, which I hereby
submit for the degree Philosophiae Doctor at the University of Pretoria, is my
own work and has not previously been submitted by me for a degree at this or
any other tertiary institution.
_________________________
Jeroen Kroon
April 2008
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vi
SUMMARY
THE ECONOMIC ASSESSMENT OF WATER FLUORIDATION IN SOUTH AFRICA
AND ITS IMPACT ON HUMAN RESOURCES AND ORAL HEALTH SERVICE
DELIVERY
by
JEROEN KROON
Supervisor:
Professor PJ van Wyk
Department:
Community Dentistry
Degree for which the thesis is submitted: Philosophiae Doctor
Water fluoridation has been confirmed by three recent reviews as one of the most
cost-effective and safe primary preventive measure against dental caries. Despite
this evidence no artificially fluoridated water scheme exists in South Africa. The
economic impact of water fluoridation in times of a reduction in dental caries should
be weighed against its benefits.
A minimum package of oral care has been
proposed for implementation in the public oral health services. Irrespective of the
implementation of water fluoridation and/or a minimum package or oral care, it will
impact on the required oral health human resources.
The aim of this study was to investigate the economic viability of the implementation
of water fluoridation and the delivery of the minimum package of oral care and the
impact this will have on human resources planning for oral health in South Africa.
Computerised simulation models were developed for this study.
Per capita cost,
cost-effectiveness and cost-benefit of the implementation of water fluoridation was
calculated for seventeen major metropolitan cities, towns and water boards in South
Africa. Treatment need data was converted to a per capita cost to express the
delivery of the minimum package of oral care as a monetary value. The World
Health Organization/Fédération Dentaire Internationale and a “Service Targets
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vii
Method” model were used to calculate the oral health human resources required to
deliver the minimum package of oral care.
The average per capita cost of water fluoridation for the total population is R2.08. At
an anticipated 30% caries reduction achieved with water fluoridation, average costeffectiveness is R33.16 and cost-benefit was calculated as 0.18. Cost-benefit equals
or exceeds 0.8 for only three municipalities or water boards at an anticipated 10%
caries reduction as a result of the implementation of water fluoridation.
The average per capita cost to provide the minimum package of oral care is R245.95
without the impact of water fluoridation and R186.03 at an anticipated 30% caries
reduction due to water fluoridation.
Oral hygienists represent more than 50%, dental therapists between 30 to 40% and
dentists less than 10% of the total oral health human resources required to deliver
the minimum package of oral care. At an anticipated caries reduction of 30% due to
the introduction of water fluoridation, the number of dentists required decrease by
29%, dental therapists between 27.5 and 29.8% and oral hygienists between 2.1 and
10.5%. This converts to a saving in salaries of R14,8 million per year.
It is recommended that water fluoridation remains a viable option for South Africa,
even if only a 10% caries reduction as a result of its introduction is achieved. All
provinces should actively pursue the introduction of the minimum package of oral
care with appropriate modes of delivery by creating a number of posts as well as
incentives to attract especially oral hygienists and dental therapists to the public
service. The impact of the introduction of water fluoridation on human resources
should always be considered in planning the number of oral health professionals to
be trained.
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viii
ACKNOWLEDGEMENTS
“Your biggest break can come from never quitting. Being at the right place at the
right time can only happen when you keep moving toward the next opportunity.”
Arthur Pine
I wish to express my sincere gratitude and appreciation to the following people for
their contribution and assistance in this study:
My supervisor, Prof Flip van Wyk, Head of the Department of Community Dentistry,
University of Pretoria, for his support, encouragement, guidance and constructive
criticism throughout and also for being a mentor, friend and colleague.
Prof Flip van Wyk, Ms Sannie Booyens and Dr Pratima Kissoon-Singh, whose
research on water fluoridation and human resources planning served as the
inspiration for this study.
Prof Tshepo Gugushe, Dean of the School of Dentistry, University of Limpopo and
Prof Newell Johnson, Foundation Dean and Head of the School of Dentistry and Oral
Health, Griffith University, for allowing me the time to complete this study while
employed at their institutions.
Staff from municipalities, local authorities and water boards for providing me with the
information needed for this study.
Mr Eddy Valkenburgh and Mr Martin de Klerk, Pelchem, and Peter Leopold, SüdChemie, for information on the cost and transport of fluoride chemicals.
Ms Marica Erasmus, Department of Water Affairs and Forestry, for allowing me
access to their database on natural fluoride concentrations.
Dr Johan Smit, Director Oral Health, Department of Health, for his support and
interest.
Mrs Susan Marsh, Department of Library Services, University of Pretoria, for always
being there when assistance was required.
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ix
Mrs Wilma Steinbach, Oral and Dental Hospital, University of Pretoria, for providing
me with information and her patience with explaining the UPFS fee schedule.
Mrs Gollie Venter, Personal Assistant, Department of Community Dentistry,
University of Limpopo, for her assistance and encouragement in sometimes difficult
times.
Professor Peter Cleaton-Jones and Prof Elly Grossman, Dental Research Institute,
University of the Witwatersrand, for providing me with opportunities and introducing
me to the wonderful world of research so many years ago which has culminated in
this thesis.
Professor Willie Snyman, previous Head of the Department of Community Dentistry,
University of Pretoria, for his role in my development, his advice and leadership over
a number of years.
My wife, Amanda, for her love, understanding, support and dedication to our family
which has carried me through this study.
My son, Marco, whose enthusiasm for and dedication to the things I also love kept
me motivated to complete this study.
My daughter, Rianca, for just being the daughter every father wishes for and for
keeping the balance in the family.
My parents, I dedicate this thesis to you for providing me with the opportunities in
life.
My friends and other family members, for their understanding during the past number
of years.
Soli Deo Gloria
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x
LIST OF TABLES
Table 1: Summary of early studies into the relationship between fluoride in
community water supplies, dental caries and dental fluorosis................................ 8
Table 2: Savings in cost of dental treatment, working time and cost-benefit analysis
for water fluoridation studies in five countries (Davies, 1974) .............................. 25
Table 3: Cost evaluation of the implementation of water fluoridation in Gauteng (Van
Wyk et al., 2001) .................................................................................................. 29
Table 4: Summary of advantages, disadvantages and indications of the four
approaches to human resources planning (Hall, 1978; Kissoon-Singh, 2001)..... 35
Table 5: Summary of landmark human resources developments in South Africa from
1910 to 1993 (Van Wyk, 1996) ............................................................................ 40
Table 6: Human resources required for the delivery of oral health services in South
Africa based on the WHO/FDI model (Booyens, 1996)........................................ 43
Table 7: The need for oral health personnel in South Africa by 2011 (Van Wyk, 1996)
............................................................................................................................. 44
Table 8: Human resources requirements for KwaZulu-Natal (2000 and 2010) for
selected procedures of the basic oral health care package (Kissoon-Singh, 2001)
............................................................................................................................. 48
Table 9: Magisterial districts with the lowest and highest operator to population ratios
in South Africa (Van Wyk et al., 1994) ................................................................. 53
Table 10: Number and percentage of South African dental graduates, first year
students and dental specialists by gender and racial group (Lalloo et al., 2005;
Lalloo et al., 2006) ............................................................................................... 56
Table 11: Oral health professionals registered with the HPCSA on 30 March 2007
(Health Professions Council of South Africa, 2007) ............................................. 58
Table 12: Recommended ratios for oral health personnel in the public sector
(Department of Health, 1999)............................................................................... 63
Table 13: The minimum package of oral care (Department of Health, 2001a; Pick et
al., 2001) .............................................................................................................. 64
Table 14: A model to calculate per capita cost, cost-effectiveness and cost-benefit of
the implementation of water fluoridation............................................................... 68
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xi
Table 15: Properties of the three commonly used fluoridation chemicals (Department
of Health, 2003c; Pelchem, 2007)........................................................................ 70
Table 16: Number of water purification plants and daily water purification rate per
municipality or water board .................................................................................. 72
Table 17: Natural fluoride content of municipalities and water boards (Erasmus,
2004; Grobler et al., 2006) ................................................................................... 73
Table 18: Total delivery cost of chemical per metric tonne (De Klerk, 2006; Leopold,
2006).................................................................................................................... 75
Table 19: Average operator salary, number of operators required, annual operator
salary and annual labour cost .............................................................................. 78
Table 20: Capital cost for a water fluoridation plant for Category A, B and C water
providers .............................................................................................................. 80
Table 21: Operating and total cost of water fluoridation ........................................... 82
Table 22: Caries prevalence (DMFT) for 15-year-olds per district and province: 19992002 NCOHS ....................................................................................................... 84
Table 23: Average cost of a two surface restoration (Council for Medical Schemes,
2006).................................................................................................................... 86
Table 24: Cost of the introduction of water fluoridation ............................................ 87
Table 25: Per capita cost of water fluoridation for the total population and those
younger than fifteen years.................................................................................... 90
Table 26: Cost-effectiveness of water fluoridation.................................................... 92
Table 27 : Cost-benefit of water fluoridation............................................................. 95
Table 28: A model to calculate per capita cost of delivering the minimum package of
oral care ............................................................................................................. 107
Table 29: 2006 South African mid-year population estimates by province (Statistics
South Africa, 2006) ............................................................................................ 107
Table 30: Example of calculation of mean weighted national values ..................... 109
Table 31: Percentage treatment need for 4- to 5-, 6-, 12- and 15-year-olds for all
provinces............................................................................................................ 110
Table 32: Treatment need per tooth for 4- to 5-, 6-, 12- and 15-year-olds for all
provinces............................................................................................................ 111
Table 33: Prevalence and severity of periodontal disease (bleeding and calculus
only) for 15-year-old South African children (Department of Health, 2003b)...... 114
Table 34: Treatment need values used in this study .............................................. 114
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xii
Table 35: UPFS oral health procedure and consultation fees for middle (H2) and high
(HG) income patients (Gauteng Provincial Government, 2005) ......................... 117
Table 36: NRPL and UPFS fees used in this study................................................ 118
Table 37: Summary of treatment need variables and NRPL/UPFS codes and fees
used in this study ............................................................................................... 119
Table 38: National per capita cost of delivering the minimum package of oral care by
age cohort .......................................................................................................... 122
Table 39: Impact of water fluoridation on the average national per capita cost of
delivering the minimum package of oral care (including examination and bitewing
radiographs)....................................................................................................... 123
Table 40: Impact of water fluoridation on the average national per capita cost of
delivering the minimum package of oral care (excluding examination and bitewing
radiographs)....................................................................................................... 124
Table 41: Impact of an oral examination and bitewing radiographs on the average
national per capita cost of delivering the minimum package of oral care ........... 125
Table 42: Mean per capita cost of delivering the minimum package of oral care per
province ............................................................................................................. 126
Table 43: The WHO/FDI model to calculate human resources required to deliver the
minimum package of oral care (World Health Organization/Fédération Dentaire
Internationale, 1989) .......................................................................................... 133
Table 44: Caries prevalence of 4- to 5- and 15-year-old South African children: 19992002 NCOHS (Department of Health, 2003b)................................................... 135
Table 45: Mean number of sextants with bleeding and calculus in 15-year-old South
African children (Department of Health, 2003b) ................................................. 138
Table 46: Utilization of services based on time elapsed since previous visit to a
dentist or dental clinic for the South African adult population (Department of
Health, 1994) ..................................................................................................... 140
Table 47: 2006 South African mid-year population estimates for the 4- to 5- and 6- to
15-year-old age cohorts (Statistics South Africa, 2006) ..................................... 142
Table 48: A “Service Targets Method” model to calculate human resources needed
to deliver the minimum package of oral care...................................................... 144
Table 49: Treatment need as a percentage of the population or mean number of
teeth/sextants for the 4- to 15-year-old age cohort ............................................ 145
Table 50: Treatment times used in the “Service Targets Method” model ............... 146
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xiii
Table 51: Summary of human resources requirements for 4- to 15-year-old South
African children calculated with the WHO/FDI and “Service Targets Method”
models ............................................................................................................... 151
Table 52: Difference between human resources requirements for 4- to 15-year-old
South African children calculated with the WHO/FDI and “Service Targets Method”
models ............................................................................................................... 153
Table 53: Requirements for oral hygienists for 4- to 15-year-old South African
children using the WHO/FDI and “Service Targets Method” models.................. 156
Table 54: Requirements for dental therapists and dentists for 4- to 15-year-old South
African children using the WHO/FDI and “Service Targets Method” models...... 157
Table 55: Summary of recommendations from this study ...................................... 176
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xiv
LIST OF FIGURES
Figure 1: The health manpower system (Mejía and Fülöp, 1978) ............................ 31
Figure 2: Schematic representation of the four approaches to human resources
planning (Hall, 1978) ............................................................................................ 33
Figure 3: Flow chart of the WHO/FDI human resources planning model (World
Health Organization/Fédération Dentaire Internationale, 1989) ........................... 39
Figure 4: Location of cities, towns and water boards................................................ 67
Figure 5: Cost of the introduction of water fluoridation for Category A, B and C
municipalities and water boards as a percentage of the total cost ....................... 89
Figure 6: Per capita cost for the total population and those younger than fifteen years
for Category A, B and C municipalities and water boards .................................... 91
Figure 7: Cost-effectiveness of water fluoridation for the total population for Category
A, B and C municipalities and water boards at three anticipated levels of caries
reduction .............................................................................................................. 93
Figure 8: Cost-effectiveness of water fluoridation for those younger than fifteen years
for Category A, B and C municipalities and water boards at three anticipated
levels of caries reduction...................................................................................... 93
Figure 9: Cost-benefit of water fluoridation for the total population for Category A, B
and C municipalities and water boards at three anticipated levels of caries
reduction .............................................................................................................. 96
Figure 10: Cost-benefit of water fluoridation for those younger than fifteen years for
Category A, B and C municipalities and water boards at three anticipated levels of
caries reduction.................................................................................................... 96
Figure 11: National human resources requirements calculated with the WHO/FDI
model for delivering the minimum package of oral care to 4- to 15-year-old South
African children .................................................................................................. 154
Figure 12: National human resources requirements calculated with the “Service
Targets Method” model for delivering the minimum package of oral care to 4- to
15-year-old South African children..................................................................... 154
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xv
LIST OF ABBREVIATIONS
ANC
African National Congress
ART
Atraumatic Restorative Technique
BER-BCI
Bureau for Economic Research’s Building Cost Index
CBA
Cost-benefit analysis
CCS
Compulsory Community Service
CEA
Cost-effectiveness analysis
CEO
Chief Executive Officer
CPI
Community Periodontal Index
CPITN
Community Periodontal Index of Treatment Need
CSIR
Council for Scientific and Industrial Research
CSS
Central Statistics Service
DASA
Dental Association of South Africa
dmft/DMFT
decayed, missing and filled teeth
FDI
Fédération Dentaire Internationale
FTE
Full-time equivalents
GDC
General Dental Council
HPCSA
Health Professions Council of South Africa
IADR
International Association for Dental Research
JFIC
Joint Fluoridation Implementation Committee
MEDUNSA
Medical University of Southern Africa
MRC
Medical Research Council
NAMDA
National Medical and Dental Association
NCOHS
National Children’s Oral Health Survey
NFC
National Fluoridation Committee
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xvi
NHRP
National Human Resources Plan for Health
NOHS
National Oral Health Survey
NRPL
National Reference Price List
PHC
Primary Health Care
ppm
parts per million
SAAWU
South African Association of Water Utilities
SADA
South African Dental Association
SADJ
South African Dental Journal
SALGA
South African Local Government Association
SAMDC
South African Medical and Dental Council
STATOMET
Bureau for Statistical and Survey Methodology
UK
United Kingdom
UPFS
Uniform Patient Fee Schedule
USA
United States of America
WHO
World Health Organization
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xvii
CHAPTER 1: PROBLEM STATEMENT, AIMS, RESEARCH
DESIGN AND STRUCTURE
1.1
Problem statement
Since the “discovery” of fluoride and conclusive evidence provided by Dean
and Elvove (1935) on the caries reducing potential of natural fluoride in
drinking water, in excess of 100 studies have been conducted in more than 40
countries indicating similar results with the artificial fluoridation of drinking
water (Murray, Rugg-Gunn and Jenkins, 1991a). Three recent reviews have
confirmed water fluoridation as the most cost-effective and safe primary
preventive measure against dental caries (Forum on Fluoridation, 2002;
Medical Research Council, 2002; NHS Centre for Review and Dissemination,
2000).
Despite all this evidence in favour of water fluoridation and a Commission of
Inquiry into water fluoridation recommending the fluoridation of public water
supplies to the optimal fluoride concentration (Republic of South Africa, 1966),
no artificially fluoridated water scheme exists in South Africa. A National
Fluoridation Committee (NFC) was appointed by the Minister of Health in
1996 to finalise regulations for water fluoridation. These regulations were
promulgated on 8 September 2000 (Republic of South Africa, 2000). Water
providers are compelled by the regulations to fluoridate public water supplies,
but may apply for exemption under special circumstances such as optimal
natural fluoride levels already being present.
These regulations were
repealed with the repealing of the Health Act of 1977 and have been
amended and will follow the normal legal process for approval (Smit, 2007).
Both the United Kingdom (UK) Medical Research Council (MRC) (Medical
Research Council, 2002) and University of York
reports (NHS Centre for
Review and Dissemination, 2000) have concluded that there is a need to
extensively research the economic impact of water fluoridation where the cost
___________________________________________________________________
Chapter 1
1
of the programme should be weighed against its benefits, especially in times
of a trend of a reduction in dental caries and exposure to other fluoride
products.
Dental caries was included in a South African National Children’s Oral Health
Survey (NCOHS) (Department of Health, 2003b) to determine reliable
baseline data and monitor trends in oral health status in all provinces of South
Africa. The report on this survey concluded that caries in the primary dentition
was more severe than in the permanent dentition. Caries severity for 12-yearolds ranged between very low to low according to the World Health
Organization (WHO) classification (Barmes, 1977). High levels of untreated
caries were however recorded.
The report recommended that the
implementation of water fluoridation be evaluated for South Africa taking into
account caries levels in areas where water is supplied by water providers,
cost of water fluoridation, levels of fluorosis and trends in dental caries
prevalence and severity (Department of Health, 2003b).
The cost and consequences of water fluoridation in any assessment model
are dependent on the perspective of the analysis by society, the public health
sector, a third-party payer or a particular segment of the population (White,
Antczak-Bouckoms and Weinstein, 1989). Guidelines to calculate the cost of
water fluoridation based on 44 communities in Florida, United States of
America (USA) (Ringelberg, Allen and Brown, 1992) were used to develop a
computerised simulation model to evaluate the cost of water fluoridation for
Gauteng (Van Wyk, Kroon and Holtshousen, 2001).
The White Paper for the Transformation of Health Services in South Africa
presents implementation strategies to meet the basic needs of the population.
It
recognises
dental
practitioners,
oral
hygienists,
dental
therapists,
technicians and dental assistants as members of the oral health workforce
delivering these services. Adoption of the Primary Health Care (PHC)
approach and reducing the incidence of common oral diseases through a
minimum package of care, water fluoridation, and reduction of the
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2
consumption of refined sugar have been identified as the main principles to
address oral health (Republic of South Africa, 1997b).
A package of PHC services was agreed to at a meeting of the Provincial
Restructuring Committee in Bloemfontein on 13 April 2000 (Pick et al., 2001)
and have been published in separate documents (Department of Health,
2001a; Department of Health, 2001b). For oral health it consists of:
•
Oral examination and charting of dental status;
•
Intra-oral radiographs;
•
Scaling and polishing of teeth;
•
Promotive and preventive oral health services;
•
Basic curative services including emergency relief of pain and sepsis
(including dental extractions);
•
Simple restorations (1-3 tooth surfaces);
•
Treat traumatic injuries to teeth; and
•
Treat post-extraction bleeding.
Irrespective of the implementation of water fluoridation and/or a minimum
package or oral care, it will impact on human resources required in future.
Three studies have been conducted in South Africa over the past number of
years investigating human resources required.
Booyens (1994) applied the WHO/Fédération Dentaire Internationale (FDI)
needs model (World Health Organization/Fédération Dentaire Internationale,
1989) to the 1988/89 National Oral Health Survey (NOHS) data (Department
of Health, 1994) to provide quantitative and qualitative information regarding
oral health human resources needs for South Africa. This study concluded
that more oral hygienists should be trained to address the need for more
primary preventive dental services.
Van Wyk (1996) developed a model to determine the future human resources
needs for optimal oral health care for the total population of South Africa
where the actual demand for services was used as a point of departure. This
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Chapter 1
3
study concluded that the levels of human resources required for 2011 would
be difficult to attain and a programme of optimal fluoridation was suggested as
an absolute necessity to address oral health to the population of South Africa.
Kissoon-Singh (2001) also used the WHO/FDI needs based model (World
Health Organization/Fédération Dentaire Internationale, 1989) and the basic
oral health care package (Department of Health, 2001a) to plan human
resources for oral health care for KwaZulu-Natal. This study concluded that
there was a gross shortage of oral health personnel to meet the oral health
needs of this province.
The majority of reports on human resources in South Africa have highlighted
the inequitable distribution between urban and rural on the one side and the
private and public sectors on the other.
The recently published National Human Resources Plan for Health (NHRP)
identifies human resources planning and development as a key priority area
and provides a framework to guide all stakeholders to provide an adequate
workforce in partnership with government (Department of Health, 2006a).
The NHRP proposes annual productions for the various members of the oral
health team (Department of Health, 2006a). In doing so it recognises that
targets may appear high, but consideration has to be given to mobility of
health professionals to and from the private sector, migration overseas and
other attrition factors. The recommendations contained in the NHRP have
been criticised by the Chief Executive Officer (CEO) of the South African
Dental Association (SADA) (Campbell, 2006).
The challenge to any planner of health and oral health programmes and
services is to establish a health system which is available, accessible,
affordable and acceptable to all citizens and meets the needs and demands in
the most cost-effective way to lead to improved health for all.
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4
1.2
Aims and objectives of the study
The aim of this study was to perform an economic assessment of the
implementation of water fluoridation and the delivery of the minimum package
of oral care and the impact this will have on human resources planning for
oral health in South Africa.
The objectives of the study were:
•
To determine per capita cost, cost-effectiveness and cost-benefit of the
implementation of water fluoridation for seventeen major metropolitan
cities, towns and water boards in all nine provinces of South Africa by way
of a model taking into account operating cost, opportunity cost and capital
depreciation;
•
To determine the per capita cost of delivering the minimum package of
oral care to 4- to 15-year-old children based on the treatment needs as
determined in the 1999-2002 NCOHS and National Reference Price List
(NRPL) and Uniform Patient Fee Schedule (UPFS) fees;
•
To calculate human resources needed for the implementation of the
minimum package of oral care to 4- to 15-year-old children based on the
WHO/FDI
model
(World
Health
Organization/Fédération
Dentaire
Internationale, 1989) and a “Service Targets Method” model (Bui Dang Ha
Doan, 1981; Hall, 1978). Both models considered different scenarios for
caries reduction achieved through water fluoridation.
1.3
Research design
This study was conducted in three parts based on the three objectives of the
study:
•
Part 1: Cost evaluation for the implementation of water fluoridation in the
metropolitan areas and larger towns of South Africa;
•
Part 2: Costing the delivery of the minimum package of oral care
(Department of Health, 2001a; Department of Health, 2001b);
•
Part 3: Calculate the oral health human resources needs for the
implementation of the minimum package of oral care.
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Chapter 1
5
The following databases and information documents were used in this study:
•
2006 South African mid-year population estimates (Statistics South Africa,
2006);
•
1999-2002 NCOHS (Department of Health, 2003b);
•
Council for Medical Schemes’ 2006 NRPL (Council for Medical Schemes,
2006);
•
2006 UPFS (Gauteng Provincial Government, 2005); and
•
Minimum package of oral care (Department of Health, 2001a; Department
of Health, 2001b).
1.4
Structure of thesis
Chapter 2 presents a literature review on water fluoridation (including a
historical perspective, water fluoridation in South Africa and economic
assessment),
human
resources
planning
(including
approaches,
the
WHO/FDI model, a South African perspective and human resources
distribution and trends) and South African policy documents on health and
oral health service delivery.
Chapter 3 describes a model, results and discussion of the per capita cost,
cost-effectiveness and cost-benefit of the implementation of water fluoridation
for seventeen major metropolitan cities, towns and water boards in all nine
provinces of South Africa.
Chapter 4 describes a model, results and discussion of the per capita cost of
delivering the minimum package of oral care to 4- to 15-year-old children
taking into account different scenarios for caries reduction achieved through
water fluoridation.
Chapter 5 describes two models, results and discussion to calculate the oral
health human resources required for the implementation of the minimum
package of oral care to 4- to 15-year-old children taking into account different
scenarios for caries reduction achieved through water fluoridation.
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6
Chapter 6 describes the conclusions and recommendations from this study
linked to water fluoridation and delivering the minimum package of oral care.
1.5
Summary
This chapter provided the background, aims and objectives and a brief
overview of the three phases of this study.
Chapter 2 will present a literature review of water fluoridation, human
resources planning and South African policy documents on health and oral
health service delivery.
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Chapter 1
7
CHAPTER 2: LITERATURE REVIEW
2.1
Overview of water fluoridation
2.1.1 Historical perspective
a)
The early years
The classic epidemiological study involving research conducted independently
by Dr Frederick McKay (a dentist from Colorado Springs, USA), Mr H.V.
Churchill (chief chemist from the ALCOA Company) and Dr H. Trendley Dean
(a dentist from the United States Public Health Service) is well document and
is described in detail in all major textbooks dealing with preventive dentistry,
fluoride and dental public health. Without repeating this entire study into the
“discovery” of fluoride in community water supplies and its relationship
between dental caries and dental fluorosis, key findings of this study,
spanning from 1900 to 1942, are summarised in Table 1.
Table 1: Summary of early studies into the relationship between fluoride in
community water supplies, dental caries and dental fluorosis
Year
Early 1900s
1916
1918
1928
1931
1931
1933
1934
1935
Description
Dr Frederick McKay describes the “Colorado Stain” in his patients seen in his
Colorado Springs, Colorado practice (Murray, Rugg-Gunn and Jenkins, 1991b)
McKay enlists the collaboration of Dr G.V. Black who describes this phenomenon as
“mottled enamel” (Black and McKay, 1916)
McKay concludes that a “mysterious element” in the community water supply is
responsible for mottled enamel (McKay, 1918)
McKay observes a reduced caries experience in patients with mottled enamel
(McKay, 1928)
Mr H.V. Churchill identifies high fluoride levels in water samples sent to him by
McKay for analysis (Churchill, 1931)
Dr H. Trendley Dean is appointed as the first dentist of the newly established
National Institute of Health’s Dental Hygiene Unit which became the National
Institute of Dental Research in 1948 (Burt and Eklund, 2005)
Dean publishes his first report of the distribution of mottled enamel in the United
States (Dean, 1933)
Dean describes his seven-point, ordinal scale index of fluorosis (Dean, 1934)
Dean starts using the term “fluorosis” to replace mottled enamel (Dean and Elvove,
1935)
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Chapter 2
8
Table 1: (continued)
1936
1938
1939
1941/1942
b)
Dean concludes the minimal threshold of fluoride in water should be 1 ppm (Dean,
1936) and that fluorosis in communities where fluoride levels were below this
threshold were of no public health significance (Dean and Elvove, 1936)
Dean’s first report on the inverse relationship between dental caries and dental
fluorosis (Dean, 1938)
Dean and McKay provide conclusive and direct proof that fluoride in public water
supplies is the primary cause of dental fluorosis (Dean and McKay, 1939)
Dean reports on his “21 cities study” indicating that dental caries experience
decreases sharply as fluoride concentration increases towards 1 ppm (Dean,
Arnold and Elvove, 1942; Dean et al., 1941) which led to the adoption of 1.0-1.2
ppm as the appropriate concentration of fluoride in drinking water in temperate
climates
North American studies
This initial phase linked to natural fluoride in drinking water, was followed by
the first controlled fluoridation trials in the United States and Canada
commencing in 1945 and 1946 in Grand Rapids, Michigan (Muskegon as
control), Newburgh, New York (Kingston as control), Evanston, Illinois (Oak
Park as control) and Brantford, Ontario (Sarnia as control) (Burt and Eklund,
2005). All of these studies, some reporting results of up to fifteen years after
the commencement of controlled fluoridation, clearly indicated a sharply
reduced caries experience in each of the study populations (Arnold et al.,
1962; Ast and Fitzgerald, 1962; Blayney and Hill, 1967; Hutton, Linscott and
Williams, 1956).
These studies, all of which were of a sequential cross-
sectional design, also reported fluorosis levels of between 7-16% as
described by Dean in earlier studies at a fluoride concentration of 1 parts per
million (ppm).
c)
The Dutch Tiel-Culemborg study
The first truly longitudinal study into the controlled fluoridation of public water
supplies was conducted in The Netherlands in the towns of Tiel (fluoridated)
and Culemborg (control). This study also described the caries inhibitory effect
of fluoride in drinking water being of more benefit to smooth surfaces
compared to pits and fissures and confirmed the benefits of lifelong exposure
to water fluoridation on oral health. Evidence from this study suggests that
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Chapter 2
9
adequate ingestion of fluoride during enamel formation is important to prevent
pit and fissure caries, but is of less importance where smooth surface caries is
concerned (Backer Dirks, Houwink and Kwant, 1961; Backer Dirks, 1967;
Kwant et al., 1972; Kwant et al., 1974).
d)
The New Zealand Hastings study
This was a retrospective study reporting on baseline examinations conducted
in 1954, 1964 (10 years after the introduction of fluoridation) and 1970 after
16 years of fluoridation.
This study indicated a caries reduction of 49%
between 1954 and 1970 and also demonstrated the selective caries inhibitory
effect of fluoride on different tooth surfaces (Ludwig, 1965; Ludwig, 1971).
e)
United Kingdom studies
The earliest studies in the UK confirmed Dean’s findings. Caries in South
Shields was reported to be 50% lower than in North Shields (Weaver, 1944).
Similar finding were reported from studies in the North-East of England
(Weaver, 1950) and other parts in Britain where fluoride levels varied from 0.9
to 5.8 ppm (Forrest, 1956).
A study conducted in East Anglia confirmed the benefits of continuous
exposure to fluoride compared to those exposed to fluoride in drinking water
for different periods of time (James, 1961).
A British Government mission to the USA to study fluoridation in operation
recommended that water fluoridation should be implemented in selected
communities first before general implementation. Watford, Kilmarnock and a
part of Anglesey were chosen. Fluoride was added to the drinking water in
1955-1956. After 5 years a report confirmed that fluoridation of water supplies
was highly effective in reducing dental caries (Murray et al., 1991b).
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Chapter 2
10
f)
The World Health Organization and water fluoridation
The WHO has always taken a keen interest in this public health topic and in
1958 produced their first report endorsing the findings that water containing
approximately 1 ppm was a practical and effective health measure to reduce
dental caries (World Health Organization, 1958).
A report on fluoridation was submitted to the World Health Assembly which
resulted in the adoption of the following resolution on 22 July 1969:
“The World Health Organization recommends member states to examine the
possibility of introducing and where applicable to introduce fluoridation of
those community water supplies where the fluoride intake from water and
other sources for the given population is below optimal levels, as a proven
public health measure, and where fluoridation of community water supplies
is not practicable to study other methods of using fluoride for the protection of
dental health” (World Health Organization, 1969).
This resolution was reaffirmed in the Report of the WHO Director General in
1975 (Murray et al., 1991b).
The 2003 World Oral Health Report confirmed the evidence that long-term
exposure to an optimal level of fluoride results in diminishing levels of caries
in both children and adults. This report did however recognise the various
sources of fluoride and requests public health administrators to maximise
caries reduction and at the same time minimise dental fluorosis. This report
estimated that 210 million people benefit from fluoridated water (Petersen,
2003).
g)
Current status of community fluoridation throughout the world
It came as no surprise that the favourable results of initial studies led to many
other communities adding fluoride to their public water supplies.
It was
estimated that by 1981 approximately 210 million people worldwide were
exposed to fluoridated water (Murray, 1986).
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Chapter 2
11
A summary of the world status of fluoridation shows (Burt and Eklund, 2005):
•
According to the FDI 34 countries reaching 246 million people had
fluoridated water;
•
Fluoridation in Singapore reached 100% of its population in 2004;
•
Ireland is the only nation with a mandatory fluoridation law;
•
More than 50% of the population in Australia, Ireland, Malaysia, New
Zealand and the USA are reached by water fluoridation;
•
10% of the population in Spain (mainly Seville and Córdoba) and the UK
(Birmingham and Newcastle) received fluoridated water;
•
Fluoridation projects in Eastern European and South and Central
American countries are of uncertain status; and
•
By the end of 1992, 135 million persons in the USA were served by
fluoridated water with a further 10 million having naturally fluoridated
water.
WHO in collaboration with the FDI and the International Association for Dental
Research (IADR) hosted a global consultation on “Oral Health through
Fluoride” from 17-19 November 2006.
The aim and objectives of the
Consultation were to (World Health Organization, 2006):
•
Review and highlight successes in promoting oral health through the use
of fluoride;
•
Identify barriers for making fluoride available to all;
•
Explore effective strategies for making fluoride available and affordable to
all; and
•
Develop an action plan for fluoride promotion and advocacy.
A declaration from this consultation reaffirmed the efficiency, costeffectiveness and safety of the daily use of optimal fluoride and that access to
fluoride for dental health forms part of the basic human right to health
(Fédération Dentaire Internationale, 2006).
___________________________________________________________________
Chapter 2
12
2.1.2 Caries prevention from water fluoridation
The extensive literature on the effectiveness of water fluoridation reports
mostly on studies conducted in children (Burt and Fejerskov, 1996). A
summary of studies of artificial fluoridation throughout the world showed that
of the 113 studies conducted in 23 countries, 66 reported on the effect on
deciduous teeth and 86 on permanent teeth (Murray et al., 1991a). More than
half of these studies were conducted in the USA. Modal percentage caries
reduction for deciduous teeth was 40 to 49% and 50 to 59% for permanent
teeth. Reports from these studies as well as the four pioneering studies
described earlier, has led to the statement “water fluoridation reduces dental
caries by half” (Burt and Eklund, 2005).
A review of the effectiveness of water fluoridation in the USA between 1979
and 1989 found that caries reduction varied from 8 to 37% amongst
adolescents (Newbrun, 1989).
Since the early days of water fluoridation,
caries has declined in both fluoridated and non-fluoridated communities,
mainly due to:
•
the diffusion of fluoridated water to areas through bottling and processing
of foods and beverages; and
•
the widespread use of fluoride toothpaste (Horowitz, 1996).
McKay was the first to report on the beneficial effect of water fluoridation on
adults. He reported a 60% difference in mean decayed, missing and filled
teeth (DMFT) scores between adults in naturally fluoridated Colorado Springs
and the non-fluoridated town of Boulder (McKay, 1948). Increased retention
of teeth in ageing populations can lead to an increase in the prevalence of
root caries. Studies which indicated a reduction in root caries in fluoridated
areas are therefore important to emphasise its benefits to adults and the
elderly as well (Burt, Ismail and Eklund, 1986; Stamm, Banting and Imrey,
1990).
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Chapter 2
13
2.1.3 Recent international reports
a)
University of York (2000)
The York review was the first systematic review to be undertaken on water
fluoridation.
The protocol and all stages were subject to external review
(Treasure et al., 2002).
The aim was to assess available evidence on both the positive and negative
effects of water fluoridation as a strategy to prevent dental caries. The worldwide-web and 25 electronic databases were searched, 214 studies met the
inclusion criteria for one of the 5 objectives of this review (McDonagh et al.,
2000).
Objective 1: Effect of water fluoridation on dental caries
The best evidence found suggested that fluoridation of drinking water does
reduce caries incidence as measured by the proportion of children who are
caries free and by the mean change in dmft/DMFT scores. The degree to
which this applied was not clear from this review. Evidence from studies after
withdrawal of water fluoridation suggested an increase in caries prevalence
levels approaching that of low fluoride groups (Treasure et al., 2002).
Objective 2: Beneficial effect of water fluoridation over and above other
interventions
This review found no difference in the mean dmft/DMFT or percentage caries
free individuals in studies conducted before or after 1970, suggesting that
water fluoridation may still be of benefit after the introduction of fluoride
toothpaste during the 1970’s (Treasure et al., 2002).
Objective 3: Equity of water fluoridation
No longitudinal studies were found to investigate this. Cross-sectional studies
were limited to the UK. Where dmft/DMFT was used, it seemed as if water
fluoridation did reduce the inequalities in dental health in social classes aged
5 and 12. The authors suggested that caution should be taken in interpreting
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Chapter 2
14
these results due to the few studies which investigated equity of water
fluoridation (Treasure et al., 2002).
Objective 4: Possible negative effects of water fluoridation
Dental fluorosis is regarded as the most widely reported negative effect of
water fluoridation.
This report identified a significant dose-response
relationship between water fluoridation and dental fluorosis with a prevalence
of 48% at a level of 1 ppm, fluorosis of aesthetic concern at this level was
12.5%. At 0.1 ppm the corresponding figures were 15% (prevalence) and 6%
(aesthetic concern). Altitude and temperature were not found to be significant
factors affecting dental fluorosis (Treasure et al., 2002).
The majority of studies investigating bone fractures as a consequence of
water fluoridation were divided into hip and other fractures. No clear
association could be found between hip or other fractures and water
fluoridation. The majority of studies reported a small variation around the no
effect outcome (Treasure et al., 2002).
No clear association could be indicated between any form of cancer and water
fluoridation (Treasure et al., 2002).
This report concluded that studies of a much higher quality needed to be
conducted to be conclusive of any negative effects of water fluoridation
(Treasure et al., 2002).
Objective 5: Differences between natural and artificial water fluoridation
Very few studies compared natural to artificial fluoridation, no major
differences were apparent, however evidence was found to be inadequate
(Treasure et al., 2002).
In summary this report concluded that little high quality research had been
conducted into public water fluoridation, including any negative effects. It was
suggested that future studies should include ethical, environmental,
ecological, cost and legal issues of the implementation of water fluoridation.
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Chapter 2
15
None of these aspects were included in this review (McDonagh et al., 2000).
It was concluded however that water fluoridation does prevent caries and is
associated with dental fluorosis (Treasure et al., 2002).
b)
Ireland Forum on Fluoridation (2002)
This forum was established by the Ireland Minister of Health in May 2000 with
the overall objective to review fluoridation of public water supplies in Ireland to
inform the public, legislators and health professionals about the benefits and
risks of fluoridation for human health. This would be the first major review of
fluoridation in Ireland since its introduction in 1964 (Forum on Fluoridation,
2002).
It was prompted by an increased interest among the public and
advocacy groups leading to a subsequent increase in media coverage
(Clarkson, McLoughlin and O'Hickey, 2003). The report covered scientific,
technical and ethical issues relating to fluoridation.
The overall conclusions of the final report were (Forum on Fluoridation, 2002):
•
Fluoridation was very effective to improve oral health of children, adults
and the elderly;
•
The best evidence suggested that at the maximum permitted level of 1
ppm human health was not adversely affected; and
•
Dental fluorosis is well recognised and evidence suggested that it was on
the increase in Ireland.
Two of the eight recommendations referred to water fluoridation with the
remaining six aimed at fluoride toothpaste, the oral health care industry, infant
formula, fluoride research, education, information and public participation and
public health and professional practice. All were aimed to achieve maximum
protection against dental caries and minimising the occurrence of dental
fluorosis (Forum on Fluoridation, 2002). Only those applicable to this study
are highlighted:
•
Policy aspects of water fluoridation: Fluoridation should continue, but
the optimal level should be amended from 0.8 to 1.0 ppm to between 0.6
___________________________________________________________________
Chapter 2
16
and 0.8 ppm. This level should be sufficient to maintain low caries levels
and reduce the prevalence of dental fluorosis (Clarkson et al., 2003).
•
Technical aspects of water fluoridation: Guidelines should be
developed to support ongoing quality assurance and external audit of
fluoridation plants should be put in place.
Fluoride monitoring and
reporting procedures should be updated.
•
Fluoride toothpaste: The continued use of fluoride toothpaste was
recommended due to the additive benefit from the combination of this and
water fluoridation. Fluoride toothpaste should not be used up to the age of
2 and parents should supervise the brushing of their children’s teeth
between ages 2 and 7 with only a pea-sized amount of toothpaste used.
Swallowing of fluoride toothpaste should be avoided during these ages.
c)
United Kingdom Medical Research Council (2002)
Following on the York report commissioned by the Chief Medical Officer of the
UK Department of Health, the MRC was requested to investigate what further
research would be required to improve the evidence base of fluoride and
health in light of the conclusions and recommendations of the York report, the
results of which were published as a separate report. The following
recommendations were made (Medical Research Council, 2002):
•
Risk assessment, management and perception: Evaluate methods for
gauging public opinion, especially relating to water fluoridation, increase
understanding on how to engage the public when planning research,
assess methods to communicate results to the public and improved
involvement of public opinion in reaching policy decisions.
•
Total fluoride exposure and uptake: Differences in bioavailability and
absorption of fluoride from natural compared to artificially fluoridated
sources, calculate lifetime intake of fluoride, trends in fluoride exposure as
a result of the use of discretionary fluorides such as fluoride toothpaste by
infants.
•
Dental caries: Effect of fluoridation against a background of widespread
use of other fluoride sources, effect of water fluoridation on differences in
___________________________________________________________________
Chapter 2
17
social class, impact of fluoridation on caries in adults and root caries in the
elderly, impact of fluoridation on quality of life and economic indices.
•
Dental fluorosis: Determine levels of fluorosis in both fluoridated and
non-fluoridated communities, the public’s perception of dental fluorosis
and what level is aesthetically acceptable, fluorosis to be included as an
outcome measure in any prospective study into water fluoridation.
•
Potential negative health outcomes: Does bio-availability of fluoride
from artificial and natural sources affect health differently, the relation
between hip fractures and long-term consumption of artificially fluoridated
water, update analysis of UK data on water fluoridation and cancer rates.
2.1.4 Water fluoridation in South Africa
a)
The history of water fluoridation from 1935-1996
The history of water fluoridation for this period can be categorised into three
phases (Moola, 1996).
During Phase 1 (1935-1968) the presence of fluorosis in children in high
fluoride areas, delineation of areas of endemic fluorosis, levels of fluoride in
different areas in South Africa and the observation of dental caries in these
areas were reported (Ockerse, 1941; Ockerse, 1942; Ockerse, 1944; Ockerse
and Meyer, 1941).
This work led to an investigation by the Council for
Scientific and Industrial Research (CSIR) into the desirability of water
fluoridation, the report of which approved the suggestions to add fluoride to
community water supplies as a preventive health measure to reduce dental
caries (Staz, 1963).
Towards the end of this phase, in view of the divergence of opinions between
those who supported and those with objections to fluoridation of public water
supplies, a Commission of Inquiry was appointed by the State President to
report on (Republic of South Africa, 1966):
•
The maximum exposure to fluoride which was safe for the human body;
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Chapter 2
18
•
Possible short and long-term beneficial and detrimental effects on the
health of human beings of all ages; and
•
Safe methods of utilising the possible advantages of the use of fluoride.
The Commission was overwhelmingly in favour of fluoridating the drinking
water and the report recommended (Republic of South Africa, 1966):
•
Local authorities should be encouraged, advised and assisted to fluoridate
the water supplies of their communities as soon as possible;
•
Fluoridation schemes should aim to achieve optimal concentration of
fluoride in the drinking water for the prevalent climatic conditions;
•
Where fluoride was naturally present in public water supplies, adjustment
should not exceed the recommendations published in the report;
•
Where natural fluoride concentrations exceeded the recommended levels,
defluoridation should be considered;
•
Consumers should be informed of the best means of obtaining the
beneficial effects of fluoride;
•
Where supplementation of fluoride in drinking water was practiced, the
average concentration should be kept within the upper and lower limits as
recommended in the report;
•
Regulations should be developed and published to ensure the monitoring
and safe and uniform standards were maintained in fluoridation plants;
•
Local authorities should be legally authorised to decide whether or not the
public water supplies over which they have jurisdiction should be
fluoridated.
No action was taken by the then government of the day to implement water
fluoridation.
Phase 2 (1978-1989) was characterised by a number of reports and
symposia (Moola, 1996). A publication on the views of the profession and the
Department of Heath (Taljaard, 1978) triggered public debate from those
opposed to water fluoridation. This prompted a National Symposium on Water
Fluoridation which ended inconclusively with no clear mandate to government
___________________________________________________________________
Chapter 2
19
to implement water fluoridation (Department of Health, 1979). During this
phase considerable research was conducted into the levels of fluoride in
drinking water as well as research supported by the MRC on alternative
sources of fluoride (Dreyer and Grobler, 1984; Grobler and Dreyer, 1988;
Grobler et al., 1994; Grobler, Van Wyk Kotze and Cleymaet, 1991; Janse van
Rensburg et al., 1991; Louw and Van Wyk, 1984; Zietsman, 1991).
Phase 3 (1990-1996) occurred during major political change in South Africa
(Moola, 1996). Water fluoridation was discussed at the National Medical and
Dental Association (NAMDA) and the MRC organised another symposium
(Medical Research Council, 1991; National Medical and Dental Association,
1990). The National Health Plan of the African National Congress (ANC)
included water fluoridation as a PHC measure (African National Congress,
1994a). In 1995 the Oral Health Committee, appointed by the Ministry of
Health, recommended that government implement water fluoridation as part of
its Reconstruction and Development Programme (African National Congress,
1994b).
Subsequent to this the Oral Health Committee set up a
Subcommittee on Water Fluoridation to oversee the implementation of water
fluoridation.
This committee was renamed the National Fluoridation
Committee (NFC) shortly after.
Towards the end of this phase, a number of journal articles reported on the
effectiveness of water fluoridation in South Africa (Du Plessis, 1995; Du
Plessis et al., 1996; Du Plessis et al., 1995). Children from the black and
white population groups on the Free State Goldfields (0.54 ppm fluoride)
showed respective caries reductions of 85% and 31% when compared to
children in the coastal areas (<0.01 ppm fluoride). From this study it was
concluded that an acceptable level of fluoride in public water supplies on the
Free State Goldfields should not exceed 0.7 ppm. As part of a severe drought
in the coastal city of Port Elizabeth (<0.1 ppm fluoride), water from the
Orange/Fish/Sundays River schemes was transferred to this city. This water
has a natural fluoride concentration of on average 0.62 ppm.
A study
investigated caries prevalence in children receiving the high fluoride water
compared to the low fluoride water 16 months after this change was made.
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Chapter 2
20
No statistically significant difference could be indicated for the primary
dentition. In the permanent dentition, 12- and 15-year-old children consuming
the higher fluoride concentration water respectively had 14% and 7.8% less
caries compared to the lower fluoride group.
b)
The history of water fluoridation from 1996
One of the main objectives of the NFC of the Department of Health was to
draft regulations for the fluoridation of water supplies. On 8 September 2000
the Minister of Health approved these regulations as part of Health Act No. 63
of 1977. These regulations were published in the Government Gazette
(Republic of South Africa, 2000)
and compelled every water supplier to
initiate fluoridation unless exempted thereof, in writing by the Director
General: Health.
An
advisory
committee
to
the
NFC,
called
the
Joint
Fluoridation
Implementation Committee (JFIC), was formed in 2002 consisting of members
from the South African Association of Water Utilities (SAAWU), South African
Local Government Association (SALGA), Department of Health and the
Department of Water Affairs and Forestry. The JFIC was chaired by the CEO
of the Water Research Commission.
The JFIC drafted criteria for the
identification of “front runner sites” for the safe implementation of water
fluoridation (Smit, 2007).
Cape Town, Port Elizabeth, East London and
Durban, (coastal areas) were identified as potential front runner sites
(Department of Health, 2003a).
A new Health Act (Act No. 61 of 2003) for South Africa (Republic of South
Africa, 2003) necessitated an amendment to the regulations on fluoridating
water supplies, since the previous regulations were repealed with the
repealing of the Health Act of 1977. SAAWU and SALGA also demanded a
change to the regulations as certain legal and technical aspects in the original
regulations had to be amended. They furthermore complained that the
regulations were an unfunded mandate and that that they did not have the
funds to implement water fluoridation. The regulations have now been
___________________________________________________________________
Chapter 2
21
amended and will follow the normal legal process of consultation through the
invitation of comments, including via the Government Gazette. The NFC will
consider inputs received, where after the regulations will be submitted to the
Minister of Health for promulgation (Smit, 2007).
c)
Attitudes to water fluoridation in South Africa
A National Fluoridation Survey was conducted in 1998 prior to the publication
of the Regulations on Fluoridating Water Supplies.
The findings were
presented in three parts (Chikte and Brand, 1999; Chikte and Brand, 2000;
Chikte et al., 2000).
This survey found that 25.6% of the population surveyed had heard or read
about fluoridation, 65.6% had not, with 8.9% unsure.
In terms of racial
classification 62.6% of the white population group had heard about
fluoridation, whilst 72.2% of the black population group had not. The highest
percentage of respondents who had heard about fluoridation resided in the
Western Cape (46.3%), the highest no response (82.8%) was found in North
West province.
The electronic media were the most dominant source of information (40%),
followed by the print media (27%). More than a third of respondents (36%)
could identify the purpose of water fluoridation correctly, 28% believed it to
purify water, 29% were unsure.
The majority of respondents (61.9%) agreed that fluoride should be added to
water, 9% disagreed with the remaining 29.1% unsure. The main reasons for
a support vote was given as prevention of tooth decay (30%) and affecting
health positively (30.6%), whilst the main reasons for a negative response
was that water should stay as it is (26.1%), it will create bigger problems as it
remains in the water (15.6%) and it affects health negatively (12.3%). The
majority of respondents who were uncertain of adding fluoride to water could
not provide a reason (90%).
___________________________________________________________________
Chapter 2
22
As was expected a strong relationship was found between educational level
and knowledge of and attitude towards fluoride with 59% of respondents in
the highest educational group having heard or read about fluoridation.
Similar trends were found related to income (70%) and occupation (68% of
professional/executive).
When compared to previous similar studies (Chikte, 1997; Gilbert and Chikte,
1993), this study concluded that support for water fluoridation has increased.
Educational programmes on water fluoridation should be aimed at lower
educational and income groups with the electronic media as the vehicle of
choice.
A small resistant, yet influential, group existed which opposed
fluoridation.
Especially in South Africa, water fluoridation is needed to
address inequalities in oral health and based on these results health
authorities and policy makers should proceed with its implementation.
2.1.5 The economics of water fluoridation
Costing water fluoridation and its benefits is a complex process looked upon
differently by city councils, proponents of fluoridation, dental practitioners and
even those opposed to fluoridation (Burt and Eklund, 2005). In general per
capita cost of fluoridation is affected by the size of the community, number of
fluoride injection points, amount and type of equipment required, amount and
type of fluoride chemical as well as its transport and storage, training and
expertise of personnel required to run the plant.
Although the actual cost of water fluoridation cannot and should not be
ignored, estimates of saving in treatment cost may be more important than
per capita cost. Health economists at the conclusion of a 1989 workshop in
Michigan concluded that water fluoridation was one of a few public health
measures where it actually saved more money than it cost to operate
(Anonymous, 1989).
___________________________________________________________________
Chapter 2
23
Benefits from fluoridation can be expressed in several ways (Davies, 1974):
•
Saving in the cost of dental treatment based on the reduction in number of
restorations and extractions;
•
Saving in the oral health worker’s working time or salary as a result of the
reduction in treatment required; and
•
Less pain and discomfort and a reduction in loss of time from school and
industry. This is difficult to express in monetary terms.
Cost- effectiveness and cost-benefit analysis in relation to dental procedures
are defined as follows (Horowitz and Heifetz, 1979):
•
Cost-effectiveness analysis (CEA) is expressed as the cost per person per
year to save 1 DMFT; and
•
Cost-benefit analysis (CBA) is expressed as the cost of implementing the
procedure divided by the savings in the cost of treatment.
CEA and CBA frequently overlap and are sometimes difficult to distinguish.
Where CBA is used to make broad decisions about competing programmes,
CEA assists in choosing among alternative programmes to achieve the same
outcome, for example as defined by Horowitz and Heifetz (1979) to save 1
DMFT. While costs can usually be accurately assessed with CBA, it has the
disadvantage that the benefit to an individual’s freedom from pain, discomfort
or inconvenience cannot be reliably established in monetary terms. CEA is
therefore the less complicated technique (Fédération Dentaire Internationale,
1981).
Saving in the costs of dental treatment, working time and CBA for the
fluoridation studies conducted in Hastings (New Zealand), Newburgh (USA),
Watford (United Kingdom), Tiel (Netherlands) and Basel (Switzerland) are
shown in Table 2. It should be noted that cost-benefit ratios vary because of
differences in cost of dental treatment between countries, in all cases
however the value of the benefits substantially exceeded the cost of
implementation (Davies, 1974).
___________________________________________________________________
Chapter 2
24
Table 2: Savings in cost of dental treatment, working time and cost-benefit
analysis for water fluoridation studies in five countries (Davies, 1974)
Study
(country)
Hastings (1965)
(New Zealand)
Newburgh
(1966/70)
(USA)
Watford (1962)
(United Kingdom)
Tiel (1972)
(Netherlands)
Basel (1967)
(Switzerland)
Savings in cost of
dental treatment per
child
NZ$1.79
(2.5-13.5-year-olds)
NZ$ 5.72
(13.5-15-year-olds)
US$4.81-8.17
(5-year-olds)
US$1.99-9.40
(6-year-olds)
£1.62 (age 3) to £4.32
(ages 6-7)
26 Dutch Guilder (age
7) to 229 Dutch
Guilder (age 15)
90.75 Swiss Francs
over 5 years
Savings in working
time
Cost-benefit analysis
0.65
whole-time
dental nurse per
1,000 children
NZ$4.4 saved for every NZ$
spent on water fluoridation
16.7 minutes
child per year
US$4.1 saved for every US$
spent on water fluoridation
per
Not available
Not available
70% in dentist manhours over 5 years
£2.5 saved for every £ spent on
water fluoridation
10 Dutch Guilder saved for every
Dutch Guilder spent on water
fluoridation (age 7)
4.4 Swiss Francs saved for every
Swiss Franc spent on water
fluoridation
A decrease in caries prevalence is reported from both fluoridated and nonfluoridated communities. Especially where limited resources is an issue, the
continued adjustment of water fluoride levels in public water sources should
be investigated in terms of the economic outcomes of the investment (White
et al., 1989).
Cost estimates of water fluoridation should include the following (White et al.,
1989):
•
To initiate a new fluoridation program, costs for a referendum and
associated campaigns should be included, although this is a once off
activity only;
•
The number of employee hours required to adjust the level of fluoride,
maintain equipment and to monitor fluoride levels linked to the hourly
wage rate or salary for these employees;
•
Choice of chemical, cost per unit, amount of chemical needed per year
and the cost of transporting these chemicals;
•
Equipment needed, expected annual maintenance costs, expected length
of time this equipment can be used and the replacement cost;
___________________________________________________________________
Chapter 2
25
•
Opportunity cost of purchasing equipment (and not other things) as well as
depreciation costs as the equipment loses value over time;
•
Overhead costs such as electricity, rent, insurance, shared space costs,
etc.;
•
Cost of testing equipment to measure compliance, expected length of time
this equipment can be used and the replacement cost;
•
Amount of natural fluoride in water affects both cost and consequences of
the fluoridation programme;
•
Temperature of the region affects water consumption which will impact on
cost as more or less chemical will be needed;
•
Number of injection sites required for fluoridation; and
•
Cost of installation and consulting engineers’ fees.
In a study of 44 fluoridated Florida communities it was estimated that per
capita costs ranged from US $0.31 (communities more than 50,000 residents)
to US $2.12 (communities less than 10,000 residents) and was still regarded
as the most cost-effective in terms of cost per saved tooth surface (Ringelberg
et al., 1992). An economic analysis in the United States estimated that the
prevention of dental caries, largely attributed to fluoridation and fluoridecontaining products, led to a saving of $39 billion in dental care expenditures
from 1979 to 1989 (Brown, Beazoglou and Heffley, 1994).
A more recent study in the USA to determine if the reduction in cost of
restorative care due to averted disease still exceeded the program cost of
water fluoridation in a time where caries reductions were observed in both
fluoridated and non-fluoridated communities, came to the conclusion that
water fluoridation was still cost saving with the exception of communities with
less than 5,000 residents (Griffin, Jones and Tomar, 2001).
A similar study conducted in New Zeeland (Wright et al., 2001) still regarded
water fluoridation as cost-saving for communities for 1,000 residents or above
and was also higher for lower socio-economic communities and a high
___________________________________________________________________
Chapter 2
26
proportion of children. This study also indicated that the break-even point for
five fluoride injection points, was a community of 10,000 residents.
A UK study expressed the benefits of water fluoridation projects in the context
of population sizes of 60,000, 120,000 and 600, 000 (Birch, 1990). For these
communities the ratio of cost to benefit implies that the fluoridation
programme would reduce dental caries at an average cost of £4.80 per dmft
per person per year avoided for a population of 60,000, £3.07 for a population
of 120,000 and £1.60 for a population of 600,000 in high caries areas. In low
caries areas the discounted costs were £19.46, £12.44 and £6.49 respectively
for population sizes of 60,000, 120,000 and 600,000. This study concludes
that with all things being equal, caries reduction as a result of water
fluoridation would cost four times as much in a low caries area compared to a
high caries area, suggesting that considerable economies of scale exist in
terms of the reduction in cost per unit of benefit as population size increases.
Although population sizes as low as 1,000 have traditionally been considered
as unfavourable for the introduction of water fluoridation, technological
advances are resulting in new and more cost-effective options in its delivery.
An Australian study reported on the feasibility, costs of installation and
operation of fluoridation units over two years in two remote Indigenous
communities in the Northern Territory of Australia (Ehsani and Bailie, 2007).
These communities had populations of 2,000 and 1,300 respectively at the
time of the study.
Several technical, operational and policy issues were
identified which need to be addressed.
Capital cost for each of the two
fluoridation plants was estimated to be US$130,000, with annual operational
and maintenance cost of about US$11,800. The authors concluded that this
investment should lead to a substantial and significant improvement in oral
health of remote Indigenous Australian communities in the medium to long
run.
___________________________________________________________________
Chapter 2
27
Based on previous studies (Davies, 1973; Doessel, 1985; Ringelberg et al.,
1992), an economic model for the implementation of water fluoridation for
Gauteng, South Africa was developed (Smalberger, 1998). This model took
into account:
•
Factors which modify input variables:
Natural fluoride content
Rainfall
Pollution
Labour action
Remuneration
Exchange rates
Inflation
Population size and growth
Health profile
•
Input variables:
Opportunity costs
Cost of water
Chemical cost
Capital cost
Financing
•
Process variables:
Labour cost
Expertise
Maintenance
Financing
•
Output variables:
Per capita cost
Saving per person
Cost-effectiveness
___________________________________________________________________
Chapter 2
28
The output variables for Gauteng as found in this study were (Smalberger,
1998):
•
Per capita cost:
•
Saving per person: Estimated 55% caries reduction: R25.86 – R61.36
R0.11 – R2.40
Estimated 35% caries reduction: R16.41 – R38.15
Estimated 25% caries reduction: R11.70 – R26.60
In another South African study a computerised simulation model, based on
the studies by White et al. (1989) and Ringelberg et al. (1992), was developed
to report on cost-effectiveness and cost-benefit (Horowitz and Heifetz, 1979)
of water fluoridation for Gauteng (Van Wyk et al., 2001). The results of this
study for adjusting the fluoride level to 0.7 ppm are summarised in Table 3.
Table 3: Cost evaluation of the implementation of water fluoridation in Gauteng
(Van Wyk et al., 2001)
A.
B.
C.
D.
E.
F.
Chemical cost per year
Labour cost
Capital cost
Maintenance cost
Opportunity cost
Capital depreciation
G. Operating cost
H. Total cost
Total annual cost
Sodium silicofluoride
6 operators/1 hour per day
2.4% of capital cost
13.5% of capital cost
Buildings: over 15 years
Mechanical/electrical/Instrumentation:
over 8 years
A+B+D
E+F+G
Cost-effectiveness and cost-benefit analysis
Total population for Gauteng
Cost per person per year for total
population
Cost per person per year younger than
15 years
Cost-effectiveness analysis (cost per
person per year to save 1 DMFT)
Cost-benefit
analysis
(cost
of
implementation of water fluoridation
divided by saving in cost of treatment)
R2,744,727.72
R38,824.40
R14,000,000.00
R366,000.00
R1,890,000.00
R1,578,839.04
R3,119,552.12
R6,588,391.16
9,000,000
R0.73
R2.93
Estimated 50% caries reduction
Estimated 30% caries reduction
Estimated 10% caries reduction
Estimated 50% caries reduction
Estimated 30% caries reduction
Estimated 10% caries reduction
R3.95
R6.58
R19.73
0.04
0.07
0.22
___________________________________________________________________
Chapter 2
29
Results of this study indicated that even at caries reductions of 10% and 30%,
it would still be cost-effective and of benefit to implement water fluoridation for
Gauteng. It recommended that water fluoridation should not be considered if
the cost-benefit ratio approached, equalled or exceeded one (Van Wyk et al.,
2001).
2.2
Human resources planning
2.2.1 Brief overview
Demands for health care is increasing rapidly in virtually all countries due to
population growth, rising social expectations, socio-economic development,
advances in health technology and a shift in patterns of disease from acute to
chronic illnesses. Human resources is one of the critical elements needed for
the provision of health care to all citizens of any country and consume a
significant portion of the total health expenditure. A lack of human resources
is therefore one of the most obvious constraints in any health service.
Human resources planning can be defined as “the process of estimating the
number of persons and the kind of knowledge, skills and attitudes they need
to achieve predetermined health targets and ultimately health status
objectives” (Mejía and Fülöp, 1978).
Human resources cannot be improvised and the three components of the
development process (planning, production and management), must be
brought into closer and more functional relationships with each other and with
developments in the health services themselves (Mejía and Fülöp, 1978).
These three components involve the following (Van Wyk, 1996):
•
Planning: The end result should be to develop and implement a human
resources plan that will fulfil the needs and demands of the health
services. This process is dynamic and feedback mechanisms are required
to be able to make changes to it.
___________________________________________________________________
Chapter 2
30
•
Production: Involves the training and education of the workforce. It is
controlled by both the health and educational sectors which necessitates
coordination to ensure that the needs and demands of the public are met.
•
Management: Involves employment, utilisation and motivation of all
categories of health workers and determines the productivity of the health
system and ability to retain its workforce.
The interaction between these three components is illustrated in Figure 1
(Mejía and Fülöp, 1978).
HEALTH SYSTEM
EDUCATION SYSTEM
Health planning
Health
manpower
planning
Health
manpower
production
Health
manpower
utilisation
THE HEALTH MANPOWER SYSTEM
Figure 1: The health manpower system (Mejía and Fülöp, 1978)
Any human resources model should take into account the influences of a
number of other systems (Mejía, 1978):
•
The political system: through formal legislative and executive procedures
and informal political influence of individuals and organisations;
•
The education system: the manner in which human resources for health
are produced and utilised;
•
Professional bodies: exerts influence by control over licensing, curricula,
career structures, income by way of fee structures and standards of
practice;
___________________________________________________________________
Chapter 2
31
•
Health service agencies: regard themselves as qualified to determine
population needs and demands; and
•
Health services consumers.
2.2.2 Approaches to human resources planning
Human resources planning is influenced by a number of factors (Hall, 1978):
•
Demographic: Size, distribution, density, growth rate, age structure,
gender ratio with population size and distribution being regarded as the
most important;
•
Economic: Driven by supply and demand based on disposable income and
demand for services;
•
Social and cultural: These may influence the degree to which the public is
aware of the availability of health services and the value placed on
obtaining it;
•
Health status of the population;
•
Accessibility to health services;
•
Resource availability; and
•
Health care technology.
When applied to human resources planning, need and demand can be
defined as follows (Hall, 1978):
•
Need: An estimation based on professional judgement and current medical
technology of the number of workers or amount of services necessary to
provide an optimum standard of health care.
•
Demand: The sum of the amounts of the various types of health services
that the population of a given area will seek and has the means to
purchase at the prevailing prices within a given time period.
Based on these definitions of need and demand, four methods for estimating
humans resources have been described (Hall, 1978):
•
Human resources to population ratio approach;
•
Health needs approach;
___________________________________________________________________
Chapter 2
32
•
Health demands approach; and
•
Service targets approach.
The health needs, service targets and health demands approaches convert
people into the health services that they desire which are then converted into
human resources. The human resources to population approach converts
people directly into human resources (Hall, 1978). The main differences
between these approaches are presented in Figure 2.
HEALTH NEEDS:
Estimated by experts
taking into account the
health services needed
to attain and preserve
good health
Population to
be served
according to
age, sex,
location,
and/or other
characteristics
Health services
needed (numbers,
kind, quality)
SERVICE TARGETS:
Health service targets
specified by experts
taking into account
priorities, health wants
and technical,
administrative and
financial feasibility of
providing health
services
Health services to be
provided (numbers,
kind, quality)
HEALTH DEMANDS:
Estimated by taking into
account the effective
demand (actual use) for
services as a function
of wants, price,
accessibility, etc.
Health services to be
demanded (numbers,
kind and,
occasionally, quality)
Services converted
into manpower by use
of empirical or
normative staffing and
productivity standards
Manpower
required taking
into account
numbers, kind,
levels of
qualification,
distribution, etc.
Services converted
into manpower
generally by use of
empirical or normative
staffing and
productivity standards
MANPOWER POPULATION RATIOS: Population to be served
converted into manpower requirements directly by means of
desired, empirical or normative ratios, based on diverse criteria
Figure 2: Schematic representation of the four approaches to human
resources planning (Hall, 1978)
a)
Human resource to population ratio approach
This method is very simple, low cost and easy to interpret and requires (Hall,
1978):
•
Projected population;
•
Number of human resources present; and
___________________________________________________________________
Chapter 2
33
•
b)
A desired human resources to population ratio.
Health needs approach
This approach is normative and based on the perception that health
professionals are best equipped to determine the health needs of a
population. This approach requires (Hall, 1978):
•
Disease-specific mortality and morbidity rates;
•
Norms and standards which affect the number, kind, frequency and quality
of services to be provided;
•
Staffing norms to convert the various services required into the amount of
time needed for each category of health worker to provide the service;
•
Total personnel hours needed in a target year for the projected population;
and
•
c)
The average number of hours worked annually per person.
Health demands approach
This approach is based on projections of health services that users are willing
to pay or ask for, regardless of their need for these services (Bui Dang Ha
Doan, 1981). This is determined by factors such as disposable income, costs
of services, access to services, level of education and membership of medical
aid schemes.
This approach is more predictive than normative and this
approach requires (Hall, 1978):
d)
•
Observation and quantification of present demand;
•
Projection of demand for an entire year; and
•
Change of demand for services into demand for personnel.
Service targets approach
This approach involves the setting of targets for the production and delivery of
specific health services and then converting these into human resources
requirements by means of staffing and productivity standards. Is normative
and many regard it as micro-analytical since it considers each of the various
___________________________________________________________________
Chapter 2
34
components of the health sector separately with a primary focus on provision
of services. It attempts to strike a balance between needs and wants of the
population, available technology and what can be delivered. This approach
requires (Hall, 1978):
•
Targets for production and delivery of services;
•
A description of the planned services;
•
Calculation of the sum of services required;
•
Types and mix of human resources needed to deliver the service; and
•
Consideration of productivity.
The main advantages, disadvantages and indications of each of these
methods is summarised in Table 4 (Hall, 1978; Kissoon-Singh, 2001).
Table 4: Summary of advantages, disadvantages and indications of the four
approaches to human resources planning (Hall, 1978; Kissoon-Singh, 2001)
Human
resources
to population
approach
Advantages
- Easy to use and interpret
to others
- Requires modest data
- If current health situation
is adequate, it can be
used to justify the status
quo
- Useful to provide baseline
projections for different
kinds of human resources
required
- Can be a useful short to
medium term planning
instrument
if
used
together with a more
precise method
Disadvantages
- Easy to select unrealistic
ratios
- Generally used with single
occupational
categories
only
- Relatively
difficult
to
estimate cost
- Will inevitably show a
human
resources
shortage
- Overlooks the relevance
of demand
- Does
not
address
productivity, distribution,
utilisation and relevance
of services
- Fails
to
recognise
accessibility of services to
the population
- Adequate ratios do not
automatically
provide
good health
Indications
- Countries
with
fairly
satisfactory health status
and adequate health
systems
- A stable health sector
- Limited
planning
resources
- Either an active or
passive
approach
to
health services
- Either public or private
sector dominance
- Applicable where fairly
similar
international
models have been used
___________________________________________________________________
Chapter 2
35
Table 4: (continued)
Health
needs
approach
Health
demands
approach
Advantages
- Easy
to
understand,
based
on
scientific
knowledge, logical and
workable
- Ethical to consumers
since it is based on
services
to
entire
population
- Emphasis
is
on
production of services,
not human resources
- Encourages evaluation of
health technology
- Encourages allocation of
resources where needed
most
- Useful in design of
educational programmes
- Promotes concern about
quality of care
- Facilitates cost estimation
- Facilitates health team
planning
- Facilitates understanding
of demand
- Allows
for
separate
consideration of different
components
- Produces
economically
realistic projections
- Results
in
a
good
estimate of minimum
growth in demand likely
to occur
- Some variants of this
approach are simple
- Provides
useful
information for comparing
economic returns with
those in other fields
- Identifies and quantifies
market
forces
which
affect consumers and
suppliers
- Applicable in a fee-forservice system
Disadvantages
- Costly
and
requires
extensive and detailed
data
- Does
not
consider
cultural, economical and
other barriers that will
prevent
need
being
converted to demand
- May encourage detailed
planning
- Setting
of
standards
complicated by a possible
lack of consensus
- Gives little attention to
alternatives
- Likely
to
result
in
requirements in excess of
country’s ability to provide
them
- Based on physician’s
model for health services
delivery which are mainly
curative
- Some variants require
sophisticated data and
can be complicated and
costly
- May neglect political and
societal reasons for health
services distribution and
delivery
- Does
not
take
into
account quality of services
or their relevance
- May neglect ways to
improve productivity
- May be difficult to explain
rationale and results to
authorities and public
- Often arduous to collect
reliable data from the
private sector
- May enhance or continue
inequalities in access to
care
- Changes within the health
services
could
alter
projections of demand
- Cannot assess changes in
health status
Indications
- Countries
with
sophisticated
data
systems,
survey
capabilities and planning
expertise
- An
adequate
health
services delivery system
is required
- Active government policy
required
- Dominant public sector
with control over human
resources and services
- Elevated awareness of
public health matters
- Applicable
where
prevention,
promotion
and
specific
health
programmes are in place
- Dominant private sector
- Passive
government
attitude towards service
delivery
- Where
health
care
system provided equally
for all sectors
- Promotes allocation of
human
resources
to
entire health team
- Relatively
minor
imbalances in delivery of
services
to
different
segments
of
the
population
___________________________________________________________________
Chapter 2
36
Table 4: (continued)
Service
targets
approach
-
-
-
-
-
Advantages
Various components of
demand are separated
with
most
suitable
method chosen for each
Facilitates
study
of
productivity,
utilisation,
staffing ratios
Emphasis on production
of services, not human
resources
Simple to explain and
easy to interpret
Cost estimation is simpler
Readily usable with other
planning methods
Facilitates planning for
the total health team
Facilitates demand model
revision when data is
updated
Requires modest data
and planning capabilities
Disadvantages
- Standards set more on
what people perceive is
needed rather than reality
- Assumes the utilisation of
services
- Restricted where poor
government
regulation
and control over health
services exists
- May
encourage
excessively
detailed
planning
Indications
- Dominant public sector
with control over human
resources and service
- Active government role
required
- More
useful
in
prevention, but can also
be used for curative
services
2.2.3 World Health Organization/Fédération Dentaire Internationale planning
model
In 1970 the WHO took a leading role in planning health services and more
specifically human resources when a Scientific Group on the Development of
Studies on Health Manpower was established with the request to review
development and methods of health manpower studies and to recommend
future lines of research to WHO.
One of the recommendations of the
Scientific Group was that WHO should promote health manpower planning in
member states (World Health Organization, 1971).
A WHO Expert Committee report identified five steps of planning a public
dental health services which served as basis for future WHO planning models
(World Health Organization, 1976). These steps are:
•
Situation analysis;
•
Problem identification and formulation of objectives;
•
Formulation and analysis of alternative strategies;
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Chapter 2
37
•
Strategy selection; and
•
Programme formulation.
Following on this the WHO publication “Planning Oral Health Services” was
aimed at the more practical aspects of planning taking into account resources,
including human resources. It recognises manpower production goals as an
integral part of the planning process where the human resources are divided
into professionals (dentists, stomatologists), operating auxiliaries (dental
therapists, dental hygienists), non-operating auxiliaries (dental assistants,
dental technicians) and other supporting staff (health auxiliaries, teachers,
parents). It also recognised the setting of goals based on existing resources
and identified five options of care from “Type 1”, where a minimal service is
rendered every five years, to “Type 5”, where services are based on a six
monthly recall (World Health Organization, 1980).
The acceptance of the concepts and approaches of “Health for All by 2000”
through PHC led to a joint WHO/FDI publication describing a human
resources model based on the needs and demands of a population and
placing a much bigger emphasis on prevention and control of disease,
maintenance of health and high quality restorative care. Figure 3 illustrates a
planning flow chart of this model (World Health Organization/Fédération
Dentaire Internationale, 1989).
This model translates need into full-time equivalents (FTE) of oral health
human resources required to provide a calculated level of care. The model
makes provision for modifying factors. Recommendations for time estimates
are based on the prevailing conditions in a country. Variables in the model
can be altered to suit the situation of that country. Limitations of this model
include (Kissoon-Singh, 2001) :
•
Calculations are made for the general population and do not take into
account different communities such as urban, peri-urban and rural;
•
The model may over-projects human resources; and
•
Model doesn’t take into account the capacity of training institutions.
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38
DATA NEEDED FOR
CALCULATIONS
CALCULATIONS
Oral health status:
- Disease levels,
profiles and trends
- Preventive services
and treatment needs
estimates
Average time needed
per person per year for
preventive and
treatment services at
the start and end of
planning period for
each of 4 cohorts
(i) 0-14 years
(ii) 15-29 years
(iii) 30-64 years
(iv)65-79 years
Proposed goals
Population estimates
for planning period by
age cohort
Demand for services
estimates
DATA NEEDED FOR MODIFYING
FACTORS
Social/political policies for health
- Care organization and approaches
- Funding parameters and policies
Care facilities
- Care profiles and procedures
- Personnel types and skills
- Training facilities and output
Population parameters
- Urban/rural distribution and trends
- Ecology-based factors affecting
demand
Average time which can
actually be delivered
per person per year for
preventive treatment
services at each end of
planning period,
weighted by cohort and
demand percentages
DECISIONS
-
Agreed goals
Types of services and organization
Personnel types, skills and numbers
Appropriate personnel production policies
TO
Maximize oral health and
achieve agreed goals
Figure 3: Flow chart of the WHO/FDI human resources planning model (World
Health Organization/Fédération Dentaire Internationale, 1989)
2.2.4 A South African perspective on human resources planning
a)
Historic overview
The historical development of the provision of health services in South Africa
since 1652 can be divided into three phases (Van Wyk, 1996):
•
Phase 1: 1652 to 1918: The first 150 years of this phase was
characterised by the establishment of a health service under the influence
of the Dutch settlers. The last 100 years commenced with the British
occupation of the Cape Colony and was characterised by the expansion,
consolidation and control over health services, including registration of
health providers.
•
Phase 2: 1918 to the second half of the seventies: This phase
commenced with the unification of the four colonies of South Africa and
was characterised by technological advances in health care, the
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39
establishment of a curative approach in health services and public and
private sectors of delivering health care to the community. This phase was
also characterised by government accepting responsibility for the delivery
of health services.
•
Phase 3: Second half of the seventies to 1993: This phase coincided
with the “health for all” era and concluded with the run-up to the first
democratic election in South Africa in 1994.
During this phase
government accepted responsibility for the delivery of certain oral heath
services. Similar to other countries it was soon realised that resources
were not available to deliver all services to the entire population, leading to
the development of more cost-effective approaches such as training of
auxiliary oral health workers. During this phase the PHC approach and
more emphasis on prevention was also adopted with the aim of reducing
curative services.
A detailed description of all three phases can be found in Van Wyk (1996).
Landmark developments in the delivery of health services and human
resources development in South Africa during phases 2 and 3 are
summarised in Table 5 (Van Wyk, 1996).
Table 5: Summary of landmark human resources developments in South
Africa from 1910 to 1993 (Van Wyk, 1996)
Year
1919
1928
1942 - 1944
1962
Description
Proclamation of “Act on Population Health” (Law 36 of 1919) follows on the influenza
epidemic of 1918 and leads to the establishment of a separate Ministry and
Department of Health in addition to provincial health administrations
“Act on Doctors, Dentists and Pharmacists” provides for the establishment of a
Medical and Dental Board which replaced the four provincial medical boards
The National Health Services Commission (Gluckmann Commission) follows on the
Great Depression and its findings can be summarised into four main areas:
i) Lack of coordination between the seven parties involved in health services
delivery
ii) A lack of services in general, especially in black rural and urban areas
iii) The curative nature and emphasis on profit in the private sector leading to a
maldistribution of services
iv) Inappropriate emphasis on curative services and priorities
The main recommendation was for a national health service – this was never
implemented
Commission of Enquiry into the high cost of medical services and medicines makes
50 recommendations. Three of these are aimed at oral health:
• Training of auxiliary personnel to address the shortage of dentists
• Fixed tariff structure for delivery of services in the private sector
• Training of district health nurses in terms of oral health with the purpose to refer
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40
Table 5: (continued)
Year
1967
1974
1980, 1986
1982
1984
1986
1986
1988 - 1991
Description
Commission of Enquiry into dental services and training of non-white dentists under
chairmanship of Dr J.F. van de Sandt de Villiers. The recommendations formed the
backbone of the development and delivery of oral health services over the next 30
years.
National Oral Health Policy formulated under the leadership of the first Chief Dentist
of the Republic of South Africa, Dr L.T. Taljaard. Approved by Cabinet in 1975 and
served as the official oral health policy for the next 15 years. Classifies all services
as education, preventive, curative or supplementary and identifies target groups.
Brown Commission of Enquiry into health services emphasises excessive
fragmentation of services, lack of central policy, inappropriate allocation of
resources, insufficient communication, lack of emphasis on preventive and PHC
services, overemphasis on expensive secondary and tertiary services, over
regulation of services in the private sector, shortage of certain services (including
dentistry), shortage of health workers of the non-white population groups, shortage
of statistics on the health services. A separate oral health working group chaired by
Prof L.T. Taljaard made recommendations on dentistry to the commission.
Interdepartmental committee into dental services and training (Venter Committee)
made recommendations regarding the future training of dentists, dental therapists
and oral hygienists for the white, black, coloured and asian population groups with
specific emphasis on employment in the public sector. The human resources to
population ratio approach was used in the calculations.
Committee of Enquiry into facilities for medical and dental training. Builds on the
recommendations of the Venter Committee with specific recommendations for each
of the dental schools. It also recommends a review of oral health human resources
every five years.
National Health Plan. Results from the recommendations of the Brown Commission.
Places a big emphasis on appropriate resources on each of the six levels of health
care delivery.
Report of an ad hoc committee of Federal Council of the Dental Association of
South Africa emphasises appropriate intake of students of all population groups,
defining the future role of the dental therapist, expansion of services for the oral
hygienist, creation of oral health educators, expansion of public oral health services.
Committee of Dental Deans 2020 Seminars. Three seminars were held culminating
in a report after the 1991 seminar which recommended:
• Emphasis on the 15-year-old age group in terms of prevention, pain relief and 1to 2-surface restorations
• Oral health workforce consisting of oral health educator, dental assistant, oral
hygienist, dental therapist, dentist, dental specialist, dental technician – minimum
training requirements were formulated for each
• Reduction of dentists, increase in dental auxiliaries and closer monitoring within
the public and private sectors
• Job descriptions for each category of oral health worker
• Consideration of a “denturist” for the provision of dentures (to practice
independently)
• Training of community health workers for extractions and procedures to relieve
pain ad sepsis
• Compulsory community service provided adequate facilities and posts are
created
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41
Most commissions and committees during phases 2 and 3 commented on the
fragmentation of services as well as lack of adequate preventive services.
The majority of reports concluded that oral hygienists are mostly employed in
the private sector and that dental therapists and dentists placed a too large
emphasis on curative services (Van Wyk, 1996).
In summary, the history of health services and human resources planning in
South Africa can be considered against the three components of the human
resources development process. Although production of oral health human
resources commenced in 1927 with the establishment of a dental school at
the University of the Witwatersrand, little planning for oral health related
human resources was done until the 1970s (Van Wyk, 1996).
It is clear from the available literature that despite several committees and
commissions reporting on oral health, very few have been taken seriously and
only a limited number of recommendations have been implemented.
b)
Human resources studies, reports and publications since 1994
After a 1992 referendum effectively brought about an end to “apartheid”,
citizens of all races took part in the first democratic elections in 1994. Since
then several postgraduate studies and reports into human resources for the
new South Africa have been published. These are briefly summarised below.
•
Booyens (1994)
The purpose of this study was to determine human resources needed for
delivering primary preventive services by using needs as determined by
the 1988-89 NOHS, slightly modified by demand from the same survey
(Department of Health, 1994). A modified version of the WHO/FDI human
resources
model
was
used
for
the
calculations
(World
Health
Organization/Fédération Dentaire Internationale, 1989).
Since oral health status varies between the different population groups,
separate calculations were done based on the WHO variables for an
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42
industrialised country with stable caries for the white population group, a
developing country with increasing caries for the black, asian and
coloured population groups (Scenario I) and an industrialised country with
stable caries for all population groups (Scenario II), both assuming a
1,750 hour working year per operator. Results are summarised in Table 6
(Booyens, 1994; Booyens, 1996).
This study concluded that the need for oral health personnel was not in
line with the human resources available at the time of the study based on
registration with the South African Medical and Dental Council (SAMDC).
Table 6: Human resources required for the delivery of oral health services in
South Africa based on the WHO/FDI model (Booyens, 1996)
Population group
Scenario I *
Scenario II **
1,860
1,860
White
4,594
4,094
Black
225
196
Asian
583
550
Coloureds
Total
6,700
7,262
* Highly industrialised country, stable caries (white) / developing country, increasing caries (black,
asian, coloured)
** Highly industrialised country, stable caries (all population groups)
Suggested percentage distribution of oral health personnel needed for South Africa
Suggested %
Registered with SAMDC
(1992)
6%
6 – 8%
Specialists
77%
21 – 24%
Dentists
3%
22 – 27%
Dental Therapists
14%
42 – 49%
Oral Hygienists
•
Van Wyk (1996)
The purpose of this study was to determine human resources needed
based on the principles of supply and demand taking into consideration
modifying factors, treatment needs and trends. Demand data was
obtained from the 1988-89 NOHS (Department of Health, 1994).
Based on this study, 5,594 oral health personnel would be needed in
2011 to address demand for oral health services. Based on personnel
and attrition rates, between 2,482 and 2,923 oral health personnel have to
___________________________________________________________________
Chapter 2
43
be trained between 2000 and 2011, an average of between 207 and 244
per year, to address the demands as reflected in the 1988/89 NOHS (Van
Wyk, 1996).
The need for oral health personnel by 2011 as found in this study is
summarised in Table 7 (Van Wyk, 1996).
Table 7: The need for oral health personnel in South Africa by 2011 (Van Wyk,
1996)
Dentists
Dental therapists
Oral hygienists
Dental technicians
Dental assistants/oral heath educators *
* Public sector only
•
Needed by 2011
3,337
2,515
1,040 – 1,267
1,001
4,982
Training per year (2000-2011)
29 – 66
160 – 170
16 – 30
15
294
Dental Association of South Africa (DASA), Federal Council (1996)
This report by the Health Services and Dental Education Committees of
the DASA expressed a concern that by 2010 there would be an oversupply of dentists (Rossouw, 1996). Based on the needs-based study by
Booyens (1994), the report justified not to increase the number of dentists
trained.
Based on demand as determined in the 1988/89 NOHS
(Department of Health, 1994), the report stated that utilisation of dental
services by the white population group had reached levels as described for
industrialised countries such as Canada, Ireland, Norway and the USA. It
also concluded that since 75% of the population of South Africa is state
dependent, access to the public dental services should be improved and
that these services could adequately be rendered by dental therapists.
According to dentists surveyed during the 1988/89 NOHS, 88% were of
the opinion that there were enough white dentists already, 54% felt that
there were not enough black dentists.
This report estimated that the
greatest demand for dental services will come from the state dependent
section of the black population group (Rossouw, 1996).
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44
In terms of human resources to population ratio, two studies were quoted
in this report indicating that only 4 of the 156 main metropolitan
areas/cities in the nine provinces had not yet reached a dentist to
population ratio of 1:3,600 (Rossouw and Van Rensburg, 1995; Van Wyk,
Kroon and Cleaton-Jones, 1994). Some of these cities/areas had reached
a dentist to population ration where similar ratios in industrialised countries
had led to the closing of dental schools. On the other hand several rural
areas have extremely unsatisfactory ratios (1:10,000+).
These results
indicated a persistent maldistribution of dentists (Rossouw, 1996).
This report concluded that dental schools should reduce the number of
dentists trained, increase the number of auxiliaries trained and that the use
of models should continue to monitor human resources for oral health. It
further recommended that DASA facilitate efforts to establish a consensus
view regarding the over-supply and distribution of dentists and contribute
to efforts to establish agreement between all role players regarding future
supply of dentists (Rossouw, 1996).
•
Committee of Dental Deans (1996 – 1997)
In a guest editorial the Committee of Dental Deans cautioned against
action following on the study by Van Wyk (1996) and the DASA Federal
Council report (Rossouw, 1996) until this contentious issue has been
further debated and totally clarified (Anonymous, 1996).
This resulted in a report where the annual growth in oral health care
workers (dentists/specialists, dental therapists and oral hygienists) over a
period of fifteen years up to the end of 1996 was calculated as 160 per
year, comprising of 104 dentists, 42 oral hygienists and 14 dental
therapists. At the same time the total clinically available oral health care
workforce for 2010 was projected at 5,828 consisting of 4,000 dentists,
556 dental therapists, 972 oral hygienists and 300 specialists. In order to
achieve this the expansion of present academic oral health centres to
deliver a larger output of dental therapists and oral hygienists was
recommended (Dreyer, Rossouw and Chikte, 1997).
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Chapter 2
45
•
Compulsory Community Service reports (1999-2005)
In terms of the Medical, Dental and Supplementary Health Service
Professions Amendment Act, 1997 (Act 89 of 1997) (Republic of South
Africa, 1997a), every person registering for a profession shall perform
remunerated community service in terms of the regulations of the Act, and
shall, on completion of such service, be entitled to practice the profession
in question.
An audit was undertaken prior to the introduction of Compulsory
Community Service (CCS) for dentists by way of a self administered
questionnaire to seek information on physical, human and financial
resources and their distribution within each of the nine provinces. Site
visits were undertaken to validate information supplied (Gugushe, 1999).
Of the 368 dentists employed within the public sector in 1999 (excluding
academic oral health centres), 267 were full time, 63 part time and 38 had
patients referred to their practices by agreement with the province. A total
of 213 auxiliaries (100 dental therapists and 113 oral hygienists) were
employed of which close to 90% full time. Approximately 70% of public
dental clinics were urban based, with 38.9% in urban districts and 30% in
peri-urban districts. The most frequently utilized clinical procedure was
dental extractions (Gugushe, 1999).
The outcome of this study indicated a variation by province in the
organizational structure and management of oral health services. This
report identified several problems and constraints and recommended that
a national operational team be appointed for the national planning,
organisation, implementation and control of CCS for dentists. Availability
of adequate financial support from the national department of health was
identified as a prerequisite for the successful implementation of CCS for
dentists (Gugushe, 1999).
Following on this audit CCS for dentists was introduced in July 2000. A
cross-sectional descriptive study was conducted at the end of the first
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46
year of CCS. Response rate was only 35%, with 45% of respondents of
the opinion that the allocation process was not handled efficiently. Only
52% were provided with accommodation and 26% described the condition
of the clinics as poor.
Almost a quarter did not have a full set of
instruments, 10% did not have an autoclave or high-speed hand piece
and 50% reported that equipment broke down often without immediate
repairs being done.
Although 75% felt their clinical competence was
enhanced, more than three-quarters reported that they had lost some
form of clinical competence during the year of CCS (Naidoo and Chikte,
2002).
A “Dentist Satisfaction Survey” was administered to the 2003 cohort of
graduates from the Medical University of Southern Africa (MEDUNSA)
shortly before graduation and upon completion of their year of CCS.
Comparison of the two surveys revealed a general downward trend in the
level of job satisfaction upon completion of CCS. In this study 62% of
CCS dentists were dissatisfied that they were unable to practice dentistry
to its full potential with too much emphasis on extractions. CCS dentists
also commented on the lack of respect from medical colleagues who
appeared ignorant on the extent to which dentists are trained (Harris and
Zwane, 2005).
•
Kissoon-Singh (2001)
In a similar study to Booyens (1994), this study reported on a human
resources plan for oral health care for the province of KwaZulu-Natal
based on the primary oral health care package (Department of Health,
2001a) and the results of the 1988/89 NOHS (Department of Health,
1994) and 1999-2002 NCOHS (Department of Health, 2003b). The joint
WHO/FDI human resources model was used for the calculations (World
Health Organization/Fédération Dentaire Internationale, 1989).
Human
resources requirements calculated for 2000 and 2010 for selected
procedures of the minimum package of oral care are indicated in Table 8
(Kissoon-Singh, 2001).
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47
Table 8: Human resources requirements for KwaZulu-Natal (2000 and 2010) for
selected procedures of the basic oral health care package (Kissoon-Singh,
2001)
Year
2000 complete package
(optimal number, baseline data for planning
process)
2010 with current DMFT levels
(selected procedures to target groups)
2010 with reduced DMFT due to fluoridation
(selected procedures to target groups)
2010 with current DMFT levels
(selected procedures to target groups and simple
fillings provided to the first two cohorts only)
Human
resources
Dental
operators
Oral
hygienists
404
184
220
309
196
113
294
181
113
219
106
113
This study concluded that a gross shortage and inequitable distribution of
oral health personnel existed within the public service of KwaZulu-Natal
with only 6% of dentists in this province working in this sector and 78% of
the population dependent on this service for oral care.
Due to this
shortage not even the minimum package of oral care could be
implemented. Training of the correct number and an appropriate mix of
oral health personnel, intersectoral collaboration, continuing education
courses, equitable distribution of resources, CCS, cooperation within the
department of health, community health workers and water fluoridation
were just some of the recommendations of this study to alleviate the
problems of oral health care delivery (Kissoon-Singh, 2001).
•
Pick Report (2001)
This report served as a first attempt to provide a national strategy on
human resources for health and resulted as an outcome of a 1999
workshop of the Provincial Health Restructuring Committee and the
Heads of Human Resources for Health in the nine provinces and is based
on the underpinning philosophy of PHC. It proposed a strategy to better
utilise existing resources, focused strongly on the needs of the
underserved and attempted to produce greater synergy between
knowledge, skills, attitudes and behaviour of health workers and
population health care needs (Pick et al., 2001).
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Computer simulation models developed by the WHO and historical
information from registers of the statutory councils were used to project
supply of a number of health workers (including oral health) over a 30
year period to the year 2029 using different demographic assumptions
(Pick et al., 2001).
In terms of training and education it regarded the following as major
challenges (Pick et al., 2001):
1. Revision of admission criteria and training programmes to develop
skills relevant to the delivery of PHC;
2. Attraction and retention of previously disadvantaged persons, firstly as
students and then as staff; and
3. Provision of continuing professional development with a minimal
disruption in service delivery.
According to this report the supply of dentists exceeded population growth
(assuming an annual 2% population growth rate and a 25% net loss of
graduates to other countries). It also emphasised the unequal distribution
between the public and private sectors and mentioned the introduction of
CCS to dentists as a possible solution.
The report suggested (Pick et al., 2001):
1. The creation of a single dental auxiliary to replace the oral hygienist
and dental therapist;
2. A downward revision of the annual intake of dental students;
3. Dental assistants in underserved areas should receive a 1 year
training by dentists to perform simple procedures such as the
Atraumatic Restorative Technique (ART);
4. The scope of the dental therapist should be expanded to include
placement and removal of sutures and removable orthodontic
appliances and care of wounds (It should be noted that this
recommendation contradicts recommendation 1); and
5. A projected requirement for 2029 of 6,413 dentists and 435 oral
hygienists.
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49
•
A National Human Resources Plan for Health (2006)
Chapter 7 of the National Health Act of 2003 (Act 61 of 2003) (Republic of
South Africa, 2003) mandates the Minister of Health to take steps to
develop and manage human resources in the national health system.
Building on the Pick report (Pick et al., 2001), the NHRP identified human
resources planning and development as a key priority area and provided
a framework to guide all stakeholders to provide an adequate workforce in
partnership with government (Department of Health, 2006a).
A set of 11 core guiding principles underpin the NHRP (Department of
Health, 2006a):
1. Stewardship for health care lies with the National Department of
Health;
2. South Africans must enjoy a reliable supply of skilled and competent
health professionals for self-sufficiency;
3. Planning and development of human resources linked to the needs
and demands of the health system must be strengthened;
4. The optimal balance, equitable distribution and use of skilled health
professionals to promote access to health services must be
developed;
5. Health workers must have the capacity and skills to render accessible,
appropriate and high quality care at all levels;
6. Work environments should be conducive to good management
practice in order to maximise the potential for the health work force to
deliver quality health services;
7. South Africa’s role in international health issues contributing to
leadership, scientific advances and global health professions is critical;
8. South Africa’s contribution in the short to medium term to the global
health market must be managed in such a way that it contributes to
the skills development of health professionals;
9. Mobilisation of funding to ensure successful implementation of the
plan;
10. The Department of Health must ensure that it has the technical
expertise necessary to lead health workforce planning; and
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11. There must be adequate remuneration of health professionals and
good work conditions to enable them to regard the public health sector
as employer of choice.
The NHRP proposed the following annual productions for the various
members of the oral health team (Department of Health, 2006a):
Dental practitioners: Reduce to 120 by 2008.
It is the opinion that
maintaining current levels will be adequate for both the public and private
sectors with aggressively recruiting dentists back to the public sector.
Dental Therapists: Increase to 600 by 2009. Dental Therapists are
regarded as critical to the provision of PHC services related to oral health.
Training must occur at every dental school.
Career mobility must be
improved in the public sector.
Dental Technicians: Current levels to be maintained.
Oral Hygienists: Increase to 150 by 2009.
Dental Assistants: 300 by 2008.
The NHRP recognised that targets may appear high, but consideration
had to be given to mobility of health professionals to and from the private
sector, migration overseas and other attrition factors.
By way of an editorial in the South African Dental Journal (SADJ), the
CEO commented as follows on the NHRP (Campbell, 2006): “…, but alas,
those who know little to nothing about dentistry have yet again elected to
ride rough-shod over the advice advanced by dental educators and the
profession itself.”
This editorial continued to compare the suggested
reduction in number of dentists to be trained to similar experiences in The
Netherlands and the UK which eventually led to massive shortages in
both countries, ironically two countries favoured by South African qualified
dentists as a possible option for employment upon graduation.
The
editorial did however welcome the suggestion for an increase in number
of oral hygienists to 150 per year, but questioned where the figure
originated from. It furthermore expressed great concern on the suggested
number of dental therapists to be trained, especially since current facilities
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51
were only equipped to train 300 dentists/dental therapists per year. It
referred to a SADA position paper on dental therapists (South African
Dental Association, 2000) which recommended an immediate moratorium
on the training of dental therapists until all key stakeholders had debated
future training and urged the Health Professions Council of South Africa
(HPCSA) to rescind a previous decision to allow dental therapists to
practice independently which was not in the best interest of the public
sector, especially since the intention was that dental therapists be
employed by this sector.
2.2.5 Human resources distribution and trends in South Africa
a)
Number of dentists to be trained
The majority of reports on human resources in South Africa have highlighted
the inequitable distribution between urban and rural on the one side and the
private and public sectors on the other. Recommendations were put forward
by the Commission of Enquiry into the Dental Services and the Training of
Non-White Dentists as a result of which three new dental schools were
opened and existing facilities expanded.
The Commission predicted that
1,708 dentists would be registered in South Africa by 1980
(Republic of
South Africa, 1967). Another study indicated that this figure had already been
reached in 1973 and that South Africa would be faced with an overproduction
of dentists by 1983 (Germishuys, 1979).
Reports and opinions on training of dentists in South Africa continued during
the 1980s.
In 1984 it was suggested that no new dental schools be
established, but that existing faculties be expanded and opened to all ethnic
groups (Dreyer, Lemmer and Dreyer, 1984). An ad hoc committee of the
DASA warned that an overproduction of white dentists might become a reality
and that intake of white students had to be reduced (Dreyer et al., 1986).
During the 1990s there was a shift in emphasis on dentists as the main dental
service providers to an oral health care workforce consisting of health
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52
educators, assistants, oral hygienists, dental therapists, dentists, specialists
and technicians.
A 50% decrease in the number of dentists trained was
suggested with a corresponding increase of 250 auxiliaries per annum over
the next 5 to 10 years (Dreyer et al., 1992).
b)
Dentist to population ratios
A comparison of the geographical spread of dentists in South Africa between
1972 and 1982 confirmed a decrease in dentist to population ratio from
1:12,133 in 1972 to 1:9,868 in 1992 (Smith and Cleaton-Jones, 1985). A
follow-up study indicated that this had further decreased to 1:7,991 in 1992
(Van Wyk et al., 1994). Both these studies highlighted the maldistribution of
dentists in South Africa.
The number of dentists increased by 135.6% from 1,599 in 1972 to 3,767 in
1992. When dental therapists were included (112 in 1992), the operator to
population ratio decreased further to 1:7,991.
This represented 1.25
dentists/operators per 10,000 of the population (Van Wyk et al., 1994).
Any health system attempts to achieve the objective of equitable distribution
of resources. Table 9 summarises the dental operators to population ratios
for magisterial districts with the lowest (all urban) and the highest (all rural)
ratios. It clearly illustrates the extent of maldistribution of dental operators in
South Africa (Van Wyk et al., 1994).
Table 9: Magisterial districts with the lowest and highest operator to
population ratios in South Africa (Van Wyk et al., 1994)
Lowest operator : population ratio
Magisterial
Operators
Operator :
district
population ratio
1:1,069
169
Cape Town
1:1,374
486
Pretoria
1:1,788
151
Bellville
1:1,880
252
Durban
1:1,965
11
Hermanus
Highest operator : population ratio
Magisterial
Operators
Operator :
district
population ratio
1:151,338
2
Seshego
1:169,153
1
Nongoma
1:171,443
2
Witsieshoek
1:446,155
1
Morokeng
1:458,529
1
Ntuzuma
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Chapter 2
53
It was estimated that 78% of all oral health personnel are employed in the
private sector with the remaining 13% in the public sector required to serve 65
to 80% of the total population (Rossouw, 1995).
Based on information from the 1988/89 NOHS (Department of Health, 1994),
57% of dentists practice within the five major metropolitan areas of South
Africa with male dentists dominating the profession (92.8%). Of the dentists
responding to the questionnaire, 68.5% qualified after 1970 and 38% after
1980. Only 12.8% of dentists employed an oral hygienist on a full-time and
11% on a part-time basis. There was a perception amongst dentists that
there was no need to employ oral hygienists (62%), with 11% of dentists
indicating they did not do so because of unavailability. Conservative dentistry
was the most frequently practiced service (91.6%) followed by scaling and
polishing (74.2%).
Topical fluoride application and placement of fissure
sealants were ranked low (Rudolph, Brand and Gilbert, 1995).
A Health Systems Trust report estimated the distribution of public sector
dentists per 100,000 of the public sector dependent population decreased
from 1.7 in 2000 to 1.58 in 2003. Some provinces had 4 times as many
dentists in the public sector compared to others. The 2003 ratios for the
Eastern Cape and KwaZulu-Natal were 0.7 and 0.99 respectively, compared
to 2.79 and 3.35 for Gauteng and the Western Cape. Despite the introduction
of CCS for dentists in 2000, the number of dentists in the public sector had
steadily declined. Based on a 2% population growth per annum, a 25% net
loss of graduates to other countries and using WHO simulation models, this
report estimated that the dentist to population ratio would decrease from
1:9,400 in 1999 to 1,7800 by 2029 (Padarath, Ntuli and Berthiaume, 2004).
c)
South African qualified dentists in the United Kingdom
Shortly after the emergence of the new democratic South Africa, several
concerns were expressed on the political arena about the so called “brain
drain” of professionals to other countries. A Central Statistics Service (CSS)
report published in the lay press estimated that 3,000 people left South Africa
___________________________________________________________________
Chapter 2
54
during the first quarter of 1996, 1.3% of these belonged to the medical and
dental professions (Beeld, 1996). This was followed by an attempt by the
Minister of Health to stop qualified health professionals from working and
living in the UK (Rapport, 1996). It was estimated that between 1989 and
1997 nearly 250,000 people left South Africa for Australia, New Zealand,
Canada, the UK and the USA. Of the total health workforce in the UK, 6%
were South African qualified (Padarath et al., 2004).
Information on South African qualified dentists living abroad is essential for
human resources planning. The 1967 Commission of Enquiry into Dental
Services estimated that 9% of dentists registered with the then SAMDC were
practising in the UK (Republic of South Africa, 1967). Little information is
available on this for the seventies and eighties, but a 1992 editorial referred to
a “massive brain drain” of final year dental students to the UK (Wiltshire,
1992). The same editor one year later reported an increase in total number of
dentists due to a massive influx from India and Eastern Europe (Wiltshire,
1993).
Following on this editorial, it was reported that 726 South African
qualified dentists were registered with the General Dental Council (GDC) in
London (Holtshousen, 1993). Another study reported that 80% of dentists
who qualified in South Africa during the period 1962 to 1991 were still
registered with the SAMDC with the majority of the remaining 20% practicing
in the UK (Germishuys, 1994).
A study into the number of South African qualified dentists registered with the
GDC reported that this figure had increased from 726 in January 1992 to
1,160 in December 1995, an increase of 59.8% over a 4 year period. Of
these dentists 49.3% still had addresses in South Africa listed with the GDC.
When expressed as a percentage of the number qualified during the same
period, the number of South African dentists registered with the GDC
increased from 4.6% for the period 1940 to1949 to 32.4% for the period 1990
to 1995. Of the dentists qualifying in South Africa between 1990 and 1995,
76.3% registered with the GDC during this same period. Less than 50% of
these were actually working or living in the UK (Holtshousen and Van Wyk,
1997).
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Chapter 2
55
Reasons why professional people were leaving South Africa since 1990,
especially dentists in the UK, were the high levels of crime, followed by
economical considerations, either their own or the general economy of the
country and uncertainty about economical, political, professional and the
educational future of their children (Van Wyk, Holtshousen and Geldenhuys,
1999).
The reasons given were no different to findings of other reports
dealing with the same subject.
d)
Gender and race distribution of dentists and specialists
Two recent studies reported on the pre-democracy (1985 to 1994) and postapartheid (1995 to 2004) gender and race distribution of dental graduates and
first year dental students (2000 to 2005) as well as dental specialist training in
South Africa (Lalloo et al., 2005; Lalloo, Naidoo and Myburgh, 2006). A total
of 3,353 dentists graduated from the five dental training institutions between
1985 and 2004 of which 64% were male. Based on racial group, 59% were
white, 17% black, 17% asian and 8% coloured. The breakdown for each of
the two periods under study as well as first year students for the period 2000
to 2005 and dental specialists (1985 to 2004) is found in Table 10.
The
number of female and black students entering and graduating from the
dentistry programme had increased since 1994, but this needed to continue
for black students to reflect the national population distribution. This also
applied to specialist training.
Table 10: Number and percentage of South African dental graduates, first year
students and dental specialists by gender and racial group (Lalloo et al., 2005;
Lalloo et al., 2006)
Male
Female
Asian
Black
Coloured
White
Dental graduates
Pre-democracy Post-apartheid
(1985-1994)
(1995-2004)
1,043 (79%)
1,104 (54%)
271 (21%)
926 (46%)
451 (22%)
121 (9%)
476 (24%)
77 (6%)
163 (8%)
93 (7%)
932 (46%)
1,018 (78%)
Total
First year
students
Dental
specialists
2,147 (64%)
1,197 (36%)
572 (17%)
553 (17%)
256 (8%)
1,950 (58%)
674 (43%)
895 (57%)
456 (29%)
424 (27%)
147 (9%)
542 (35%)
266 (86%)
43 (14%)
44 (14%)
18 (6%)
19 (6%)
228 (74%)
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Chapter 2
56
e)
Dental therapists
The first dental therapists qualified in 1977 and although this had increased to
294, only 158 were registered with the SAMDC in 1993 (Van Wyk, 1996). Of
these 117 were employed by the public services. This represented a loss of
60.2% of trained dental therapists.
Poor salaries and limited career
opportunities were listed as the main reasons (Prinsloo, 1994).
Regulations were changed during 1993 to allow dental therapists to enter the
private sector and open their own practices. It is difficult to estimate their
geographical distribution, but it can be assumed that this will have changed
from the original intention of being employed by the public sector in mainly
rural areas to be similar to dentists with a preference for urban and
metropolitan areas.
f)
Oral hygienists
The first group of oral hygienists qualified at the end of 1973. At the end of
1991 a total of 682 were registered with the SAMDC at which stage 450 were
employed by dentists in the private sector (Van Wyk, 1996). It is safe to
assume that the majority will still be employed in the private sector in urban
and metropolitan areas.
g)
Current registrations of oral health professionals with the HPCSA
A summary of the number of oral hygienists, dental therapists and dentists
registered with the HPCSA as on 30 March 2007 is presented in Table 11
(Health Professions Council of South Africa, 2007).
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Chapter 2
57
Table 11: Oral health professionals registered with the HPCSA on 30 March
2007 (Health Professions Council of South Africa, 2007)
Female
Male
Asian
Black/African
Coloured
White/European
Other/Unknown/Left blank
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Oral Hygienists Dental Therapists
961 (15.5%)
456 (7.3%)
By gender
949
198
12
258
By racial classification
74
55
190
117
2
45
26
518
164
226
By province
3
301
6
10
11
39
24
45
149
83
148
369
31
32
27
45
57
37
Dentists
4,792 (77.2%)
Total
6,209
1,322
3,470
2,469 (39.8%)
3,740 (60.2%)
570
444
87
1,650
2,041
699 (11.3%)
751 (12.1%)
134 (2.2%)
2,194 (35.3%)
2,431 (39.2%)
1,092
69
249
173
649
2,027
158
211
164
1,396 (22.5%)
85 (1.4%)
299 (4.8%)
242 (3.9%)
881 (14.2%)
2,544 (41%)
221 (3.6%)
283 (4.6%)
258 (4.2%)
This information clearly illustrates the domination of dentists who make up
77.2% of the total oral health workforce.
The oral health profession also
continues to be dominated by white males. The maldistribution of oral health
professionals is also clear with 41% indicating Gauteng as their registered
address. Information on how many of these oral health professionals practice
their professions overseas, but who are still registered with the HPCSA, is
impossible to obtain.
2.3
South African policy documents on health and oral health
service delivery
2.3.1 Transformation of health services
The White Paper for the Transformation of the Health System in South Africa
(Republic of South Africa, 1997b) presented a set of policy objectives and
principles upon which the national health system of South Africa would be
based. It also presented implementation strategies to meet the basic needs
___________________________________________________________________
Chapter 2
58
of the population and was guided by the principles of PHC and decentralising
the management of health services with emphasis on a district health system.
The chapter on oral health recognised dental practitioners, oral hygienists,
dental therapists, technicians and assistants as members of the workforce
delivering these services. Two main principles were identified to address oral
health and will be discussed briefly (Republic of South Africa, 1997b).
a)
Adoption of the Primary Health Care approach in the development of
oral health services
•
Prioritisation of service delivery: Mothers, children, pregnant women,
physically and mentally disabled and the elderly were identified as priority
groups for preventive and other services. These priority groups should be
provided with at least a minimum package of services.
An equitable
distribution of services should be reached in the shortest possible time.
•
Focus on prevention: Cost-effective and innovative preventive strategies
should be employed which include purchasing services from the private
sector. Based on oral disease profiles most treatments could be delivered
by oral hygienists and dental therapists, staffing levels at clinics should
keep this in mind.
•
Integration of oral health care: Oral health services should be integrated
with other health services at all levels of care. A basic package of oral
health services should be provided at all PHC facilities.
When PHC
facilities were planned, oral health facilities should be included.
•
Training of oral health personnel: It was recommended that training
should be reviewed to prepare professionals for different environments
and to work amongst different sections of the population. Deployment and
utilisation of oral health personnel should meet everyone’s needs and be
based on the new focus of oral health service delivery.
___________________________________________________________________
Chapter 2
59
b)
Reducing the incidence of common oral diseases
It was suggested that this be achieved through health promotion, prevention
of oral diseases and the provision of basic curative and rehabilitative oral
health services. Implementation strategies to achieve this included:
•
Minimum package of oral care: Should consist of an annual
examination, bitewing radiographs, cleaning of teeth, simple 1- to 3surface restorations, fissure sealants and emergency relief of pain and
infection control.
•
Water fluoridation: It was suggested that water fluoridation be
implemented immediately in the major metropolitan areas with the
remaining areas being phased in systematically. Alternative methods of
fluoridation such as use of fluoridated toothpaste and mouth rinses should
be introduced in schools and among priority groups. Legislation to enable
fluoridation of milk and salt should be pursued and dietary supplements
should be included as part of the integrated nutrition programme.
•
Reduction of the consumption of refined sugar: A call was made for a
nutrition programme to reduce levels of sugar in infant and baby foods,
medicines, fruit juices, vitamin preparations and common foods and to
ensure the availability of accurate information of sugars and their levels on
food labels.
2.3.2 National Oral Health Policy
The South African National Oral Health Strategy (Department of Health, 2005)
was approved by the Minister of Health and the provincial representatives for
health in February 2004 with the aim to improve the oral health of the South
African population by promoting oral health and to prevent, appropriately treat,
monitor and evaluate oral diseases.
___________________________________________________________________
Chapter 2
60
a)
Oral health functions
Specific oral health functions on the different levels of government were
identified (Department of Health, 2005):
•
National level
Formulation, implementation and review of the national oral health strategy
process;
Formulation, implementation, monitoring and evaluation of a national water
fluoridation programme and alternative fluoride measures in collaboration
with the NFC; and
National norms and standards.
•
Provincial level
Formulation, implementation and review of provincial oral health
operational strategies;
Prevention of oral diseases and oral health promotion as priority including
water fluoridation, alternative fluoride programmes, identify and develop
collaborative approaches to disease based on common risk factors, raise
awareness of oral disease risk and integrate oral health into programmes
and policies;
Co-ordinate the oral health care system in the province;
Plan, support and evaluate district oral health services;
Collect data from districts for own and national use; and
Implement national norms and standards for oral health delivery.
•
District level
Provision of appropriate disease prevention and health promotion
measures based on the minimum package of care and cost-effective and
evidence-based strategies;
Devise an appropriate oral health plan for each health setting;
Collect appropriate data; and
Establish an adequate referral system for advanced and specialised oral
health services.
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Chapter 2
61
b)
National goals
National goals set for 2010 included:
•
An increase of PHC facilities delivering oral care services through district
hospitals, community health centres and clinics, mobile or portable dental
units;
•
An increase the percentage of children who were caries free at age 6 to
50%;
•
Reduce the mean DMFT at age 12 to 1.0;
•
60% of the population on piped water systems to receive optimally
fluoridated water; and
•
c)
100% of clinics offer the primary oral health care package.
Resources
The South African National Oral Health Strategy suggested that oral health
human resources should form part of the integrated health human resources
plan. In terms of financial resources the national directorate for oral heath has
its own budget and oral health at provincial levels should have cost centres for
budgeting purposes. Provinces would be responsible for capital expenditure
and equipping oral health facilities. It was furthermore suggested that patients
will be charged for services rendered according to the UPFS. Oral health
programme managers should be consulted in the planning of clinics and
upgrading programmes (Department of Health, 2005).
d)
Links between national and provincial health authorities
To facilitate better communication between the national and provincial health
authorities, it was suggested that (Department of Health, 2005):
•
The national Directorate of Oral Health met with provincial oral health
programme managers at national office at least three times per year;
•
The national Directorate of Oral Health visited provinces to assist and
guide provincial oral health services;
___________________________________________________________________
Chapter 2
62
•
The national Department of Health would be responsible to annually
assess the implementation and outcomes of this strategy and make
recommendations accordingly; and
•
The national Department of Health was also responsible for collating
information provided by provincial health authorities and to disseminate
summary data reports.
e)
Guidelines for oral health personnel
A previous version of the oral health policy recommended ratios for delivery of
oral health services.
These are summarised in Table 12 (Department of
Health, 1999)
Table 12: Recommended ratios for oral health personnel in the public sector
(Department of Health, 1999)
Human resource
Specialist : Population
Dentist : Population
Oral Hygienist : Population
Dental Therapist : Population
Dentist : Dental Therapist
Dentist : Oral Hygienist
Dental Therapist : Oral Hygienist
Clinical : Dental Assistant
Dentist : Dental Technician
Ratio
1:1,000,000
1:60,000
1:50,000
1:12,000
1:5
1:1.2
5:1
1:1.5
6:1
2.3.3 Primary oral health care package
A package of PHC services was agreed to at a meeting of the Provincial
Restructuring Committee in Bloemfontein on 13 April 2000 (Pick et al., 2001).
It was fully recognised that the better-endowed provinces might be in a
position to provide more services than stated with others only able to deliver
some elements of the PHC package. The basic elements of the PHC package
and associated norms and standards were published in separate documents
(Department of Health, 2001a; Department of Health, 2001b).
A minimum package of oral care was first mentioned in the White Paper for
the Transformation of Health Services in South Africa (Republic of South
___________________________________________________________________
Chapter 2
63
Africa, 1997b). A summary of procedures included in this minimum package
of oral care as well as its translation to personnel requirements appears in
Table 13 (Department of Health, 2001a; Pick et al., 2001).
Table 13: The minimum package of oral care (Department of Health, 2001a;
Pick et al., 2001)
Components of work
• Oral examination and
charting of dental status
• Intra-oral radiographs
• Scaling and polishing of
teeth
• Promotive and preventive
oral health services
• Basic curative services
including emergency relief
of
pain
and
sepsis
(including
dental
extractions)
• Simple restorations (1-3
tooth surfaces)
• Treat traumatic injuries to
teeth
• Treat
post-extraction
bleeding
Skills and knowledge
requirements
• Communication
skills
(verbal and non-verbal e.g.
oral health education,
charting of dental status)
• Clinical skills e.g. oral
examination,
history
taking, taking of intra-oral
radiographs
• Practical
skills
e.g.
medicine
prescription,
dental extractions and
simple restorations, treat
traumatic
injuries
and
post-extraction bleeding,
scaling and polishing of
teeth
Personnel requirements for skills
Communication skills:
• Dentist at District Hospital,
Community Health Clinic
• Dental Therapist
• Oral Hygienist
• Dental Assistant
Clinical Skills:
• Dentist
• Dental Therapist
• Oral Hygienist
Practical Skills:
(extractions/restorations/traumatic
injuries/post-extraction bleeding)
• Dentist
• Dental Therapist
(scaling and polishing of teeth)
• Dental Therapist
• Oral Hygienist
A recently published editorial suggests that from a public health perspective
large inequalities in dental disease and a large variation in the amount of
restorative care provided to children are two problems which impact on
improving the oral health of young children in the UK (Tickle, 2006). Effective
population-based interventions such as water fluoridation are recognised
strategies to address inequalities. Far less is known on how to address the
latter problem, this results in a wide variation of the amount of restorative care
provided. This editorial continues by quoting two independently conducted
studies which both reported that 80% of diseased primary teeth exfoliate
without causing pain. This suggests that a less interventionist approach may
be more appropriate. The provision of dental care to children should strike a
balance between effective treatment and minimising any harm to the patient.
___________________________________________________________________
Chapter 2
64
Until more evidence is available as to which approach is most effective, it
should be accepted that the provision of the minimum package of oral care to
South African children is appropriate.
2.4
Summary
This chapter provided a brief overview of the three main elements of this
study.
For water fluoridation a historical perspective (including South Africa) was
presented as well as an overview of caries prevention, recent international
reports and the economics of this well recognised community-based
preventive measure.
For human resources planning the different approaches described by Hall
(1978)
and
the
WHO/FDI
planning
model
(World
Health
Organization/Fédération Dentaire Internationale, 1989) was presented.
As
part of a South African perspective on human resources planning several
previous studies, reports and publications were summarised including the
recently published NHRP (Department of Health, 2006a). Human resources
distribution and trends in South Africa were also discussed.
The final part of this chapter was dedicated to South African policy documents
on health and oral health service delivery. These include the White Paper for
the Transformation of Health Services (Republic of South Africa, 1997b)
which adopted the PHC approach as part of health services, National Oral
Health Strategy (Department of Health, 2005) and the primary oral health care
package.
Chapter 3 will present a model, outcomes and discussion of the economic
variables of the implementation of water fluoridation for seventeen major
metropolitan cities, towns and water providers from all nine South African
provinces taking into account operating cost, opportunity cost and capital
depreciation.
___________________________________________________________________
Chapter 2
65
CHAPTER 3: COST EVALUATION OF THE
IMPLEMENTATION OF WATER FLUORIDATION IN SOUTH
AFRICA
3.1
Introduction
This chapter describes a model to determine the per capita cost, costeffectiveness and cost-benefit of the implementation of water fluoridation for
seventeen major metropolitan cities, towns and water boards from all nine
South African provinces. It takes into account operating cost, opportunity cost
and capital depreciation. This model is an expansion of the simulation model
developed to report on cost-effectiveness and cost-benefit of water
fluoridation for Gauteng (Van Wyk et al., 2001), which was based on the
principles of similar models described by White et al. (1989) and Ringelberg et
al. (1992).
In general per capita cost of fluoridation is affected by the size of the
community, number of fluoride injection points, amount and type of equipment
required, amount and type of fluoride chemical (including its transport and
storage) and training and expertise of personnel required to run the plant.
Although the actual cost of water fluoridation cannot and should not be
ignored, estimates of saving in treatment cost may be more important than
per capita cost. The model presented in this chapter calculates both.
3.2
A model to calculate per capita cost, cost-effectiveness and
cost-benefit of the implementation of water fluoridation in
South Africa
Figure 4 provides an indication of the location of the seventeen major
metropolitan cities, towns and water boards from all nine South African
provinces included in this study.
___________________________________________________________________
Chapter 3
66
13
Republic of South Africa
10
9
11
12
D
C
8
7
6
B
5
4
A
3
1
2
Province
Western Cape
Eastern Cape
Cities/Towns
1: City of Cape Town Metropolitan Municipality
2: Nelson Mandela Bay Metropolitan Municipality
(Port Elizabeth only)
3: Buffalo City Municipality (East London only)
KwaZulu-Natal 4: eThekwini Metropolitan Municipality (Durban)
5: Pietermaritzburg Msunduzi Municipality
Free State
6: Motheo District Municipality (Botshabelo only)
7: Mangaung Local Municipality (Bloemfontein)
Northern Cape 8: Solplaatje Municipality (Kimberley)
North West
9: Mafikeng Local Municipality
Gauteng
10: Tshwane Metropolitan Municipality (Pretoria)
11: City of Johannesburg Metropolitan Municipality
Mpumalanga 12: Ehlanzeni District Municipality (Nelspruit only)
Limpopo
13: Polokwane Municipality
Water boards
A: Amatola Water
B: Umgeni Water
C: Bloem Water
D: Rand Water
Figure 4: Location of cities, towns and water boards
___________________________________________________________________
Chapter 3
67
Table 14 presents all the input variables used in the model. Each variable
has been allocated a unique number (in square brackets) which indicates
where it is used in the different formulas. Variables have been grouped as
follows:
(A)
Chemical cost
(B)
Labour cost
(C)
Maintenance cost
(D)
Opportunity cost
(E)
Capital depreciation
(F)
Operating cost
(G)
Total cost
(H)
Per capita cost
(I)
Caries data
(J)
Cost-effectiveness
(K)
Cost-benefit ratio
Table 14: A model to calculate per capita cost, cost-effectiveness and costbenefit of the implementation of water fluoridation
Variable
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
(A)
[11]
[12]
[13]
[14]
(B)
(A) CHEMICAL COST
Daily water purification rate (litre per day)
Natural fluoride content of water (mg F/litre)
Adjustment of fluoride level to (mg F/litre)
Fluoride needed per day (metric tonne)
Fluoride needed per year (metric tonne)
Chemical needed per year (metric tonne)
Cost of chemical (Rand per metric tonne)
Percentage handling fee by agent
Delivery cost (metric tonne)
Total delivery cost of chemical
Cost of chemical per year
(B) LABOUR COST
Average operator salary
Number of operators needed
Annual operator salary for number of operators needed
Number of hours needed per operator per day
Annual labour cost for number of hours needed per day
Formula
[1] x ([3] - [2]) / (1 x 109)
[4] x 365
[5] / (% available fluoride x % purity)
[7] + ([7] x [8] / 100) + [9]
[6] x [10]
[11] x [12]
[13] / 8 x [14]
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Chapter 3
68
Table 14: (continued)
Variable
[15]
[16]
[17]
[18]
[19]
[20]
[21]
(C)
[22]
(D)
[23]
[24]
[25]
[26]
(E)
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
(J)
(J)
[37]
[38]
[39]
[40]
(K)
(K)
Formula
(C) MAINTENANCE COST
Capital cost per Mega litre of water processed
Percentage cost of buildings and storage
[1] / 1,000,000 x [15] x [16] / 100
Cost of buildings and storage
Percentage cost of mechanical and electrical plant
[1] / 1,000,000 x [15] x [18] / 100
Cost of mechanical and electrical plant
[17] + [19]
Total capital cost
Percentage
[20] x [21] / 100
Maintenance cost: % of total capital cost
(D) OPPORTUNITY COST
Prime Overdraft Rate of Banks
[20] x [22] / 100
Opportunity cost: % of total capital cost
(E) CAPITAL DEPRECIATION
Years for building and storage
[17] / [23]
Capital depreciation of buildings and storage
Years for mechanical and electrical plant
[19] / [25]
Capital depreciation of mechanical and electrical plant
[24] + [26]
Total capital depreciation per annum
(F) OPERATING COST
Chemical cost + Labour cost + Maintenance cost
(A) + (B) + (C)
(G) TOTAL COST
Opportunity cost + Capital depreciation + Operating cost
(D) + (E) + (F)
(H) PER CAPITA COST
Population served by water provider
(G) / [27]
Per capita cost for total population
Percentage of population younger than 15 years
[27] x [29] / 100
Population served by water scheme younger than 15 years
(G) / [30]
Per capita cost younger than 15 years
(I) CARIES DATA
DMFT
Age for DMFT score
[32] / ([33] - 6)
DMFT increment per year
(J) COST-EFFECTIVENESS
(the cost per person per year to save 1 DMFT)
Decrease in caries incidence (%)
[35] / 100 x [34]
Decrease in DMFT per child per year
[28] / [36]
Cost-effectiveness for total population
[31] / [36]
Cost-effectiveness for population younger than 15 years
(K) COST-BENEFIT RATIO
(the cost of the implementation of water fluoridation divided by the savings in cost of treatment)
Cost of a 2 surface amalgam restoration
Cost of a 2 surface anterior resin restoration
Cost of a 2 surface posterior resin restoration
([37] + [38] + [39]) / 3
Average cost of a 2 surface restoration
[28] / ([36] x [40])
Cost-benefit ratio for total population
[31] / ([36] x [40])
Cost-benefit ratio for population younger than 15 years
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Chapter 3
69
Microsoft Excel software was used to computerise this model. An example of
the model applied to the City of Tshwane Metropolitan Municipality (Pretoria)
is presented in Annexure 1.
3.2.1 Chemical cost (Variable Group (A))
a)
Chemicals used in water fluoridation
Any compound which easily forms fluoride ions in solution can be used for the
artificial adjustment of fluoride in water. The three commonly used fluoride
chemicals are sodium fluoride, sodium fluorosilicate and fluorosilicic acid.
These compounds have been approved for use in the artificial fluoridation of
public water supplies in South Africa (Republic of South Africa, 2000).
The properties of these three fluoride compounds are presented in Table 15
(Department of Health, 2003c; Pelchem, 2007).
Table 15: Properties of the three commonly used fluoridation chemicals
(Department of Health, 2003c; Pelchem, 2007)
Chemical formula
Molecular mass
Available fluoride
in formula
Commercial purity
Packaging
Appearance
General
Sodium fluoride
NaF
42
Sodium fluorosilicate
Na2SiF6
188.06
Fluorosilicic acid
H2SiF6
144.08
45.2%
60.6%
79.1%
90-95%
>99%
25 kg bags
White odourless nonhygroscopic
crystalline
powder
40%
210 L drums
Straw-coloured transparent, corrosive liquid with
sour pungent odour
•
•
•
•
White odourless hygroscopic powder or crystal
•
•
•
•
Widely used in water
fluoridation
Mainly in small installations
Not used in large
plants because of
high cost and bulky
saturators
Dust control is necessary
•
•
•
Usually the cheapest
fluoridation chemical
Used in large
installations
Dosed with dry feeder
Dust control is necessary
Inexpensive
Simple to dose
Suitable for both large
or small installations
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Chapter 3
70
For the purpose of this study, fluorosilicic acid (H2SiF6) will be used in the
calculations due to it being relatively inexpensive, requiring a simple dosing
technique and its suitability for both large and small water plants.
b)
Daily water purification rate (Variable [1])
This information was obtained from metropolitan, district and local
municipalities and water boards where water is provided to more than one
municipality. A combined water purification rate (expressed as litre per day)
was used where more than one plant supplies the municipality with water.
Based on the total daily water purification rate, municipalities and water
boards were classified as follows:
•
Category A: Water purification rate of more than 700 Mega litre per day
•
Category B: Water purification rate of less than 700 and more than 100
Mega litre per day
•
Category C: Water purification rate of less than 100 Mega litre per day
A summary of the classification of all municipalities and water boards, the
number of water purification plants and the total combined daily water
purification rates is presented in Table 16.
Detailed information on the
number of water plants, water purification rate and population served by
municipalities and water boards is presented in Annexure 2.
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Chapter 3
71
Table 16: Number of water purification plants and daily water purification rate
per municipality or water board
Municipality/ water board
Cape Town
Umgeni Water
Durban/Pietermaritzburg combined
Durban
Rand Water
Johannesburg
Tshwane (Pretoria)
Port Elizabeth
Amatola Water
Pietermaritzburg
Bloem Water
Bloemfontein
Kimberley
Buffalo City (East London)
Botshabelo
Mafikeng
Nelspruit
Polokwane
c)
Number of water purification plants
Category A
11
11
6 (Umgeni Water)
8 (Umgeni Water)
2
2 (Rand Water)
5 (1 Rand Water)
Category B
7
14
2 (Umgeni Water)
7
2 (Bloem Water)
2
Category C
3 (Amatola Water)
1 (Bloem Water)
2
2
5
Water purification rate
(Mega litre per day)
850.3
1,107.5
1,083
971.5
3,558
1,280
722
282
102.2
118
165.7
106.8
129.7
79
27.9
37
42
24
Natural fluoride content of water (Variable [2])
Natural fluoride content of water as published by Grobler et al. (2006) were
used for this study, although a number of municipalities did not return their
samples and information. These included Bloemfontein and Botshabelo. For
both as well as for Bloem Water the natural water fluoride content was
obtained from the Department of Water Affairs and Forestry database
(Erasmus, 2004).
Table 17 presents the values used in this study. It should be noted that the
fluoride concentration of drinking water for a number of coastal municipalities
was found to be less than 0.1 ppm (mg/litre) (Grobler, Chikte and Louw,
2006). Where this applied a value of 0.1 ppm was used in the calculations.
The highest natural fluoride concentration was 0.47 ppm for Polokwane and
0.26 ppm for Kimberley.
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Chapter 3
72
Table 17: Natural fluoride content of municipalities and water boards
(Erasmus, 2004; Grobler et al., 2006)
Municipality / water board
Natural fluoride content
(milligram / litre)
Category A
Cape Town
Umgeni Water
Durban / Pietermaritzburg combined
Durban
Rand Water
Johannesburg
Tshwane (Pretoria)
Category B
Port Elizabeth
Amatola Water
Pietermaritzburg
Bloem Water
Bloemfontein
Kimberley
Category C
Buffalo City (East London)
Botshabelo
Mafikeng
Nelspruit
Polokwane
d)
< 0.1
0.1
0.1
0.1
0.2
0.2
0.2
< 0.1
< 0.1
< 0.1
0.3
0.3
0.26
0.18
0.3
0.15
< 0.1
0.47
Adjustment of fluoride level (Variable [3])
For the purpose of this study fluoride levels of community water supplies for
all municipalities and water boards was adjusted to 0.7 ppm which is in line
with the recommendation for the optimal fluoride concentration as published in
the regulations for the fluoridation of water supplies (Republic of South Africa,
2000).
e)
Chemical needed (Variables [4] to [6])
The amount or chemical needed expressed as metric tonnes was calculated
for fluorosilicic acid (H2SiF6) by applying the formulas as indicated.
•
Fluoride needed per day (Variable [4]):
Daily water purification rate x (Adjusted fluoride level – Natural fluoride
content) / (1 x 109)
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Chapter 3
73
The factor of 1 x 109 converts the amount of fluoride needed per day from
milligram to metric tonne.
•
Fluoride needed per year (Variable [5]):
Fluoride needed per day x 365
•
Chemical needed per year (Variable [6]):
Fluoride needed per year / (% available fluoride from H2SiF6 x % purity of
H2SiF6)
f)
Total delivery cost of chemical (Variables [7] to [10])
The cost of fluorosilicic acid (H2SiF6) (Variable [7]), percentage handling fee
charged by the agent (Variable [8]) and the delivery cost per metric tonne
(Variable [9]) were supplied by Pelchem and Süd-Chemie (De Klerk, 2006;
Leopold, 2006).
The total delivery cost of fluorosilicic acid (H2SiF6) (Variable [10]) was
calculated by applying the formula:
Cost of chemical + (Cost of chemical x Percentage handling fee by agent) +
Delivery cost
g)
Cost of chemical per year (Variable Group (A))
The cost of the chemical needed per year was calculated by applying the
formula:
Chemical needed per year x Total delivery cost of chemical
Table 18 presents the total delivery cost of fluorosilicic acid used as supplied
by Pelchem and Süd-Chemie.
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Chapter 3
74
Table 18: Total delivery cost of chemical per metric tonne (De Klerk, 2006;
Leopold, 2006)
Cost of fluorosilicic acid per metric tonne (Pelchem):
R7,044.00
Agent’s handling fee (Süd-Chemie):
12.5%
Delivery cost per
Total delivery cost
Cost of chemical
Municipality /
metric tonne
per metric tonne
per year
water board
(Süd-Chemie)
Category A
R5,281,898.86
R8,974.50
R1,050.00
Cape Town
R6,465,628.05
R8,434.50
R510.00
Umgeni Water
R6,322,596.10
R8,434.50
R510.00
Durban/Pietermaritzburg
combined
R5,671,654.77
R8,434.50
R510.00
Durban
R16,632,539.53
R8,104.50
R180.00
Rand Water
R5,983,600.51
R8,104.50
R180.00
Johannesburg
R3,375,124.66
R8,104.50
R180.00
Tshwane (Pretoria)
Category B
R1,706,835.75
R8,744.50
R820.00
Port Elizabeth
R618,576.64
R8,744.50
R820.00
Amatola Water
R688,888.59
R8,434.50
R510.00
Pietermaritzburg
R637,262.61
R8,334.50
R410.00
Bloem Water
R410,740.18
R8,334.50
R410.00
Bloemfontein
R555,232.53
R8,434.50
R510.00
Kimberley
Category C
R414,401.97
R8,744.50
R820.00
Buffalo City
(East London)
R8,334.50
R107,300.10
R410.00
Botshabelo
R8,394.50
R196,801.48
R470.00
Mafikeng
R8,394.50
R244,034.80
R470.00
Nelspruit
R8,394.50
R53,455.24
R470.00
Polokwane
3.2.2 Labour cost (Variable Group (B))
a)
Operator salary and number of operators required (Variables [11] to [13])
The Department of Water Affairs and Forestry would be responsible for the
standard of training of personnel involved in water purification. Based on the
requirements of the regulations on fluoridating water supplies, the lowest rank
of an operator involved in monitoring water fluoride content would be a plant
superintendent (Republic of South Africa, 2000).
Information on the annual salary and benefits of a plant superintendent as
well as the number of plant superintendents required to manage the
fluoridation process was provided by municipalities and water boards. This
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Chapter 3
75
information varied greatly between water providers.
In an attempt to
standardise on the number of plant superintendents required per water
purification plant to monitor this process over a 24 hour period of time and
based on the daily water purification rate of each plant, the following was used
as a guideline in this study (Variable [12]):
•
Water purification rate of more than 250 Mega litre per day: 4 plant
superintendents
•
Water purification rate between 100 and 249 Mega litre per day: 3 plant
superintendents
•
Water purification rate between 50 and 99 Mega litre per day: 2 plant
superintendents
•
Water purification rate less than 50 Mega litre per day: 1 plant
superintendent
•
Water purification rate less than 1 Mega litre per day: Serviced by
superintendents from other plants
Remuneration rates were provided by water boards and municipalities in
2004. These were adjusted by 4.6% for 2005 and a further 5.3% for 2006
according to the annual salary adjustments recommended by the Department
of Public Service and Administration for post levels 1 to 12 (Department of
Public Service and Administration, 2005; Department of Public Service and
Administration, 2006).
Based on these guidelines and linked to the daily water purification rate of
each plant, the average annual salary of a plant superintendent was
calculated (Variable [11]) for each municipality and water board.
More
detailed information can be found in Annexure 2.
Where only part of the water processed by a water board is supplied to a
municipality, the same proportion was used to calculate the number of
operators needed to process the water supplied to that municipality.
For
example both the Rand Water Zuikerbosch and Vereeniging plants require 4
operators each, but only 36% of the water processed by these plants is
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Chapter 3
76
provided to Johannesburg Municipality, which would then require 2.88
operators (36% of 8 operators).
The annual operator salary for the number of operators required (Variable
[13]) was calculated by applying the formula:
Average operator salary x Number of operators needed
b)
Number of hours needed per operator per day (Variable [14])
Labour costs were based on an operator spending one hour per working day
(or eight hour shift) on the fluoridation process (Ringelberg et al., 1992).
c)
Annual labour cost for number of hours needed per day (Variable Group
(B))
The majority of municipalities indicated that a working day or shift for a plant
superintendent would be eight hours. The annual labour cost for the number
of hours needed per day was calculated by applying the formula:
Annual operator salary for number of operators needed / 8 hours per day x 1
hour needed per day per operator for fluoridation process
Table 19 presents the average annual operator salary (Variable [11]), number
of operators required (Variable [12]), the annual operator salary for the
number of operators required (Variable [13]) and the annual labour cost for
the number of hours needed per day for the municipalities and water boards
included in this study.
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Chapter 3
77
Table 19: Average operator salary, number of operators required, annual
operator salary and annual labour cost
Municipality / water
board
Number of
operators
required
Category A
18
R186,079.14
19
R255,069.85
14
R267,492.09
Average annual
operator salary
Cape Town
Umgeni Water
Durban/Pietermaritzburg
combined
Durban
Rand Water
Johannesburg
Tshwane (Pretoria)
Port Elizabeth
Amatola Water
Pietermaritzburg
Bloem Water
Bloemfontein
Kimberley
Buffalo City
(East London)
Botshabelo
Mafikeng
Nelspruit
Polokwane
14
R256,726.44
8
R275,359.50
2.88
R275,359.50
6.12
R255,162.87
Category B
10
R201,563.15
9
R132,172.56
2
R275,359.50
9
R237,392.93
2.68
R237,392.93
4
R151,535.84
Category C
3
R132,172.56
R215,530.00
R137,679.75
R132,172.56
R109,477.43
0.93
2
2
5
Annual
operator
salary
Annual
labour cost
R3,349,424.49
R4,846,327.20
R3,744,889.20
R418,678.06
R605,790.90
R468,111.15
R3,594,170.20
R2,202,876.00
R793,035.36
R1,561,596.77
R449,271.28
R275,359.50
R99,129.42
R195,199.60
R2,015,631.54
R1,189,553.04
R550,719.00
R2,136,536.39
R636,213.06
R606,143.36
R251,953.94
R148,694.13
R68,839.88
R267,067.05
R79,526.63
R75,767.92
R396,517.68
R49,564.71
R200,442.90
R275,359.50
R264,345.12
R547,387.15
R25,055.36
R34,419.94
R33,043.14
R68,423.39
3.2.3 Maintenance cost (Variable Group (C))
a)
Capital cost (Variables [15], [16] and [18])
Calculation of the capital cost for a fluoridation plant was based on information
from three previous studies/reports:
•
Cost-effectiveness and cost-benefit of water fluoridation for Gauteng (Van
Wyk et al., 2001);
•
A 2002 estimation of the cost of fluoridating water and daily water
processing rates by Rand Water (Rand Water, 2002a; Rand Water,
2002b);
•
A 2003 cost estimate for the NFC for Nelspruit based on the Van Wyk et al
(2001) model for Gauteng.
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Chapter 3
78
Based on daily water processing rates, both Gauteng and Rand Water are
classified as Category A water boards (> 700 Mega litre/day) with Nelspruit
classified as a Category C provider (<100 Mega litre/day). Information from
the three cost estimates for Gauteng, Rand Water and Nelspruit were used to
calculate the capital cost per Mega litre of water processed (Variable [15]) as
well as the percentage contribution of capital cost of buildings and storage
(Variable [16]) and mechanical and electrical plant (Variable [18]) towards the
total capital cost. The average percentage of Category A and C provider
values were used for Category B providers.
The Bureau for Economic Research’s Building Cost Index (BER-BCI) is
generally accepted as a valid indicator of inflation for the building industry
(Bureau for Economic Research, 2006).
The year-on-year BER-BCI was
applied to the 2002 Rand Water capital cost estimates with a 12%, 10% and
19% adjustment for 2003, 2004 and 2005 respectively (Davis Langdon &
Seah International, 2006).
The daily water purification rate for Rand Water
for 2005 was then used to calculate a revised capital cost per Mega litre of
water processed for 2005.
A BER-BCI of 13.2% was predicted for 2006
(Institute of Estate Agents of South Africa, 2006). The 2005 capital cost was
adjusted with this percentage to calculate capital cost for 2006. A rounded
value of R8,750.00 per Mega litre water processed per day (Variable [15])
was used in this study.
Table 20 presents the values for capital cost per Mega litre water processed,
percentage cost of buildings and storage and percentage cost of the
mechanical and electrical plant used in this study for Category A, B and C
water providers.
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Chapter 3
79
Table 20: Capital cost for a water fluoridation plant for Category A, B and C
water providers
Capital cost
Daily water
purification rate (Ml)
Capital cost per Mega litre water
Category A
Rand Water (2002) Gauteng (1998)
R18,850,000.00
R14,000,000.00
3,400
Category B
Category C
Nelspruit (2003)
R274,130.00
2,800
44
R5,000.00
R6,230.23
R2,897,338.00
R100,000.00
(21% of
(36% of
Buildings and Storage
29%
capital cost)
capital cost)
R11,102,662.00
R174,130.00
Mechanical and Electrical
(79% of
71%
(64% of
capital cost)
capital cost)
Adjustment of 2002 Rand Water capital costs for 2005
BER-BCI 2003: 12%
R21,112,000.00
BER-BCI 2004: 10%
R23,223,200.00
BER-BCI 2005: 19%
R27,635,608.00
2005 daily water purification rate (Ml)
3,558
2005 Capital Cost per Mega litre water
R7,767.17
Adjustment of 2005 Rand Water capital cost per Mega litre water for 2006
(Projected BER-BCI 2006: 13%)
2006 Capital Cost per Mega litre water
~ R8,750.00
b)
R5,544.12
Cost of buildings, storage, mechanical and electrical plant (Variables
[17], [19] and [20])
These costs were calculated from previous variables by applying the following
formulas:
•
Cost of buildings and storage (Variable [17]):
Daily water purification rate / (1 x 106) x Capital cost per Mega litre of
water processed x Percentage cost of buildings and storage
The factor of 1 x 106 converts the daily water purification rate from litre to
Mega litre.
•
Cost of mechanical and electrical plant (Variable [19]):
Daily water purification rate / (1 x 106) x Capital cost per Mega litre of
water processed x Percentage cost of mechanical and electrical plant
The factor of 1 x 106 converts the daily water purification rate from litre to
Mega litre.
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Chapter 3
80
•
Total capital cost (Variable [20]):
Cost of buildings and storage + Cost of mechanical and electrical plant
c)
Maintenance cost (Variable Group (C))
Maintenance and repair costs were calculated at 2.4% (Variable [21]) of total
capital costs (Ringelberg et al., 1992) by applying the formula:
Total capital cost x Percentage
3.2.4 Opportunity cost (Variable Group (D))
Opportunity cost is defined as the next best alternative for that amount of
money (Ringelberg et al., 1992). For this study the South African Reserve
Bank Prime Overdraft Rate of Banks (as on 3 August 2006) of 11.5%
(Variable [22]) was used in the calculations (South African Reserve Bank,
2006). Opportunity cost was calculated by applying the formula:
Total capital cost x Prime Overdraft Rate of Banks
3.2.5 Capital depreciation (Variable Group (E))
Capital depreciation was calculated using a fifteen year turnover for buildings
and storage (Variable [23]) and an eight year turnover on mechanical and
electrical equipment (Variable [25]) (Van Wyk et al., 2001) by applying the
formulas:
•
Capital depreciation of buildings and storage (Variable [24]):
Cost of buildings and storage / Years for building and storage
•
Capital depreciation of mechanical and electrical plant (Variable [26]):
Cost of mechanical and electrical plant / Years for mechanical and
electrical plant
•
Total capital depreciation per annum (Variable Group (E)):
Capital depreciation of buildings and storage + Capital depreciation of
mechanical and electrical plant
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Chapter 3
81
3.2.6 Operating cost (Variable Group (F))
Operating cost was calculated from the sum of the cost of chemical per year
(Variable Group (A)), annual labour cost for the number of hours needed per
day (Variable Group (B)) and maintenance cost (Variable Group (C))
(Ringelberg et al., 1992).
3.2.7 Total cost (Variable Group (G))
Total cost was calculated from the sum of the opportunity cost (Variable
Group (D)), capital depreciation (Variable Group (E)) and operating cost
(Variable Group (F)) (Ringelberg et al., 1992).
Table 21 presents the operating and total cost of water fluoridation for each of
the municipalities and water boards.
Table 21: Operating and total cost of water fluoridation
Municipality / water board
Operating cost
Category A
R5,879,139.92
Cape Town
R7,303,993.95
Umgeni Water
R7,018,137.25
Durban/Pietermaritzburg combined
R6,324,941.04
Durban
R17,655,079.03
Rand Water
R6,351,529.93
Johannesburg
R3,721,944.26
Tshwane (Pretoria)
Category B
R2,018,009.69
Port Elizabeth
R788,732.77
Amatola Water
R782,508.46
Pietermaritzburg
R939,126.66
Bloem Water
R512,694.81
Bloemfontein
R658,235.35
Kimberley
Category C
R480,556.68
Buffalo City (East London)
R138,214.46
Botshabelo
R238,980.92
Mafikeng
R285,897.94
Nelspruit
R126,918.64
Polokwane
Total cost
R7,573,628.39
R9,511,033.80
R9,176,353.19
R8,260,958.39
R24,745,505.91
R8,902,329.93
R5,160,754.88
R2,568,467.82
R988,225.04
R1,012,842.00
R1,262,569.61
R721,166.18
R911,387.52
R631,940.43
R191,677.84
R309,786.35
R366,380.44
R172,908.64
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Chapter 3
82
3.2.8 Per capita cost (Variable Group (H))
Information on the total population served by the water providers (Variable
[27]) was obtained from the municipalities and water boards included in this
study. Detailed information can be found in Annexure 2.
Amatola Water could not provide this information. Their website estimated
the population in their catchment area as 2.47 million (Amatola Water, 2005).
According to the 2001 South African census data, 49% of the population of
the Eastern Cape province had access to a centralised water supply within
200 metres of their dwelling (Statistics South Africa, 2003).
With this
information the population served by Amatola Water was calculated as 1.2
million people.
Per capita cost for the total population (Variable [28]) was calculated by
applying the formula:
Total cost / Population served by water provider
Information on the percentage of the population younger than fifteen years of
age (Variable [29]) (Statistics South Africa, 2006) was used to calculate the
population served by the water provider for this age cohort (Variable [30])
with the formula:
Population served by water provider x Percentage of population younger than
15 years
Per capita cost for those younger than fifteen years was calculated with the
formula:
Total cost / Population served by water scheme younger than 15 years
Results for the per capita cost for the total population as well as those
younger than fifteen years are presented in section 3.3.2 of this chapter (see
p 89).
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Chapter 3
83
3.2.9 Caries prevalence (Variable Group (I))
The 1999-2002 NCOHS recorded caries prevalence for the permanent
dentition for 6-, 12- and 15-year-olds by way of the DMFT caries index
(Department of Health, 2003b; Van Wyk, Louw and Du Plessis, 2004).
Weighted mean DMFT scores for 15-year-olds (Variable [32]) per district and
province, as reported or calculated from the Bureau for Statistical and Survey
Methodology (STATOMET) database of the NCOHS, were used in this study.
These values are presented in Table 22.
Table 22: Caries prevalence (DMFT) for 15-year-olds per district and province:
1999-2002 NCOHS
Province / District
South Africa
Western Cape
Cape Metro
Eastern Cape
Eastern Cape Western
Northern Cape
Free State
Region A (Bloemfontein)
KwaZulu-Natal
Durban
Pietermaritzburg
Gauteng
North West
Mafikeng
Mpumalanga
Lowveldt
Limpopo
Central Region
DMFT for 15year-olds
1.86
3.99
4.05
2.01
2.01
2.88
1.92
1.53
1.87
1.95
1.26
1.81
1.20
2.30
1.66
2.25
0.86
0.61
DMFT for 15-year-olds used for:
Cape Town
Amatola Water, Port Elizabeth, Buffalo City (East London)
Kimberley
Bloem Water, Bloemfontein, Botshabelo
Umgeni Water, Durban/Pietermaritzburg combined
Durban
Pietermaritzburg
Rand Water, Johannesburg, Tshwane (Pretoria)
Mafikeng
Nelspruit
Polokwane
The DMFT increment per year (Variable [34]) was calculated over a nine year
period (age 15 – age 6) by applying the formula:
DMFT / (Age for DMFT score – 6)
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Chapter 3
84
3.2.10 Cost-effectiveness (Variable Groups (J))
Cost-effectiveness is defined as the cost per person per year to save one
DMFT (Horowitz and Heifetz, 1979).
a)
Decrease in caries incidence (Variable [35])
This value was preselected and represents the anticipated caries reduction
expected after the introduction of water fluoridation. For this study costeffectiveness was calculated for anticipated caries reductions of 10%, 30%
and 50%.
b)
Decrease in DMFT per child per year (Variable [36])
This value was calculated from previous variables by applying the formula:
% decrease in caries incidence x DMFT increment per year
c)
Cost-effectiveness (Variable Group (J))
This value was calculated from previous variables for the total population as
well as for those younger than fifteen years by applying the formula:
Per capita cost for total population or for those younger than 15 / Decrease in
DMFT per child per year
The results for cost-effectiveness for the total population as well as those
younger than fifteen years are presented in section 3.3.3 of this chapter (see
p 92).
3.2.11 Cost- benefit (Variable Groups (K))
Cost-benefit is defined as the cost of implementing the procedure divided by
the savings in the cost of treatment (Horowitz and Heifetz, 1979). Should the
cost-benefit ratio approach one or be larger than one, this measure should not
be considered.
Alternatively cost-benefit can also be described as the
monetary value spent on water fluoridation to save one monetary unit of the
cost of treatment (Van Wyk et al., 2001).
___________________________________________________________________
Chapter 3
85
a)
Cost of a two surface restoration (Variables [37] to [40])
The average cost of a two surface restoration (Variable [40]) calculated from
the average 2006 NRPL fee for an amalgam (Code 8342) (Variable [37]),
anterior resin (Code 8352) (Variable [38]) and posterior resin (Code 8368)
(Variable [39]) restoration was used in this study (Council for Medical
Schemes, 2006). These fees are presented in Table 23.
Table 23: Average cost of a two surface restoration (Council for Medical
Schemes, 2006)
Description
NRPL Code
8342
2 surface amalgam restoration
8352
2 surface anterior resin restoration
8368
2 surface posterior resin restoration
Average cost of a 2 surface restoration:
b)
2006 item fee
R155.90
R174.60
R186.20
R172.23
Cost-benefit (Variable Group (K))
This value was calculated from previous variables for the total population and
for those younger than fifteen years by applying the formula:
Per capita cost for total population or for those younger than 15 / (Decrease in
DMFT per child per year x Average cost of a two surface restoration)
The results for cost-benefit for the total population as well as those younger
than fifteen years are presented in section 3.3.4 of this chapter (see p 94).
3.3
Results
A model to determine per capita cost, cost-effectiveness and cost-benefit of
the implementation of water fluoridation for seventeen major metropolitan
cities, towns and water boards in all nine South African provinces, taking into
account operating cost, opportunity cost and capital depreciation was
described in the previous section.
This section presents the results for the total population and the population
younger than fifteen served by each of the municipalities and water boards
included in this study.
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Chapter 3
86
3.3.1 Total cost of water fluoridation
Table 24 presents a summary of the cost of chemicals, labour, maintenance,
opportunity cost and capital depreciation as a monetary value as well as the
percentage contribution of each to the total cost. Operating cost is calculated
from the sum of the cost of chemicals, labour and maintenance. Total cost is
calculated from the sum of operating cost, opportunity cost and capital
depreciation.
Table 24: Cost of the introduction of water fluoridation
Municipality/ water board
Cape Town
Umgeni Water
Durban/Pietermaritzburg
combined
Durban
Rand Water
Johannesburg
Tshwane (Pretoria)
Category A Average
Port Elizabeth
Amatola Water
Pietermaritzburg
Bloem Water
Bloemfontein
Kimberley
Category B Average
Buffalo City (East London)
Botshabelo
Mafikeng
Nelspruit
Polokwane
Category C Average
Category A, B, C Average
Note: m = million
Chemicals
A
%
R5.28 m
R6.47 m
R6.32 m
R5.67 m
R16.63 m
R5.98 m
R3.38 m
Labour
B
%
Category A
R0.42 m 5.5
69.7
R0.61 m 6.4
68.0
R0.47 m 5.1
68.9
68.7
67.2
67.2
65.4
67.9
R1.71 m
R0.62 m
R0.69 m
R0.64 m
R0.41 m
R0.56 m
66.5
62.6
68.0
50.5
57.0
60.9
60.9
R0.41 m
R0.11 m
R0.20 m
R0.24 m
R53,455.24
65.6
56.0
63.5
66.6
30.9
56.5
62.4
R0.45 m
R0.28 m
R99,129.42
R0.20 m
Category B
R0.25 m
R0.15 m
R68,839.88
R0.27 m
R79,526.63
R75,767.92
Category C
R49,564.71
R25,055.36
R34,419.94
R33,043.14
R68,423.39
Maintenance
C
%
Operating cost
D = A+B+C
%
R0.18 m
R0.23 m
R0.23 m
2.4
2.4
2.5
R5.88 m
R7.30 m
R7.02 m
77.6
76.8
76.5
5.4
1.1
1.1
3.8
4.1
R0.20 m
R0.75 m
R0.27 m
R0.15 m
2.5
3.0
3.0
2.9
2.7
R6.32 m
R17.66 m
R6.35 m
R3.72 m
76.6
71.3
71.3
72.1
74.6
9.8
15.0
6.8
21.2
11.0
8.3
12.0
R59,220.00
R21,462.00
R24,780.00
R34,797.00
R22,428.00
R27,234.90
2.3
2.2
2.4
2.8
3.1
3.0
2.6
R2.02 m
R0.79 m
R0.78 m
R0.94 m
R0.51 m
R0.66 m
78.6
79.8
77.3
74.4
71.1
72.2
75.6
7.8
13.1
11.1
9.0
39.6
16.1
10.1
R16,590.00
R5,859.00
R7,759.50
R8,820.00
R5,040.00
2.6
3.1
2.5
2.4
2.9
2.7
2.7
R0.48 m
R0.14 m
R0.24 m
R0.29 m
R0.13 m
76.0
72.1
77.1
78.0
73.4
75.3
75.1
___________________________________________________________________
Chapter 3
87
Table 24: (continued)
Municipality/ water board
Cape Town
Umgeni Water
Durban/Pietermaritzburg
combined
Durban
Rand Water
Johannesburg
Tshwane (Pretoria)
Category A Average
Operating cost
Opportunity cost
D
%
E
%
Category A
R0.86 m 11.3
R5.88 m 77.6
R1.11 m 11.7
R7.30 m 76.8
R1.09 m 11.9
R7.02 m 76.5
R6.32 m
R17.66 m
R6.35 m
R3.72 m
Port Elizabeth
Amatola Water
Pietermaritzburg
Bloem Water
Bloemfontein
Kimberley
Category B Average
R2.02 m
R0.79 m
R0.78 m
R0.94 m
R0.51 m
R0.66 m
Buffalo City (East London)
Botshabelo
Mafikeng
Nelspruit
Polokwane
Category C Average
Category A, B, C Average
Note: m = million
R0.48 m
R0.14 m
R0.24 m
R0.29 m
R0.13 m
R0.98 m
76.6
R3.58 m
71.3
R1.29 m
71.3
R0.73 m
72.1
74.6
Category B
R0.28 m
78.6
R0.10 m
79.8
R0.12 m
77.3
R0.17 m
74.4
R0.11 m
71.1
R0.13 m
72.2
75.6
Category C
R79,493.75
76.0
R28,074.38
72.1
R37,180.94
77.1
R42,262.50
78.0
R24,150.00
73.4
75.3
75.1
Capital depreciation
F
%
Total cost
G = D+E+F
R0.84 m
R1.09 m
R1.07 m
11.1
11.5
11.6
R7.57 m
R9.51 m
R9.18 m
11.8
14.5
14.5
14.1
12.8
R0.96 m
R3.51 m
R1.26 m
R0.71 m
11.6
14.2
14.2
13.8
12.6
R8.26 m
R24.75 m
R8.90 m
R5.16 m
11.0
10.4
11.7
13.2
14.9
14.3
12.6
R0.27 m
R96,653.52
R0.11 m
R0.16 m
R0.10 m
R0.12 m
10.4
9.8
11.0
12.4
14.0
13.5
11.8
R2.57 m
R0.99 m
R1.01 m
R1.26 m
R0.72 m
R0.91 m
12.6
14.6
12.0
11.5
14.0
12.9
12.8
R71,890.00
R25,389.00
R33,624.50
R38,220.00
R21,840.00
11.4
13.2
10.9
10.4
12.6
11.7
12.1
R0.63 m
R0.19 m
R0.31 m
R0.37 m
R0.17 m
Figure 5 presents the cost of chemicals, labour and maintenance as well as
opportunity cost and capital depreciation as a percentage of the total cost for
Category A, B and C municipalities and water boards and well as a combined
average for Categories A, B and C water providers.
Chemical cost contributes on average 62.4% to the total cost and are higher
for Category A (67.9%) compared to Category B (60.9%) and C providers
(56.5%). The opposite applies to labour cost where this represents 16.1% of
the total cost for Category C compared to 12% for Category B and only 4.1%
for Category A providers. The average contribution of labour cost to total cost
for all providers is 10.1%.
___________________________________________________________________
Chapter 3
88
Operating cost contributes 75.1% to the total cost and only varies slightly
between the different categories of providers. On average opportunity cost
and capital depreciation contribute 12.8% and 12.1% respectively to the total
cost.
75
67.9
62.4
60.9
Percentage
60
56.5
45
30
16.1
15
12.8 12.6
4.1
12.9
12.6 11.8
12
11.7
12.8 12.1
10.1
2.7
2.6
2.7
2.7
Category A
Category B
Category C
Category A, B, C
0
Chemicals
Labour
Maintenance
Opportunity cost
Capital depreciation
Figure 5: Cost of the introduction of water fluoridation for Category A, B and C
municipalities and water boards as a percentage of the total cost
3.3.2 Per capita cost
The 2006 South African mid-year population estimates indicate the total
population
as
47.39
million
people
(Statistics South Africa, 2006).
Municipalities and water boards included in this study provided information on
the number of water purification plants which approximately serve 25 million
people. This represents almost 53% of the total population of South Africa.
Table 25 presents the per capita cost for the total population and the
population younger than fifteen years of age.
___________________________________________________________________
Chapter 3
89
Table 25: Per capita cost of water fluoridation for the total population and
those younger than fifteen years
Municipality / water board
Cape Town
Umgeni Water
Durban/Pietermaritzburg
combined
Durban
Rand Water
Johannesburg
Tshwane (Pretoria)
Category A Average
Port Elizabeth
Amatola Water
Pietermaritzburg
Bloem Water
Bloemfontein
Kimberley
Category B Average
Buffalo City
(East London)
Botshabelo
Mafikeng
Nelspruit
Polokwane
Category C Average
Category A, B, C Average
Population served
by water scheme
3,350,000
3,422,000
3,315,000
Per capita
cost
(total
population)
Category A:
R2.26
R2.78
R2.77
R2.70
R2.06
R2.76
R2.46
R2.54
Category B
R2.14
1,200,000
R0.82
1,210,286
R2.03
500,000
R1.23
1,027,000
R1.33
541,200
R4.09
223,000
R1.94
Category C
R0.93
677,379
3,064,624
12,000,000
3,225,608
2,100,000
306,900
170,000
95,000
200,556
R0.62
R1.82
R3.86
R0.86
R1.62
R2.08
% of
population
<15 years
Population
<15 years
served
by water
scheme
28.18
34.32
34.32
944,030
1,174,430
1,137,708
R8.02
R8.10
R8.07
34.32
26.46
26.46
26.46
1,051,779
3,175,200
853,496
555,660
R7.85
R7.79
R10.43
R9.29
R8.51
34.93
34.93
34.32
30.55
30.55
31.24
419,160
422,753
171,600
313,749
165,337
69,665
R6.13
R2.34
R5.90
R4.02
R4.36
R13.08
R5.97
34.93
236,608
R2.67
30.55
32.05
34.72
37.65
93,758
54,485
32,984
75,509
R2.04
R5.69
R11.11
R2.29
R4.76
R6.62
Per capita
cost
(<15 years)
Figure 6 presents the average per capita cost for Category A, B and C
municipalities and water boards as well as a combined average for Categories
A, B and C water providers for the total population as well as for those
younger than fifteen years.
___________________________________________________________________
Chapter 3
90
9
8.51
8
Per Capita Cost (Rand)
7
6.62
5.97
6
4.76
5
4
3
2.54
2.08
1.94
2
1.62
1
0
Category A
Category B
Total population
Category C
Category A, B, C
Population < 15 years
Figure 6: Per capita cost for the total population and those younger than
fifteen years for Category A, B and C municipalities and water boards
The average per capita cost of water fluoridation for the total population for all
category water providers combined is R2.08 and it ranges from R0.62
(Botshabelo), R0.82 (Amatola Water) and R0.86 (Polokwane) at the lower end
to R3.86 (Nelspruit) and R4.09 (Kimberley) at the higher end. The average
per capita cost is higher for Category A providers (R2.54) compared to
Category B (R1.94) and Category C (R1.62) providers.
Per capita cost for the population younger than fifteen years, which represents
32% of the total population (Statistics South Africa, 2006), ranges from R2.04
(Botshabelo), R2.29 (Polokwane), R2.34 (Amatola Water) and R2.67 (Buffalo
City) to R10.43 (Johannesburg), R11.11 (Nelspruit) and R13.08 (Kimberley).
The average per capita cost for all category water providers combined is
R6.62 with the highest for Category A (R8.51) and lowest for Category C
(R4.76) providers.
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Chapter 3
91
3.3.3 Cost-effectiveness
In this study cost-effectiveness (cost per person per year to save one DMFT)
was calculated for an anticipated caries reduction of 10%, 30% and 50% as a
result of the introduction of water fluoridation.
Table 26 presents cost-effectiveness for the total population as well as for
those younger than fifteen years. Figure 7 and Figure 8 present the average
cost-effectiveness for Category A, B and C municipalities and water boards
and well as a combined average for Categories A, B and C water providers for
the total population and for those younger than fifteen years.
Table 26: Cost-effectiveness of water fluoridation
Municipality / water board
Cape Town
Umgeni Water
Durban/Pietermaritzburg
combined
Durban
Rand Water
Johannesburg
Tshwane (Pretoria)
Category A Average
Total population
Estimated caries reduction
10%
30%
50%
Category A
R10.05
R16.75
R50.24
R26.75
R44.59
R133.77
R26.65
R44.41
R133.23
R178.28
R389.76
R388.19
R59.43
R129.92
R129.40
R35.66
R77.95
R77.64
R24.88
R20.51
R27.45
R24.44
R22.96
R362.50
R387.52
R518.64
R461.81
R383.82
R120.83
R129.17
R172.88
R153.94
R127.94
R72.50
R77.50
R103.73
R92.36
R76.76
R19.17
R7.31
R28.94
R14.46
R15.68
R25.54
R18.52
R274.37
R104.67
R421.60
R236.71
R256.58
R408.82
R283.79
R91.46
R34.89
R140.53
R78.90
R85.53
R136.27
R94.60
R54.87
R20.93
R84.32
R47.34
R51.32
R81.76
R56.76
R8.35
R119.59
R39.86
R23.92
R7.35
R14.26
R30.85
R25.44
R17.25
R19.89
R120.26
R222.48
R444.31
R337.85
R248.90
R313.00
R40.09
R74.16
R148.10
R112.62
R82.97
R104.33
R24.05
R44.50
R88.86
R67.57
R49.78
R62.60
R124.41
R102.54
R137.23
R122.20
R114.80
Port Elizabeth
Amatola Water
Pietermaritzburg
Bloem Water
Bloemfontein
Kimberley
Category B Average
R95.84
R36.56
R144.69
R72.32
R78.38
R127.72
R92.58
Buffalo City
(East London)
Botshabelo
Mafikeng
Nelspruit
Polokwane
Category C Average
Category A, B, C Average
R41.77
R36.74
R71.31
R154.27
R127.20
R86.26
R99.47
R41.47
R34.18
R45.74
R40.73
R38.27
Category B
R31.95
R12.19
R48.23
R24.11
R26.13
R42.57
R30.86
Category C
R13.92
R12.25
R23.77
R51.42
R42.40
R28.75
R33.16
Population < 15 years
Estimated caries reduction
10%
30%
50%
___________________________________________________________________
Chapter 3
92
120
114.8
99.47
100
Cost-effectiveness (Rand)
92.58
86.26
80
60
38.27
40
33.16
30.86
28.75
22.96
18.52
17.25
Category B
Category C
20
19.89
0
Category A
10% caries reduction
30% caries reduction
Category A, B, C
50% caries reduction
Figure 7: Cost-effectiveness of water fluoridation for the total population for
Category A, B and C municipalities and water boards at three anticipated
levels of caries reduction
400
383.82
350
Cost-effectiveness (Rand)
313
300
283.79
248.9
250
200
150
127.94
104.33
100
94.6
82.97
76.76
62.6
56.76
49.78
50
0
Category A
Category B
10% caries reduction
Category C
30% caries reduction
Category A, B, C
50% caries reduction
Figure 8: Cost-effectiveness of water fluoridation for those younger than
fifteen years for Category A, B and C municipalities and water boards at three
anticipated levels of caries reduction
___________________________________________________________________
Chapter 3
93
As expected a better cost-effectiveness is achieved when the estimated
caries reduction increases.
For the total population the average cost-
effectiveness for all water providers varies from R19.89 for a 50% caries
reduction to R99.47 for a 10% caries reduction.
For those younger than
fifteen the average cost- effectiveness varies from R62.60 (50% reduction) to
R313.00 (10% reduction).
When comparing different categories of water providers, it was slightly more
cost-effective to introduce water fluoridation for Category C compared to
Category A and B providers for the total population. The difference was larger
for those younger than fifteen in favour of Category C providers.
Cost-effectiveness varies from R7.31 (total population) and R20.93 (younger
than 15) for a 50% caries reduction for Amatola Water to R154.27
for
Nelspruit (total population) and R518.64 for Johannesburg (younger than 15)
for a 10% caries reduction.
3.3.4 Cost-benefit
Similar to cost-effectiveness, cost-benefit (the cost of implementing the
procedure divided by the savings in the cost of treatment) was also calculated
for an anticipated caries reduction of 10%, 30% and 50% as a result of the
introduction of water fluoridation.
Cost-benefit for the total population as well as for those younger than fifteen
years is presented in Table 27. Figure 9 and Figure 10 present the average
cost-benefit for Category A, B and C municipalities and water boards and well
as a combined average for Categories A, B and C water providers for the total
population and for those younger than fifteen years.
___________________________________________________________________
Chapter 3
94
Table 27 : Cost-benefit of water fluoridation
Municipality/ water board
Cape Town
Umgeni Water
Durban/Pietermaritzburg
combined
Durban
Rand Water
Johannesburg
Tshwane (Pretoria)
Category A Average
Total population
Estimated caries reduction
10%
30%
50%
Category A
0.06
0.10
0.29
0.06
0.10
0.29
0.15
0.26
0.77
Port Elizabeth
Amatola Water
Pietermaritzburg
Bloem Water
Bloemfontein
Kimberley
Category B Average
0.56
0.21
0.84
0.42
0.46
0.74
0.54
Buffalo City
(East London)
Botshabelo
Mafikeng
Nelspruit
Polokwane
Category C Average
Category A, B, C Average
0.24
0.14
0.24
0.12
0.20
0.16
0.27
0.14
0.24
0.12
0.20
Category B
0.11
0.19
0.04
0.07
0.17
0.28
0.08
0.14
0.09
0.15
0.15
0.25
0.11
0.18
Category C
0.05
0.08
0.21
0.41
0.90
0.74
0.50
0.55
0.07
0.14
0.30
0.25
0.17
0.18
0.72
0.60
0.80
0.71
0.60
0.04
0.08
0.18
0.15
0.10
0.11
Population < 15 years
Estimated caries reduction
10%
30%
50%
1.04
1.04
2.25
0.35
0.35
0.75
0.21
0.21
0.45
2.10
2.25
3.01
2.68
2.05
0.70
0.75
1.00
0.89
0.68
0.42
0.45
0.60
0.54
0.41
1.59
0.61
2.45
1.37
1.49
2.37
1.65
0.53
0.20
0.82
0.46
0.50
0.79
0.55
0.32
0.12
0.49
0.27
0.30
0.47
0.33
0.69
0.23
0.14
0.70
1.29
2.58
1.96
1.45
1.75
0.23
0.43
0.86
0.65
0.48
0.58
0.14
0.26
0.52
0.39
0.29
0.35
Similar to cost-effectiveness cost-benefit is more favourable when the
estimated caries reduction increases. For the total population the average
cost-benefit for all water providers varies from 0.11 at a 50% caries reduction
to 0.55 at a 10% caries reduction. For those younger than fifteen the average
cost-benefit varies from 0.35 (50% reduction) to 1.75 (10% reduction) for all
categories of water providers combined.
___________________________________________________________________
Chapter 3
95
0.7
0.6
0.6
0.55
0.54
0.5
Cost-benefit ratio
0.5
0.4
0.3
0.2
0.2
0.18
0.12
0.18
0.17
0.11
0.11
0.1
0.1
0.0
Category A
10% caries reduction
Category B
Category C
30% caries reduction
Category A, B, C
50% caries reduction
Figure 9: Cost-benefit of water fluoridation for the total population for
Category A, B and C municipalities and water boards at three anticipated
levels of caries reduction
2.1
2.05
1.8
1.75
1.65
Cost-benefit ratio
1.5
1.45
1.2
0.9
0.68
0.6
0.58
0.55
0.48
0.41
0.35
0.33
0.29
0.3
0.0
Category A
10% caries reduction
Category B
Category C
30% caries reduction
Category A, B, C
50% caries reduction
Figure 10: Cost-benefit of water fluoridation for those younger than fifteen
years for Category A, B and C municipalities and water boards at three
anticipated levels of caries reduction
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96
For the total population cost-benefit exceeded 0.80 for the following
municipalities/water boards (all at an estimated caries reduction of 10%):
•
Nelspruit:
0.90
•
Pietermaritzburg:
0.84
•
Johannesburg:
0.80
For those younger than fifteen cost-benefit exceeded 0.80 for the following
municipalities/water boards at an estimated caries reduction of 30%:
•
Johannesburg:
1.00
•
Tshwane (Pretoria):
0.89
•
Nelspruit:
0.86
•
Pietermaritzburg:
0.82
For those younger than fifteen years cost-benefit exceeded one at an
estimated caries reduction of 10% for all municipalities/water boards except:
•
Botshabelo:
0.70
•
Buffalo City:
0.69
•
Amatola Water:
0.61
For the total population cost-benefit did not vary much between different
categories of water providers at all estimated caries reduction levels.
3.4
Discussion
3.4.1 Introduction
Water fluoridation is generally regarded as one of the ten greatest public
health achievements in the 20th century (Centers for Disease Control and
Prevention, 1999). Before 1980 communities with fluoridated water supplies
typically experienced 50% less dental caries compared to non-fluoridated
communities (Ripa, 1993) during which time economic evaluations of water
fluoridation revealed this measure to be highly cost-effective.
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Since then caries has declined in both fluoridated and non-fluoridated
communities. Both the UK MRC (Medical Research Council, 2002) and
University of York reports (NHS Centre for Review and Dissemination, 2000)
into water fluoridation concluded that there is a need to extensively research
the economic impact of water fluoridation, especially in times of a trend of a
reduction in dental caries and exposure to other fluoride products. The 2003
World Oral Health Report confirmed the evidence that long-term exposure to
an optimal level of fluoride resulted in diminishing levels of caries in both
children and adults (Petersen, 2003).
Despite fluoride being available in
various delivery systems, only 20% of the world’s population benefited from
an appropriate exposure to fluoride (World Health Organization, 2006).
Caries prevalence for 12-year-old South African children declined from a
mean DMFT of 1.7 in the 1988/89 NOHS (Department of Health, 1994) to
1.05 in the 1999-2002 NCOHS (Department of Health, 2003b) which is very
low to low according to the WHO classification (Barmes, 1977).
The 1999-2002 NCOHS report recommended that the implementation of
water fluoridation be evaluated for South Africa taking into account current
caries levels and the cost of water fluoridation (Department of Health, 2003b).
Despite all this evidence in favour of water fluoridation and a Commission of
Inquiry into water fluoridation recommending the fluoridation of public water
supplies to the optimal fluoride concentration (Republic of South Africa, 1966),
no artificially fluoridated water scheme exists in South Africa. Regulations for
the introduction of water fluoridation in South Africa were promulgated on 8
September 2000 (Republic of South Africa, 2000) which compel water
providers to fluoridate public water supplies. These regulations were repealed
with the repealing of the Health Act of 1977 and have been amended and will
follow the normal legal process for approval (Smit, 2007).
Based on the principles of models described by White et al. (1989) and
Ringelberg et al. (1992), a model was developed to report on costeffectiveness and cost-benefit of water fluoridation for Gauteng (Van Wyk et
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98
al., 2001). This model served as the basis for this study to determine per
capita cost, cost-effectiveness and cost-benefit of the implementation of water
fluoridation for seventeen major metropolitan cities, towns and water boards
from all nine South African provinces.
3.4.2 Total and per capita cost of the introduction of water fluoridation
To determine the total cost of the introduction of water fluoridation, cost of
chemicals, labour and maintenance as well as opportunity cost and capital
depreciation was taken into account.
For all categories of water providers combined, the cost of chemicals
contributes 62.4% to the total cost (see Table 24, p 87). For the purpose of
this study, fluoride levels of community water supplies for all municipalities
and water boards was adjusted to 0.7 ppm which is in line with the
recommendation for the optimal fluoride concentration as published in the
regulations for the fluoridation of water supplies (Republic of South Africa,
2000).
It is therefore not surprising that for towns where the natural fluoride
concentrations in drinking water is higher compared to others (see Table 17, p
73), for example Polokwane (0.47 ppm), Bloemfontein and Bosthabelo (both
0.3 ppm), the contribution of the cost of chemicals is lower (see Table 24, p
87), whereas the cost of labour then increases accordingly.
In general the cost of labour for Category A water providers is much lower
(4.1%) compared to Category B (12%) and C (16.1%) providers.
Plant
operators are required to monitor the process of water fluoridation,
irrespective of the daily water purification rate. Whereas water purification
rate greatly influences the amount of chemical needed, it has less impact on
labour requirements.
Information on the annual salary and benefits of a plant superintendent as
well as the number of plant superintendents required to manage the
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99
fluoridation process varied greatly between water providers. To standardise
on the number of plant superintendents required per water purification plant,
guidelines were developed for this study based on the daily water purification
rate of each plant (see Section 3.2.2 a), p 75).
Operating cost is regarded as the cost of chemicals, labour and maintenance
combined.
For all category water providers combined, operating cost
contributes 75.1% to the total cost with little variation between Category A, B
and C providers (see Table 24, p 87).
Opportunity cost and capital
depreciation for all category water provides combined contribute 12.8% and
12.1% respectively to the total cost.
Total cost expressed as a per capita cost varies from R2.54 (Category A) to
R1.94 (Category B) and R1.62 (Category C) with an average of R2.08 for all
providers combined (See Table 25, p 90). The highest per capita cost is
R4.09 (Kimberley) and the lowest R0.82 (Amatola Water) and R0.86
(Polokwane).
Kimberley is classified as a Category B water provider, similar to
Bloemfontein. Bloemfontein however has more than double the population
compared to Kimberley (see Table 25, p 90), whereas the total cost of the
implementation of water fluoridation is slightly lower (R0.72 million) compared
to Kimberley (R0.91 million) (see Table 24, p 87). This will obviously impact
on the per capita cost for Kimberley (R4.09) compared to Bloemfontein
(R1.33).
Amatola Water could not provide information on the population served by
them and assumptions had to be made from the 2001 South African census
data (Statistics South Africa, 2003) which might still be an overestimation
leading to the low per capita cost of R0.82.
Polokwane has a high natural fluoride content (0.47 ppm) compared to the
other cities and towns included in this study. This will require much less
chemicals to increase the optimal fluoride level to 0.7 ppm. Since chemical
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100
cost is the major contributor to total cost in the majority of cities and towns, it
clearly impacts on the per capita cost resulting in a value of only R0.86.
Based on the information provided by municipalities and water boards,
populations from towns and cities included in this study represent 53% of the
total population of South Africa.
There can be no argument that water
fluoridation remains the cheapest fluoride vehicle to reach more than 50% of
the South African population.
Per capita cost of the implementation of water fluoridation was also expressed
for children younger than fifteen years, although it is well recognised that
water fluoridation benefits all ages.
The average per capita cost for all
category water providers for this cohort is R6.62.
Although the actual cost of water fluoridation cannot and should not be
ignored, estimates of saving in treatment cost may be more important than
per capita cost. Health economists at the conclusion of a 1989 workshop in
Michigan concluded that water fluoridation was one of only a few public health
measures where it actually saved more money than it cost to operate
(Anonymous, 1989).
Traditionally communities with populations as low as 1,000 have been
considered as unfavourable for the introduction of water fluoridation.
Birch
(1990) concluded that caries reduction as a result of water fluoridation in the
UK would cost four times as much in a low caries area compared to a high
caries area, suggesting that considerable economies of scale exist in terms of
the reduction in cost per unit of benefit as population size increases.
Technological advances are however resulting in new and more cost-effective
options in its delivery. Wright et al. (2001) still regarded water fluoridation as
cost-saving for New Zeeland communities of 1,000 residents or above. A
study in the Northern Territory of Australia concluded that an investment in
fluoridation plants for remote Indigenous Australian communities of
approximately 1,500 residents should lead to a substantial and significant
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101
improvement in oral health in the medium to long run (Ehsani and Bailie,
2007).
3.4.3 Cost-effectiveness
Cost-effectiveness expressed as the cost per person per year to save one
DMFT was calculated for an anticipated caries reduction of 10%, 30% and
50% as a result of the introduction of water fluoridation.
With low caries prevalence levels experienced in South Africa it would be
unrealistic to expect a 50% caries reduction with the introduction of water
fluoridation, similarly, if a caries reduction of only 10% is achieved, it will be
considered as disappointing.
It therefore seems appropriate to expect a
caries reduction of 30% with the introduction of water fluoridation.
At an anticipated caries reduction of 30%, it would cost R33.16 to save one
DMFT for all categories of water providers combined (see Table 26, p 92).
Cost-effectiveness is higher for Category A providers (R38.27) compared to
Category B (R30.86) and C (R28.75) providers.
The lowest values were
found for Amatola Water (R12.19), Botshabelo (R12.25), Buffalo City
(R13.92) and Cape Town (R16.75).
The highest values were found for
Nelspruit (R51.42), Pietermaritzburg (R48.23) and Johannesburg (R45.74).
An estimated decrease in DMFT per child per year, calculated from the DMFT
increment per year (see Table 14, p 68), linked to the per capita cost of
introducing water fluoridation, are determining variables to calculate costeffectiveness. DMFT values for 15-year-olds, as reported in the 1999-2002
NCOHS (Department of Health, 2003b) were used in this study (see Table 22,
p 84).
The combined effect of these two variables leading to the lower costeffectiveness values can clearly be seen for Cape Town (DMFT for 15-yearolds of 4.05) (see Table 22, p 84), Buffalo City, Amatola Water (both with a
DMFT value of 2.01), and Botshabelo (DMFT of 1.53). Per capita cost for the
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102
introduction of water fluoridation (see Table 25, p 90) is R2.26 for Cape Town,
R0.82 for Amatola Water, R0.93 for Buffalo City and R0.62 for Botshabelo.
The opposite is also true where a different combination of DMFT at age fifteen
and per capita cost led to the highest cost-effectiveness values for Nelspruit
(DMFT 2.25; R3.86), Pietermaritzburg (DMFT 1.26; R2.03) and Johannesburg
(DMFT 1.81; R2.76).
Despite higher cost-effective values for some cities and towns, the cost per
person per year to save one DMFT for all municipalities and water boards,
provided a caries reduction of at least 30% can be achieved as a result of the
introduction of water fluoridation, is way below the average cost of R172.73 to
restore a two surface restoration (see Table 23, p 86) (Council for Medical
Schemes, 2006).
3.4.4 Cost-benefit
Cost-effectiveness and cost-benefit analysis frequently overlap and are
sometimes difficult to distinguish. Similar to cost-effectiveness, cost-benefit
expressed as the cost of implementing the procedure divided by the savings
in the cost of treatment was also calculated for an anticipated caries reduction
of 10%, 30% and 50% as a result of the introduction of water fluoridation. As
explained in the previous section, only the results for an anticipated 30%
caries reduction will be discussed in detail.
Should the cost-benefit ratio
approach one or be larger than one, this measure should not be considered.
Water fluoridation is most effective in preventing dental caries on the
interproximal, buccal and lingual surfaces with limited effect on occlusal
surfaces (Abernathy et al., 1986).
For this study it was estimated that a
saving of one DMFT equalled the cost of a 2 surface restoration (White et al.,
1989). The cost to restore a two surface restoration (see Table 23, p 86) of
R172.73 was used to calculate cost-benefit (Council for Medical Schemes,
2006).
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At an anticipated caries reduction of 30%, the average cost-benefit for all
categories of water providers is 0.18 with little variation between the different
categories of water providers (see Table 27, p 95). The lowest values were
found for Amatola Water (0.07), Botshabelo (0.07) and Buffalo City (0.08) with
the cost-benefit for Cape Town and Umgeni Water (both Category A
providers) calculated as 0.1. The highest values were found for Nelspruit
(0.3), Pietermaritzburg (0.28) and Johannesburg (0.27).
Similar to cost-effectiveness an estimated decrease in DMFT per child per
year calculated from the DMFT increment per year (see Table 14, p 68),
linked to the per capita cost of introducing water fluoridation, are determining
variables to calculate cost-benefit. The same cities and towns with the lowest
and highest cost-effectiveness therefore also present with the lowest and
highest cost-benefit ratios.
Results from this study indicate that if an caries reduction of at least 30% can
be achieved through the introduction of water fluoridation, cost-benefit does
not exceed 0.3 for any municipality or water board.
Even at an anticipated caries reduction of 10%, the average cost-benefit for
all categories of water providers is 0.55 (see Table 27, p 95). Cost-benefit
only equals or exceeds 0.8 for Nelspruit (0.9), Pietermaritzburg (0.84) and
Johannesburg (0.8) at the 10% caries reduction level.
3.5
Summary
This chapter presented a model, results and discussion of the total and per
capita cost, cost-effectiveness and cost-benefit of the implementation of water
fluoridation for seventeen major metropolitan cities, towns and water boards
from all nine South African provinces.
The average per capita cost of water fluoridation for the total population is
R2.08. It ranges from R0.62 (Botshabelo), R0.82 (Amatola Water) and
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Chapter 3
104
R0.86 (Polokwane) at the lower end to R4.09 (Kimberley) and R3.86
(Nelspruit).
Per capita cost for the population younger than fifteen years ranges from
R2.04 (Botshabelo), R2.34 (Amatola Water) and R2.67 (Buffalo City) to
R10.43 (Johannesburg), R13.08 (Kimberley) and R11.11 (Nelspruit).
The
average per capita cost for all category water providers combined for this age
cohort is R6.62.
Cost-effectiveness (cost per person per year to save one DMFT) and costbenefit (the cost of implementing the procedure divided by the savings in the
cost of treatment) was calculated for anticipated caries reductions of 10%,
30% and 50% as a result of the introduction of water fluoridation. For the total
population average cost-effectiveness varies from R19.89 for a 50% caries
reduction to R99.47 for a 10% caries reduction. For the total population the
average cost-benefit varies from 0.11 for a 50% caries reduction to 0.55 for a
10% caries reduction.
Cost-benefit equals or exceeds 0.8 for only three
municipalities or water boards at an anticipated 10% caries reduction as a
result of the implementation of water fluoridation.
Chapter 4 will describe a model, results and discussion of the per capita cost
of delivering the minimum package of oral care to 4- to 15-year-old South
African children.
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105
CHAPTER 4: COST EVALUATION OF DELIVERING THE
MINIMUM PACKAGE OF ORAL CARE TO SOUTH AFRICAN
CHILDREN
4.1
Introduction
This chapter describes a model to express the delivery of the minimum
package of oral health care to 4- to 5-, 6-, 12 and 15-year-olds as a per capita
cost. The minimum package of oral care (see Table 13, p 64) consists of an
annual examination, bitewing radiographs, cleaning of teeth (prophylaxis), one
to three surface restorations, fissure sealants, emergency relief of pain and
infection control (Department of Health, 2001a; Pick et al., 2001).
4.2
A model to calculate the per capita cost of delivering the
minimum package of oral care
Since it is not possible to calculate the direct costs involved in delivering the
minimum package of oral care, this model converts treatment need data from
the 1999-2002 NCOHS (Department of Health, 2003b; Van Wyk et al., 2004)
to a per capita cost by applying the 2006 NRPL (Council for Medical
Schemes, 2006) and UPFS (Gauteng Provincial Government, 2005)
treatment fees. All calculations were done on a national level as well as for all
nine South African provinces.
Table 28 presents all the input variables used in the model. Each variable
has been allocated a unique number (in square brackets) which indicates
where it is used in the different formulas.
Microsoft Excel software was used to computerise this model. An example of
the model applied to the 15-year-old age cohort is presented in Annexure 3.
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Chapter 4
106
Table 28: A model to calculate per capita cost of delivering the minimum
package of oral care
Variable
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
Formula
Population size
Treatment need
Treatment fee
Monetary value for each treatment need type
Total expense to address treatment need
Total per capita cost to address treatment need
% of total cost for each treatment need type
Per capita cost of each treatment need type
[1] x [2] x [3]
[5] / [1]
[4] / [5] x 100
[6] x [7] / 100
4.2.1 Population size (Variable [1])
The 2006 South African mid-year population estimates by age and sex
(national and per province) were used in this study (Statistics South Africa,
2006).
Since these population estimates were published in five year age
intervals, the mean value for each age interval was used to calculate the
population estimates for the respective age cohorts.
Table 29 presents the population estimates for 4- to 5-, 6-, 12- and 15-yearolds as used in this study.
Table 29: 2006 South African mid-year population estimates by province
(Statistics South Africa, 2006)
Province
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
National
4- to 5-year-olds
182,980
38,600
312,260
119,940
440,360
348,300
167,900
151,180
273,800
2,035,320
6-year-olds
90,540
19,500
155,920
60,220
220,320
159,460
81,040
76,720
138,700
1,002,420
12-year-olds
84,440
18,280
180,340
60,840
227,620
139,080
79,420
74,700
153,240
1,017,960
15-year-olds
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
987,600
4.2.2 Treatment need (Variable [2])
Treatment need related to dental caries for children in the age groups 4 to 5,
6, 12 and 15 from the 1999-2002 NCOHS was presented as the percentage
of children and the mean number of teeth needing care. Periodontal diseases
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Chapter 4
107
was also included in this survey for 15-year-olds only. Although this was a
national oral survey, two of the provinces (Gauteng and Limpopo) conducted
their own surveys independent from the national survey (Department of
Health, 2003b).
Due to financial and human resource constraints the survey was only
executed in one of the regions of the Eastern Cape province. For various
reasons the survey was only conducted in two of the five regions of Gauteng
and in three of the five regions of the Northern Cape. No 4- to 5-year-old
children were included in the Northern Cape survey (Department of Health,
2003b).
Analysis of the data was conducted by STATOMET by combining the
datasets from all province. When access to the 1999-2002 NCOHS dataset
was requested for the purpose of this study, the datasets for Gauteng and
Limpopo could not be retrieved. Treatment need data for these two provinces
was therefore limited to those reported in the publications of the NCOHS
(Department of Health, 2003b).
For the purpose of this study a new mean weighted national value was
calculated from the data for those provinces for which this information was
available. This new mean weighted national value was then used for those
provinces where data could not be retrieved or was not available.
An
example of how this weighted national value was calculated is presented in
Table 30.
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Chapter 4
108
Table 30: Example of calculation of mean weighted national values
This example is for the percentage of 4- to 5-year-old children in need of care
A
B
C
Province
Population size
% needing care
Weighted value
Western Cape
155,005.60
73.2
11,346,409.92
1
Northern Cape
48.1
2
Eastern Cape
78,536.87
54.4
4,272,405.73
3
Free State
131,102.90
59.7
7,826,843.13
4
KwaZulu-Natal
406,712.90
43.7
17,773,353.73
5
Gauteng
43.0
6
North West
153,986.60
33.6
5,173,949.76
7
Mpumalanga
170,585.60
36.9
6,294,608.64
8
Limpopo
30.1
9
1,095,930.47
52,687,570.91
10
National
48.1
Notes:
• Values in Column A are the population sizes which were used by STATOMET to calculate the
original mean national weighted values
• Values in Column B for provinces were obtained from either NCOHS reports or the STATOMET
database (except those in the cells shaded grey – see later). For this example no data was
available for Northern Cape as 4- to 5-year-olds were not included in the survey for this province
• Values in Cells C1 to C9 for each province are calculated by applying the formula:
Population size (Column A) x Treatment need value (Column B)
• The value in Cell C10 represents the sum of the weighted values for all provinces (Cells C1 to C9)
• Value in Cell B10 is the mean national weighted value and is calculated by applying the formula:
Sum of weighted values (Cell C10) / National population size (Cell A10)
• This new mean national weighted value is used for those provinces where this information was
not available, in this example Northern Cape (indicated in shaded grey)
Table 31 presents data of the percentage of children in need of treatment and
Table 32 data of the mean number of teeth in need of treatment. The national
value was calculated as explained in Table 30. Where the mean national
value was used for provinces where this data was not available from the
STATOMET database or reports, it is indicated in shaded grey.
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Chapter 4
109
Table 31: Percentage treatment need for 4- to 5-, 6-, 12- and 15-year-olds for all
provinces
Province
Population
size
(STATOMET)
%
needing
care
Preventive care
Fissure
sealants
1 surface
restoration
2 or more
surface
restoration
Extraction
4- to 5-year-olds
Western
Cape
Northern
Cape
Eastern Cape
Free State
KwaZuluNatal
Gauteng
North West
Mpumalanga
Limpopo
National
Western
Cape
Northern
Cape
Eastern Cape
Free State
KwaZuluNatal
Gauteng
North West
Mpumalanga
Limpopo
National
Western
Cape
Northern
Cape
Eastern Cape
Free State
KwaZuluNatal
Gauteng
North West
Mpumalanga
Limpopo
National
155,005.6
73.2
8.8
21.9
29.5
35.3
31.4
48.1
10.2
7.3
22.7
16.7
19.8
78,536.9
131,102.9
54.4
59.7
23.7
4.6
0
7.0
33.1
34.2
13.8
15.0
22.4
28.7
406,712.9
43.7
12.6
7.7
15.7
12.6
21.6
1,095,930.5
43.0
33.6
36.9
30.1
48.1
10.2
7.3
6.7
3.2
6.7
0.5
10.2
7.3
10.2
7.3
6-year-olds
22.7
23.3
18.8
22.7
22.7
16.7
10.4
18.0
16.7
16.7
19.8
4.5
10.8
19.8
19.8
78,268.6
86.3
5.1
52.2
27.8
34.7
47.3
9,110.4
85.1
3.0
17.7
47.4
53.7
52.3
39,349.4
70,288.4
66.6
65.9
23.7
8.0
5.9
22.0
32.9
32.7
18.1
15.7
32.6
30.6
201,350.4
62.3
11.5
34.9
17.1
15.4
28.2
559,918.5
62.5
39.6
51.3
35.5
62.0
9.8
25.0
7.5
10.4
8.1
1.6
9.8
25.0
9.8
25.0
12-year-olds
24.5
21.9
28.1
24.5
24.5
20.1
15.4
22.8
20.1
20.1
28.0
10.2
18.9
28.0
28.0
78,834.5
80.5
3.9
47.9
37.9
20.2
19.6
9,297.2
57.4
2.0
5.1
30.3
22.2
18.3
28,105.7
62,643.6
38.5
58.2
0.9
14.3
3.4
27.9
22.5
28.7
11.5
8.1
16.9
14.2
148,347.1
52.3
8.6
31.6
18.2
11.3
12.1
61.6
29.8
39.2
14.1
51.5
8.1
9.7
7.9
8.1
8.1
23.8
9.1
3.3
23.8
23.8
23.4
16.7
20.2
23.4
23.4
11.1
5.0
8.3
11.1
11.1
12.4
4.1
9.9
12.4
12.4
153,986.6
170,585.6
77,224.1
84,327.3
75,559.6
70,972.5
473,760.2
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110
Table 31: (continued)
Province
Population
size
(STATOMET)
%
needing
care
Preventive care
Fissure
sealants
1 surface
restoration
2 or more
surface
restoration
Extraction
15-year-olds
Western
Cape
Northern
Cape
Eastern Cape
Free State
KwaZuluNatal
Gauteng
North West
Mpumalanga
Limpopo
National
73,851.9
85.2
3.3
42.2
56.6
26.6
26.2
6,702.3
62.2
2.0
4.6
39.6
31.5
23.5
27,872.0
58,373.1
49.7
66.6
7.2
3.8
1.7
26.0
34.0
43.0
9.1
12.3
16.0
11.7
265,310.4
59.0
10.8
22.7
25.0
13.2
12.2
47.1
31.3
44.9
24.1
57.7
9.2
12.3
12.4
9.2
9.2
20.4
8.3
4.0
20.4
20.4
31.7
20.8
30.8
31.7
31.7
13.8
6.9
11.1
13.8
13.8
12.6
3.7
7.1
12.6
12.6
71,518.1
64,747.6
568,375.3
Table 32: Treatment need per tooth for 4- to 5-, 6-, 12- and 15-year-olds for all
provinces
Province
Population
size
(STATOMET)
Mean no.
of teeth
needing
care
Preventive care
Fissure
sealants
1 surface
restoration
2 or more
surface
restoration
Extraction
4-to 5-year-olds
Western
Cape
Northern
Cape
Eastern Cape
Free State
KwaZuluNatal
Gauteng
North West
Mpumalanga
Limpopo
National
155,005.6
3.9
0.3
0.9
0.6
0.9
1.2
2.5
0.4
0.2
0.6
0.5
0.8
78,536.9
131,102.9
2.5
2.7
0.6
0.1
0
0.2
0.7
0.8
0.3
0.3
0.9
1.2
406,712.9
2.1
0.4
0.2
0.4
0.4
0.7
1.4
2.0
2.2
0.8
2.5
0.3
0.7
0.2
0.0
0.4
0.2
0.1
0.0
0.2
0.2
0.6
0.6
0.6
0.6
0.6
0.5
0.2
0.6
0.5
0.5
0.1
0.1
0.7
0.3
0.8
153,986.6
170,585.6
1,095,930.5
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Chapter 4
111
Table 32: (continued)
Province
Population
size
(STATOMET)
Mean no.
of teeth
needing
care
Preventive care
Fissure
sealants
1 surface
restoration
2 or more
surface
restoration
Extraction
6-year-olds
Western
Cape
Northern
Cape
Eastern Cape
Free State
KwaZuluNatal
Gauteng
North West
Mpumalanga
Limpopo
National
Western
Cape
Northern
Cape
Eastern Cape
Free State
KwaZuluNatal
Gauteng
North West
Mpumalanga
Limpopo
National
Western
Cape
Northern
Cape
Eastern Cape
Free State
KwaZuluNatal
Gauteng
North West
Mpumalanga
Limpopo
National
78,268.6
5.2
0.1
2.0
0.5
0.9
1.7
9,110.4
4.7
0.1
0.6
0.9
1.3
1.5
39,349.4
70,288.4
3.2
3.1
0.7
0.2
0.2
0.7
0.6
0.8
0.4
0.3
1.3
0.9
201,350.4
3.2
0.3
1.2
0.4
0.4
0.9
0.9
0.4
0.0
0.9
0.9
0.6
0.5
1.0
0.6
0.6
0.5
0.4
0.6
0.5
0.5
0.3
0.2
1.0
0.8
1.0
559,918.5
2.8
2.4
3.0
1.5
3.3
78,834.5
5.3
0.1
3.7
0.7
0.4
0.3
9,297.2
1.8
0.0
0.2
0.7
0.4
0.3
28,105.7
62,643.6
0.9
5.9
0.0
1.5
0.1
3.0
0.3
0.7
0.2
0.1
0.2
0.2
148,347.1
3.2
0.3
2.1
0.4
0.2
0.2
1.8
0.6
0.1
1.8
1.8
0.5
0.3
0.7
0.5
0.5
0.2
0.1
0.3
0.2
0.2
0.2
0.1
0.4
0.1
0.2
77,224.1
84,327.3
0.9
0.6
0.2
0.1
0.3
12-year-olds
473,760.2
4.0
2.1
1.8
0.4
3.4
73,851.9
6.2
0.1
3.4
1.6
0.5
0.5
6,702.3
2.8
0.0
0.1
1.3
0.7
0.4
27,872.0
58,373.1
2.2
4.6
1.1
0.4
0.0
2.2
0.6
1.3
0.1
0.3
0.3
0.2
265,310.4
3.7
0.4
1.5
0.6
0.3
0.2
2.7
2.6
1.9
0.8
3.7
1.6
1.4
0.3
0.1
0.5
1.5
0.5
0.1
1.5
1.5
0.8
0.4
0.9
0.8
0.8
0.3
0.1
0.3
0.3
0.3
0.1
0.1
0.1
0.3
0.2
75,559.6
70,972.5
71,518.1
64,747.6
568,375.3
3.3
1.0
0.2
0.1
0.5
15-year-olds
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Chapter 4
112
Periodontal disease for 15-year-old children in South Africa was determined in
the 1999-2002 NCOHS with the Community Periodontal Index (CPI) and was
reported as the percentage of sextants (prevalence) and the mean number of
sextants (severity) with the highest score being either healthy, bleeding,
calculus, shallow pockets or deep pockets (Department of Health, 2003b).
A study conducted in Kenya extrapolated findings from a survey of children
during which the Community Periodontal Index of Treatment Need (CPITN)
was used to the population to calculate human resources required to treat the
child population in Kenya (Manji and Sheiham, 1986). This study concluded
that the uses of CPITN data for human resources planning leads to excessive
and unrealistic requirements.
Fifteen years after the creation of the CPITN, a workshop was convened in
Manila, Philippines, to consider the strengths and weaknesses of this index. It
was recognised that the use of CPITN to determine treatment need led to
unrealistic requirements which cannot be met (Page and Morrison, 1994).
The conclusions of the workshop state that bleeding and calculus should be
reported separately from pocketing. When used for public health planning,
data must be expressed clearly and in such a way to enable the outcomes to
be evaluated.
This study recognises the limitations of the use of CPI data in health systems
planning. Results as found in this study should therefore be read in this light.
For the purpose of this study it was assumed that no periodontal care would
be required for the 4- to 5-year-old cohort. Since no data was available for
periodontal treatment need of 6- and 12-year-old children, the data for the 15year-olds was used for these two age cohorts as well.
Periodontal treatment need data as used in this study is presented in Table
33. The mean national value was used for Gauteng as periodontal disease
was not included in the survey for 15-year-olds for this province.
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Chapter 4
113
Table 33: Prevalence and severity of periodontal disease (bleeding and
calculus only) for 15-year-old South African children (Department of Health,
2003b)
Province
Weighted national mean
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Prevalence: percentage of
sextants
Bleeding
Calculus
Total
75.2
59.9
15.3
83.7
63.6
20.1
64.9
34.2
30.7
84.2
80.3
3.9
62.4
56.3
6.1
72.4
55.1
17.3
75.2
59.9
15.3
67.0
47.7
19.3
68.2
50.9
17.3
78.0
56.0
22.0
Severity: mean number of
sextants
Bleeding
Calculus
Total
3.31
2.17
1.14
3.27
1.84
1.43
2.3
0.85
1.45
2.88
2.62
0.26
3.95
2.96
0.99
3.57
2.23
1.34
3.31
2.17
1.14
2.57
1.47
1.1
1.97
1.22
0.75
4.41
2.43
1.98
Table 34 indicates whether the percentage of the population or the mean
number of teeth/sextants data were used in this study to convert the treatment
need to a per capita monetary value.
Table 34: Treatment need values used in this study
Oral health procedure
Oral examination
Two bitewing radiographs
Prophylaxis
Consultation
Preventive care
Dental sealants
One surface restoration
Two or more surface restoration
Extraction
Treatment need value used in calculations
Total population
Total population
Mean number of sextants with bleeding and calculus
% of population needing care
% of population in need
Mean number of teeth in need
Mean number of teeth in need
Mean number of teeth in need
Mean number of teeth in need
4.2.3 Treatment fees (Variable [3])
a)
The National Reference Price List (NRPL)
The NRPL is published annually by the Council for Medical Schemes and is
intended to serve as a baseline against which medical schemes and health
service providers can determine benefit levels or fees charged to patients
(Council for Medical Schemes, 2006).
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Chapter 4
114
The respective 2006 NRPL procedure descriptions, codes and fees used in
this study are presented in Table 36.
b)
The Uniform Patient Fee Schedule (UPFS)
The UPFS was developed by the Department of Health to provide a simpler
charging mechanism for publicly funded facilities and replaced the itemised
billing approach with a grouped fee approach with the intention to reduce the
amount of items that appear on bills but to still reflect the value of the service
being provided. It was adopted as policy by the Department of Health in
November 2000 and is updated on an annual basis (Department of Health,
2006b).
UPFS tariffs are determined by the procedure category, the type of facility
where the service is provided, the type of health professional delivering the
procedure and the patient classification which is based on income.
•
Procedure classification
All procedures linked to the provision of the minimum package of oral care
are classified as either category A or B procedures. The UPFS category
for the various oral health procedures used in this study related to the
corresponding NRPL code are presented in Table 36.
•
Facility classification
The UPFS classifies public facilities are either Level 1 (District Health or
Primary Health Centres), Level 2 (Regional or Community Health Centres)
or Level 3 (Special hospitals or Tertiary Health Centres).
For the purpose of this study it was assumed that the oral health services
provided as part of the minimum package of oral care would be delivered
from a Level 1 and Level 2 facility.
There is no difference in UPFS fees
between Level 1 and Level 2 facilities.
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Chapter 4
115
•
Health professional classification
UPFS categories of health care professionals for the delivery of oral health
service
include
General
Dental
Practitioners,
Specialist
Dental
Practitioners and Allied Health Practitioners which includes Oral Hygienists
and Dental Therapists.
For the purpose of this study it was assumed that the oral health services
provided as part of the minimum package of oral care would be delivered
by either a dentist, oral hygienist or dental therapist.
•
Patient classification
Patients are classified according to income and fees are charged
according to these categories:
HG en H0: Includes social pensioners and the formally unemployed. All
services are provided free with no facility or professional fees charged.
H1: Low income (<R36,000 per individual or <R50,000 per household per
year). Only a consultation fee is charged.
H2: Middle income (<R72,000 per individual or <R100,000 per household
per year). A consultation and procedure fee is charged.
HG: High income: (>R72,000 per individual or >R100,000 per household
per year). A consultation and procedure fee is charged.
For the purpose of this study results are only presented for the middle (H2)
and high income (HG) groups.
All tariffs (with the exception of anaesthesia) are divided into:
•
A facility fee which reflects the overhead costs of providing the
environment in which the health care service is delivered;
•
A professional fee which is structured to reflect the costs of health care
professionals delivering the service. These fees are charged whenever the
health care professional employed by the applicable provincial health
department provides the service; and
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Chapter 4
116
•
A consultation fee depending on the category of health care professional
providing the service.
The UPFS fees according to the procedure category (see Table 36), the oral
health professional delivering the service and the patient income category are
presented in Table 35 (Gauteng Provincial Government, 2005).
Table 35: UPFS oral health procedure and consultation fees for middle (H2)
and high (HG) income patients (Gauteng Provincial Government, 2005)
UPFS
Code
0910
0911
Procedure
Category
(see Table 36)
A
0914
0920
0921
0924
1010
1011
1014
B
Oral Health
Professional
Fee Type
Fee
(H2 / HG)
Oral health procedure fees
Facility
R5.00 / R14.00
Dentist
R10.00 / R24.00
Professional
Oral Hygienist/
R10.00 / R19.00
Dental Therapist
Facility
R20.00 / R43.00
Dentist
R25.00 / R47.00
Professional
Oral Hygienist/
R20.00 / R38.00
Dental Therapist
Consultation fees
Facility
R30.00 / R46.00
Dentist
R35.00 / R51.00
Professional
Oral Hygienist/
R20.00 / R31.00
Dental Therapist
Combined
facility/professional
fee for a Level 1 or 2
facility (H2 / HG)
R15.00 / R38.00
R15.00 / R33.00
R45.00 / R90.00
R40.00 / R81.00
R65.00 / R97.00
R50.00 / R77.00
The UPFS category for the various oral health procedures used in this study
related to the corresponding NRPL code as well as the fee and the
appropriate oral health professional responsible for delivering the procedure
are presented in Table 36.
For the purpose of this study an average NRPL fee calculated from the codes
for a one surface restoration of R138.60 and for a two or more surface
restoration of R202.99 were used in this model.
Similarly for the UPFS an average consultation fee of R57.50 for H2 and
R87.00 for HG income categories was calculated from the consultation fees
for an oral hygienist/dental therapist and a dentist.
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Chapter 4
117
Table 36: NRPL and UPFS fees used in this study
NRPL
Procedure description
Code
Fee
UPFS
Code
(see
Table 35)
Consultation
1014
Consultation
Average consultation fee
(1014, 1011)
1011
Oral examination - GDP
Category
Oral hygienist/
Dental Therapist
Dentist
8101
R103.50
0924
B
8112
R41.90
0914
A
8159
R124.90
0924
B
8161
R63.60
0924
B
Dental sealant
8163
R41.90
0914
A
Amalgam - one surface
Resin - one surface,
anterior
Resin - one surface,
posterior
Average one surface
restoration fee (Codes
8341, 8351, 8367)
Amalgam - two surfaces
Amalgam - three
surfaces
Amalgam - four or more
surfaces
Resin - two surfaces,
anterior
Resin - three surfaces,
anterior
Resin - four or more
surfaces, anterior
Resin - two surfaces,
posterior
Resin - three surfaces,
posterior
Resin - four or more
surfaces, posterior
Average two or more
surface restoration fee
(Codes 8342-8344,
8351-8354, 8368-8370)
Extraction - tooth or
exposed tooth roots
(first per quadrant)
8341
R126.50
B
8351
R138.80
B
8367
R150.50
B
Intra-oral radiograph bitewing
Prophylaxis - complete
dentition
Topical application of
fluoride - child
R138.60
0921
B
8342
R155.90
B
8343
R190.00
B
8344
R211.80
B
8352
R174.60
B
8353
R208.70
B
8354
R232.70
B
8368
R186.20
B
8369
R225.00
B
8370
R242.00
B
8201
Oral health
professional
R202.99
0921
B
R63.60
0921
B
Oral hygienist/
Dental Therapist
Oral hygienist/
Dental Therapist
Oral hygienist/
Dental Therapist
Oral hygienist/
Dental Therapist
Oral hygienist/
Dental Therapist
Dentist
Fee (see Table 35)
Middle
High
income
income
(H2)
(HG)
R50.00
R77.00
R65.00
R97.00
R57.50
R87.00
R40.00
R81.00
R15.00
R33.00
R40.00
R81.00
R40.00
R81.00
R15.00
R33.00
R45.00
R90.00
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Chapter 4
118
A summary of the treatment need variable (percentage or mean number of
teeth/sextants) and the respective NRPL and UPFS code and fees used in
this study to determine per capita cost of delivering the minimum package of
oral care are presented in Table 37.
Table 37: Summary of treatment need variables and NRPL/UPFS codes and
fees used in this study
Oral health
procedure
Oral examination
Two bitewing
radiographs
Prophylaxis
Consultation
Preventive care
Dental sealants
One surface
restoration
Two or more
surface restoration
Extraction
Treatment need value
used in calculations
(See Table 34)
Total population
NRPL code
(See Table 36)
UPFS code (H2/HG)
(See Table 36)
8101: R103.50
0924: R40.00/R81.00
Total population
8112: R41.90
0914: R15.00/R33.00
Mean no. of sextants
8159: R124.90
0924: R40.00/R81.00
Average UPFS
consultation fee:
R57.50/ R87.00
0924: R40.00/R81.00
0914: R15.00/R33.00
% of population in need of
care
% of population
Mean no. of teeth
Mean no. of teeth
Mean no. of teeth
Mean no. of teeth
8161: R63.60
8163: R41.90
Average 1 surface
restoration fee: R138.60
Average 2 or more surface
restoration fee: R202.99
8201: R63.60
0921: R45.00/R90.00
0921: R45.00/R90.00
0921: R45.00/R90.00
Since UPFS fees are identical for an oral hygienist/dental therapist, it was
assumed that both will be responsible for the oral examination, bitewing
radiographs, prophylaxis, fluoride treatment and placement of fissure sealants
while a dentist will be responsible for the restorative procedures and
extractions.
A prophylaxis was not included in the calculations for the 4- to 5-year-old
cohort as it was assumed that this age cohort would not be in need of this
treatment.
4.2.4 Monetary value for each treatment need type (Variable [4])
The formula applied to convert each of the treatment need types to a
monetary value was:
Population size x Treatment need x Treatment fee
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Chapter 4
119
4.2.5 Total expense to address treatment need (Variable [5])
This was calculated by adding all the monetary values for each treatment
need type.
4.2.6 Total per capita cost to address treatment need (Variable [6])
This was calculated by applying the formula:
Total expense to address treatment need / Population size
4.2.7 Percentage of total cost for each treatment need type (Variable [7])
The monetary value for each treatment need type was expressed as a
percentage of the total expense to address treatment need by applying the
formula:
Monetary value for each treatment need type / Total expense to address
treatment need x 100
4.2.8 Per capita cost of each treatment need type (Variable [8])
The monetary value for each treatment need type was converted to a per
capita cost by applying the formula:
Total per capita cost to address treatment need x % of total cost for each
treatment need type
4.3
Results
Per capita cost of delivering the minimum package of oral care per province
and on a national level, based on treatment need and the NRPL and UPFS
fees for middle and high income earners as explained in the previous section,
were calculated for 4- to 5-, 6-, 12- and 15-year olds.
Assuming caries reductions of 10%, 30% and 50% as a result of the
implementation of water fluoridation, treatment need expressed as a
percentage of the population or the mean number of teeth in need of
treatment (see Table 31, p 110 and Table 32, p 111) were adjusted
___________________________________________________________________
Chapter 4
120
accordingly. Per capita cost of delivering the minimum package of oral care
was calculated based on these reduced treatment needs to determine the
impact of the introduction of water fluoridation.
For all calculations the cost of an oral examination and two bitewing
radiographs was calculated for the total population and therefore remains
unchanged as this would not be affected by a reduction in dental caries as a
result of the implementation of water fluoridation.
The mean number of
sextants in need of a scaling (bleeding and calculus) also remain unchanged
as this is not affected by the implementation of water fluoridation either.
Treatment need types were grouped as follows and the contribution of each
group in terms of cost and the percentage of the total per capita cost was
expressed accordingly:
•
Examination and bitewing radiographs;
•
Prophylaxis;
•
Topical fluoride application and fissure sealants; and
•
One surface restorations, two or more surface restorations and
extractions.
Table 38 presents the per capita cost on a national level to deliver the
minimum package of oral care to each of the age cohorts included in this
study. The average per capita cost was calculated from the NRPL, UPFS
(H2) and UPFS (HG) calculations in equal weightings.
It is clear from Table 38 that the cost of providing each child with an oral
examination and two bitewing radiographs accounts for between 30 to 40% of
the total cost of providing the minimum package of oral care to all age
cohorts, irrespective whether the NRPL, UPFS (H2) or UPFS (HG) fee
schedule is used for the calculations.
___________________________________________________________________
Chapter 4
121
Table 38: National per capita cost of delivering the minimum package of oral
care by age cohort
Treatment need group
UPFS consultation
Examination/bitewings
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
UPFS consultation
Examination/bitewings
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
UPFS consultation
Examination/bitewings
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
UPFS consultation
Examination/bitewings
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
NHRPL
UPFS (H2)
%
Cost
%
Cost
4-5-year-olds
R27.64
14.9
R70.00
R187.30 37.6
44.2
R7.70
4.1
R16.61
3.9
R80.63
R220.03 43.4
51.9
R423.94
R185.97
6-year-olds
R35.65
14.5
R70.00
R187.30 28.5
33.0
R30.08
R93.92 12.2
16.5
R17.07
6.9
R42.96
7.6
R92.90
R243.95 37.8
42.9
R568.13
R245.70
12-year-olds
R29.61
14.5
R70.00
R187.30 34.4
38.1
R30.08
R93.92 14.8
19.1
R29.64
R78.92 14.6
16.0
R44.21
R131.87 21.7
26.8
R492.01
R203.54
15-year-olds
R33.16
15.1
R70.00
R187.30 31.9
34.8
R30.08
R93.92 13.7
17.4
R25.82
R67.69 11.8
12.6
R60.37
R189.35 27.5
35.2
R538.27
R219.43
UPFS (HG)
%
Cost
Average
%
Cost
11.4
40.1
4.4
44.0
R41.83
R147.00
R16.22
R161.25
R366.30
8.8
40.7
4.2
46.4
R23.16
R134.77
R13.51
R153.97
R325.40
11.1
30.3
12.6
7.6
38.3
R53.93
R147.00
R60.91
R36.87
R185.80
R484.52
8.5
30.6
13.8
7.4
39.7
R29.86
R134.77
R61.64
R32.30
R174.22
R432.78
11.0
36.2
15.0
15.9
21.8
R44.81
R147.00
R60.91
R64.64
R88.42
R405.78
8.5
36.2
16.3
15.5
23.4
R24.81
R134.77
R61.64
R57.73
R88.17
R367.11
11.5
33.8
14.0
12.9
27.8
R50.18
R147.00
R60.91
R56.15
R120.74
R434.98
8.9
33.5
15.1
12.4
30.1
R27.78
R134.77
R61.64
R49.88
R123.49
R397.56
Table 39 presents the average per capita cost for the NRPL, UPFS (H2) and
UPFS (HG) fee schedules combined without the impact of water fluoridation
and assuming an estimated caries reduction of 10%, 30% and 50% after its
introduction.
As would be expected the average per capita cost for delivering the minimum
package of oral care reduces as the anticipated caries reduction expected
with water fluoridation increases. Since water fluoridation does not influence
the cost of an oral examination, two bitewing radiographs and a prophylaxis,
the reduction in per capita cost is less than would be expected as these
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Chapter 4
122
procedures (including the UPFS consultation) contribute almost 60% to the
total per capita cost.
Table 39: Impact of water fluoridation on the average national per capita cost
of delivering the minimum package of oral care (including examination and
bitewing radiographs)
Treatment need group
UPFS consultation
Examination/bitewings
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
UPFS consultation
Examination/bitewings
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
UPFS consultation
Examination/bitewings
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
UPFS consultation
Examination/bitewings
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
No water
Estimated caries reduction with water fluoridation
fluoridation
10%
30%
50%
%
Cost
%
Cost
%
Cost
%
Cost
4-5-year-olds
R11.58
R16.21 6.3
R20.84 7.5
R23.16 8.4
8.8
R134.77
R134.77 57.8
R134.77 49.4
40.7 R134.77 43.2
R6.76
R9.46 3.0
R12.16 3.5
R13.51 4.0
4.2
R76.98
R107.78 33.0
R138.57 39.5
46.4 R153.97 44.4
R325.40
R306.34
R268.21
R230.09
6-year-olds
R14.93
R20.90 6.0
R26.87 7.3
R29.86 8.2
8.5
R134.77
R134.77 42.4
R134.77 36.7
30.6 R134.77 32.4
R61.64
R61.64 19.0
R61.64 16.5
R61.64 14.6
13.8
R16.15
R22.61 5.1
R29.07 6.2
R32.30 7.0
7.4
R87.11
R121.95 27.5
R156.80 33.3
39.7 R174.22 37.8
R432.78
R409.14
R361.87
R314.59
12-year-olds
R12.40
R17.37 5.7
R22.33 7.0
R24.81 8.1
8.5
R134.77
R134.77 47.5
R134.77 42.2
36.2 R134.77 38.0
R61.64
R61.64 21.3
R61.64 19.0
R61.64 17.1
16.3
R28.87
R40.41 10.2
R51.96 12.7
R57.73 14.7
15.5
R44.08
R61.72 15.3
R79.35 19.1
R88.17 22.1
23.4
R367.11
R350.04
R315.90
R281.76
15-year-olds
R13.89
R19.45 6.1
R25.00 7.4
R27.78 8.4
8.9
R134.77
R134.77 45.1
R134.77 39.6
33.5 R134.77 35.3
R61.64
R61.64 20.2
R61.64 17.8
R61.64 15.9
15.1
R24.94
R34.92 8.4
R44.90 10.3
R49.88 11.8
12.4
R61.74
R86.44 20.3
R111.14 24.9
30.1 R123.49 28.6
R397.56
R377.44
R337.21
R296.98
Table 40 presents the national average per capita cost without water
fluoridation and assuming a 10%, 30% and 50% caries reduction after the
introduction of water fluoridation, but excluding an oral examination and two
bitewing radiographs as part of the calculations.
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Chapter 4
123
Table 40: Impact of water fluoridation on the average national per capita cost
of delivering the minimum package of oral care (excluding examination and
bitewing radiographs)
Treatment need group
UPFS consultation
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
No water
Estimated caries reduction with water fluoridation
fluoridation
10%
30%
50%
%
Cost
%
Cost
%
Cost
%
Cost
4-5-year-olds
R11.58
R16.21 14.3
R20.84 14.3
R23.16 14.3
14.3
7.0
78.7
UPFS consultation
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
12.1
19.9
10.6
57.3
UPFS consultation
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
13.2
25.6
24.4
36.9
UPFS consultation
Prophylaxis
Topical fluoride/Fissure sealant
Restorative/Extraction
Total
13.2
22.7
18.7
45.4
R12.16
R13.51 7.0
R138.57
R153.97 78.7
R190.64
R171.57
6-year-olds
R26.87
R29.86 11.9
R61.64
R61.64 21.7
R29.07
R32.30 10.4
R156.80
R174.22 56.1
R298.01
R274.38
12-year-olds
R22.33
R24.81 12.8
R61.64
R61.64 27.7
R51.96
R57.73 23.7
R79.35
R88.17 35.8
R232.35
R215.28
15-year-olds
R25.00
R27.78 12.9
R61.64
R61.64 24.6
R44.90
R49.88 18.2
R111.14
R123.49 44.3
R262.79
R242.68
7.0
78.7
R9.46
R107.78
R133.45
7.0
78.7
R6.76
R76.98
R95.32
11.2
26.2
9.8
52.8
R20.90
R61.64
R22.61
R121.95
R227.10
10.3
33.1
8.9
47.7
R14.93
R61.64
R16.15
R87.11
R179.83
12.0
32.9
21.9
33.2
R17.37
R61.64
R40.41
R61.72
R181.13
10.7
40.7
19.4
29.3
R12.40
R61.64
R28.87
R44.08
R146.99
12.1
29.5
17.0
41.3
R19.45
R61.64
R34.92
R86.44
R202.45
11.0
36.9
15.2
36.9
R13.89
R61.64
R24.94
R61.74
R162.21
When the cost of an oral examination and two bitewing radiographs are not
taken into consideration, reductions in per capita cost for delivering the
minimum package of oral care are much greater as the anticipated caries
reduction due to water fluoridation increases.
To illustrate this better, Table 41 summarises the average per capita cost from
Table 39 and Table 40 for all age cohorts, with and without an oral
examination and two bitewing radiographs and with and without the
anticipated effect of water fluoridation.
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Chapter 4
124
Table 41: Impact of an oral examination and bitewing radiographs on the
average national per capita cost of delivering the minimum package of oral
care
4-5-year-olds 6-year-olds
No water fluoridation
12-year-olds
15-year-olds
Examination/2 x bitewings
R325.40
R432.78
R367.11
included
Examination/2 x bitewings
R190.64
R298.01
R232.35
excluded
% difference
41.4
31.1
36.7
Anticipated 10% caries reduction due to water fluoridation
Examination/2 x bitewings
R306.34
R409.14
R350.04
included
Examination/2 x bitewings
R171.57
R274.38
R215.28
excluded
% difference
44.0
32.9
38.5
Anticipated 30% caries reduction due to water fluoridation
Examination/2 x bitewings
R268.21
R361.87
R315.90
included
Examination/2 x bitewings
R133.45
R227.10
R181.13
excluded
% difference
50.2
37.2
42.7
Anticipated 50% caries reduction due to water fluoridation
Examination/2 x bitewings
R230.09
R314.59
R281.76
included
Examination/2 x bitewings
R95.32
R179.83
R146.99
excluded
% difference
58.6
42.8
47.8
R397.56
R262.79
33.9
R377.44
R242.68
35.7
R337.21
R202.45
40.0
R296.98
R162.21
45.4
When the average per capita cost for an oral examination and two bitewing
radiographs are deducted from the average per capita cost for the delivery of
the minimum package of oral care where this was included for every child, the
percentage difference ranges from 31.1% to 58.6%. As would be expected
this difference increases for all age cohorts as the anticipated caries reduction
as a results of water fluoridation increases.
Table 42 presents the average per capita cost of delivering the minimum
package of oral care per province as calculated from the average per capita
cost for all age cohorts in equal weightings, with and without the estimated
caries reduction as a result of the implementation of water fluoridation and
with and without an oral examination and two bitewing radiographs.
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Chapter 4
125
Table 42: Mean per capita cost of delivering the minimum package of oral care
per province
Province
No water
fluoridation
Ex / BW
included
Ex / BW
excluded
Estimated caries reduction with water fluoridation
10%
30%
50%
Ex / BW
included
Ex / BW
excluded
Ex / BW
included
Ex / BW
excluded
Ex / BW
included
Ex / BW
excluded
R245.95 R360.74
R380.71
National
R385.49 R486.85
R520.25
Western Cape
R290.84 R400.52
Northern Cape R425.61
R210.62 R329.50
R345.39
Eastern Cape
R271.67 R383.10
R406.43
Free State
R224.25 R341.05
KwaZulu-Natal R359.02
R214.17 R332.14
R348.94
Gauteng
R148.06 R272.14
R282.83
North West
R233.67 R349.26
R368.43
Mpumalanga
R221.66 R339.06
R356.43
Limpopo
Note: Ex = Examination; BW = Bitewings
R225.98
R352.08
R265.75
R194.74
R248.34
R206.28
R197.38
R137.38
R214.49
R204.29
R320.80
R420.04
R350.33
R297.73
R336.44
R305.10
R298.56
R250.77
R310.91
R304.32
R186.03
R285.28
R215.56
R162.97
R201.68
R170.33
R163.79
R116.00
R176.14
R169.55
R280.85
R353.24
R300.14
R265.96
R289.78
R269.15
R264.97
R229.39
R272.56
R269.57
R146.09
R218.47
R165.37
R131.19
R155.01
R134.38
R130.20
R94.63
R137.80
R134.81
Irrespective of whether an examination and bitewings are included or
excluded from the calculations and irrespective of the anticipated impact of
the introduction of water fluoridation, the minimum package of oral care
expressed as a per capita cost is the lowest for North West, Gauteng and the
Eastern Cape and the highest for the Free State, Northern Cape and Western
Cape.
On a national level, when an oral examination and bitewings are included, the
per capita cost ranges from R280.85 at an anticipated 50% caries reduction
due to water fluoridation to R380.71 with no water fluoridation.
When the
examination and bitewings are excluded, per capita cost ranges from
R146.09 (50% caries reduction due to water fluoridation) to R245.95 (no
water fluoridation).
4.4
Discussion
4.4.1 Introduction
In line with the adoption of the principles of PHC at Alma Ata in 1978 (World
Health Organization, 1978), followed by the formulation of the action areas of
health promotion as part of the Ottawa Charter (World Health Organization,
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Chapter 4
126
1986), the White Paper for the Transformation of Health Services in South
Africa was formulated to meet the basic needs of the population. Adoption of
the PHC approach and reducing the incidence of common oral diseases
through a minimum package of care, water fluoridation, and reduction of the
consumption of refined sugar have been identified as the two main principles
to address oral health (Republic of South Africa, 1997b).
A package of PHC services was agreed upon in 2000 (Pick et al., 2001) and
has been published in separate documents (Department of Health, 2001a;
Department of Health, 2001b).
For oral health it consists of an oral
examination and charting of dental status, intra-oral radiographs, scaling and
polishing of teeth, promotive and preventive oral health services, basic
curative services, emergency relief of pain and sepsis (including dental
extractions), simple one to three surface restorations, treatment of traumatic
injuries to teeth and treatment of post-extraction bleeding.
The South African National Oral Health Strategy (Department of Health, 2005)
listed the provision of appropriate disease prevention and health promotion
measures based on the minimum package of oral care on a district level.
For this study a model was developed to express the delivery of the minimum
package of oral health care to 4- to 5-, 6-, 12- and 15-year-olds based on
treatment need data from the 1999-2002 NCOHS (Department of Health,
2003b; Van Wyk et al., 2004) as a per capita cost by applying the 2006 NRPL
(Council for Medical Schemes, 2006) and UPFS (Gauteng Provincial
Government, 2005) treatment fees on a national level as well as for all nine
South African provinces.
To illustrate the possible impact of the implementation of water fluoridation on
the cost of delivering the minimum package or oral care, treatment need,
expressed as a percentage of the population or the mean number of teeth in
need of treatment (see Table 31, p 110 and Table 32, p 111), was adjusted
accordingly based on assumed caries reductions of 10%, 30% and 50%.
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Chapter 4
127
4.4.2 Per capita cost of delivering the minimum package or oral care to South
African children
Per capita cost was calculated based on a high income (NRPL and UPFS
(HG) tariffs) and a middle income (UPFS (H2) tariffs) scenario. Treatment
need types were grouped as follows:
•
Examination and bitewing radiographs;
•
Prophylaxis;
•
Topical fluoride application and fissure sealants; and
•
One surface restorations, two or more surface restorations and
extractions.
The contribution of each group in terms of cost and the percentage of the total
per capita cost were calculated.
The cost of an oral examination and two bitewing radiographs was calculated
for the total population and therefore would not be affected by a reduction in
dental caries as a result of the implementation of water fluoridation. The cost
of providing each child with an oral examination and two bitewing radiographs
accounts for between 30 to 40% of the total cost of providing the minimum
package of oral care to all age cohorts, irrespective of whether the NRPL,
UPFS (H2) or UPFS (HG) fee schedule are used for the calculations (see
Table 38, p 122).
For this reason this section will only deal with the per capita cost of a
prophylaxis and those treatment needs affected by a 30% reduction in caries
as a result of the introduction of water fluoridation. An average cost was
calculated for the NRPL, UPFS (H2) and UPFS (HG) tariffs in equal
weightings.
On an national level per capita cost of delivering the minimum package of oral
care (excluding the oral examination and bitewing radiographs), without the
impact of water fluoridation, varies from R190.64 (4- to 5-year-olds) to
R298.01 for 6-year-olds, R232.35 for 12-year-olds and R262.79 for 15-yearolds (see Table 40, p 124).
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Chapter 4
128
At an anticipated caries reduction of 30% as a results of the introduction of
water fluoridation, per capita cost decreases to R133.45 for 4- to 5-year-olds,
R227.10 for 6-year-olds, R181.13 for 12-year-olds and R202.45 for 15-yearolds (see Table 40, p 124). This represents a respective percentage cost
reduction of 30%, 23.8%, 22% and 23% for the four age cohorts included in
this study.
An explanation why a 30% caries reduction is not seen across all age groups
is that the per capita cost of a prophylaxis remains unaffected by a caries
reduction as a result of water fluoridation, yet it is still included in the per
capita cost as this procedure is considered to be part of the minimum package
of oral care. Prophylaxis was not considered as a treatment option for the 4to 5-year-old age cohort.
On a provincial level the per capita cost for delivering the minimum package
of oral care (without fluoridation versus 30% caries reduction due to water
fluoridation) for all age groups combined (oral examination and bitewing
radiographs excluded) was the lowest for North West (R148.06 versus
R116.00),
Eastern
Cape
(R210.62
versus
R162.97)
and
Gauteng
(R214.17 versus R163.79) and the highest for the Free State (R271.67 versus
R201.68), Northern Cape (R290.84 versus R215.56) and Western Cape
(R385.49 versus R285.28) (see Table 42, p 126).
The variation in per capita cost between provinces is mainly due to the large
variation in treatment needs (see Table 31, p 110 and Table 32, p 111).
Reports on the 1999-2002 NCOHS highlight the higher caries prevalence in
provinces such as the Western and Northern Cape with North West province
recording some of the lowest caries prevalence rates (Department of Health,
2003b; Van Wyk et al., 2004). This is reflected in higher treatment needs for
the Western and Northern Cape as well.
The greatest treatment need was recorded for the Western Cape where
almost 80% of children need care. For all provinces preventive care and
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Chapter 4
129
restorations were the most common forms of treatment required with the need
for restorations higher than the need for extractions for all age cohorts.
4.5
Summary
This chapter described a model, results and discussion to determine the per
capita cost of delivering the minimum package of oral care to 4- to 5-, 6-, 12and 15-year-old South African children based on treatment need from the
1999-2002 NCOHS (Department of Health, 2003b; Van Wyk et al., 2004) by
using the 2006 NRPL (Council for Medical Schemes, 2006) and UPFS
(Gauteng Provincial Government, 2005) treatment fees.
The inclusion of an oral examination and two bitewing radiographs for every
child accounts for between 30 to 40% of the total cost of providing the
minimum package or oral care.
Without the possible effect of water
fluoridation taken into consideration, the average national per capita cost for
4- to 5-, 6-, 12- and 15-year-olds (NRPL, UPFS (H2) and UPFS (HG)) is
R380.71 when the oral examination and bitewing radiographs are included
compared to R245.95 when the examination and bitewings are excluded from
the calculations.
Chapter 5 will describe two models, results and discussion of the oral health
human resources required for the implementation of the minimum package of
oral care to 4- to 15-year-old children, taking into account different scenarios
for caries reduction achieved through water fluoridation.
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Chapter 4
130
CHAPTER 5: ORAL HEALTH HUMAN RESOURCES NEEDS
FOR SOUTH AFRICAN CHILDREN
5.1
Introduction
The four approaches to human resources planning (human resources to
population ratios, health needs, health demands and service targets) (Hall,
1978) and the WHO/FDI human resources planning model (World Health
Organization/Fédération Dentaire Internationale, 1989) were reviewed in
Chapter 2.
This chapter describes two models to calculate oral health human resources
required for the delivery of the minimum package of oral care to 4- to 15-yearold children. These models are:
•
The
WHO/FDI
human
resources
planning
model
(World
Health
Organization/Fédération Dentaire Internationale, 1989); and
•
A “Service Targets Method” model.
For the purpose of this study both approaches assume that the public oral
health services would not be responsible for delivering the minimum package
of oral care to children older than fifteen.
5.2
World Health Organization/Fédération Dentaire Internationale
human resources planning model
This model is based on the needs and demands of a population. It places a
much bigger emphasis on the prevention and control of disease, maintenance
of health and high quality restorative care and also provides for modifying
factors. The WHO/FDI model translates need into FTE of oral health human
resources required to provide a calculated level of care.
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Chapter 5
131
The WHO/FDI model was used in two previous South African studies to
determine human resources needed for delivering primary preventive services
(Booyens, 1994) and to develop a human resources plan for oral health care
for the province of KwaZulu-Natal (Kissoon-Singh, 2001). The results of both
these studies were reviewed in Chapter 2.
The WHO/FDI model calculates human resources for the 0- to 14-, 15- to 29-,
30- to 64- and 65- to 79-year-old age cohorts. Based on the assumption that
the public oral health services would not be responsible for delivering the
minimum package of oral care to children older than fifteen, the WHO/FDI
model was adapted to calculate oral health human resources requirements for
the 4- to 15-year-old age cohort only.
The input variables to calculate human resources required with the WHO/FDI
model to deliver the minimum package or oral care to the 4- to 5- (primary
dentition) and 6- to 15-year-old (mixed/permanent dentition) age cohorts are
presented in Table 43. Each variable has been allocated a unique number (in
a square bracket) which indicates where it is used in the different formulas.
Variables have been grouped as follows:
(A)
Restorative Care, arresting care and extractions
(B)
Treatment time requirements
(C)
Human resources requirements
All predetermined values used in this model are based on those for a country
with stable caries levels (World Health Organization/Fédération Dentaire
Internationale, 1989).
Microsoft Excel software was used to computerise the WHO/FDI model. An
example of the model applied on a national level is presented in Annexure 4.
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Chapter 5
132
Table 43: The WHO/FDI model to calculate human resources required to
deliver
the
minimum
package
of
oral
care
(World
Health
Organization/Fédération Dentaire Internationale, 1989)
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
Variable
Formula
(A) RESTORATIVE CARE, ARRESTING CARE AND EXTRACTIONS
Number of age intervals
Predicted dmft or DMFT
Predicted dt or DT
Predicted mt or MT
Predicted ft or FT
Restoration fraction
New fillings : Teeth (NFT)
[6] x [2]
Mean replacement period in years for a restoration
Replacement fillings : Teeth (RFT)
([1] x [7]) / (2 x [8])
Ratio Surfaces / Teeth
Sealants, arresting care and remineralisation
(1 - [6]) x [2]
New fillings : Surfaces (NFS)
[7] x [10]
Replacement fillings : Surfaces (RFS)
[9] x [10]
Extraction
[4]
(B) TREATMENT TIME REQUIREMENTS
Number of Group Preventive Care sessions
Time per Group Preventive Care session
Group Preventive Care (minutes)
[15] x [16]
Number of Individual Preventive Care sessions
Time per Individual Preventive Care session
Individual Preventive Care (minutes)
[18] x [19]
Time per fissure sealant
Arresting Care (minutes)
[11] x [21]
Mean number of sextants in need of scaling
Time per scaling per sextant
Number of scaling sessions
Periodontal Care (prophylaxis only) (minutes)
[23] x [24] x [25]
% in need of Surgical Care
Time for Surgical Care
Surgical Care (minutes)
[27] / 100 x [28]
Time per restoration (new or replacement)
Restorative Care for new fillings (NFS) (minutes)
[12] x [30]
Restorative Care for replacement fillings (RFS) (minutes)
[13] x [30]
Time per extraction
Extraction (minutes)
[14] x [33]
Total minutes of need per cohort
[17]+[20]+[22]+[26]+[29]+[31]+[32]+[34]
Total minutes of need per year:
For total human resources
[35] / [1]
For Oral Hygienists
([17]+[20]+[22]+[26]) / [1]
For Dental Therapists/Dentists
([29]+[31]+[32]+[34]) / [1]
% Demand (utilization)
Minutes of demand per year:
For total human resources
[36] x [39] /100
For Oral Hygienists
[37] x [39] /100
For Dental Therapists/Dentists
[38] x [39] /100
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Chapter 5
133
Table 43: (continued)
Variable
(C) HUMAN RESOURCES CALCULATIONS
[43] Working year (hours)
[44] Working year (minutes)
Human resources : population ratio:
[45] For total human resources
[46] For Oral Hygienists
[47] For Dental Therapists/Dentists
[48] Population size
Number of human resources required:
[49] Total human resources
[50] Oral Hygienists
[51] Dental Therapists/Dentists
[52] Dentists
(Ratio 1 Dentist : 5 Dental Therapists)
[53] Dental Therapists
(Ratio 1 Dentist : 5 Dental Therapists)
[54] Dental Assistants
(Ratio 1 Dental Therapist/Dentist : 1.5 Dental Assistants)
Formula
[43] x 60
[44] / [40]
[44] / [41]
[44] / [42]
[48] / [45]
[48] / [46]
[48] / [47]
[51] / 6
[51] / 6 x 5
[51] x 1.5
5.2.1 Restorative care, arresting care and extractions (Variable Group (A))
a)
Number of age intervals (Variable [1])
Calculations were done for the 4- to 5- and the 6- to 15-year-old age cohorts.
The number of age intervals for each cohort are:
•
Age 4 to 5: Two (4-5 and 5-5.99)
•
Age 6 to 15: Ten (6-7, 7-8, 8-9, 9-10, 10-11, 11-12, 12-13, 13-14, 14-15
and 15-15.99)
b)
Predicted caries prevalence values (Variables [2] to [5])
The WHO/FDI model requires DMFT caries index data as treatment need
information.
Caries prevalence data for 4- to 5- (dmft) and 15-year-old
children (DMFT) from the 1999-2002 NCOHS (Department of Health, 2003b)
were used in the calculations. These are summarised in Table 44. The mean
national values were used for 4- to 5-year-olds in the Northern Cape as this
age cohort was not included in the survey for that province.
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Table 44: Caries prevalence of 4- to 5- and 15-year-old South African children:
1999-2002 NCOHS (Department of Health, 2003b)
Province
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
c)
dmft
(Var. [2])
2.44
4.81
2.44
3.36
2.96
2.52
1.96
1.52
2.05
0.84
4- to 5-year-olds
dt
mt
(Var. [3]) (Var. [4])
0.35
1.95
1.04
3.66
0.35
1.95
0.73
2.55
0.31
2.60
0.19
2.30
0.20
1.06
0.09
1.39
0.24
1.58
0.10
0.82
ft
(Var. [5])
0.16
0.10
0.16
0.07
0.05
0.03
0.66
0.04
0.23
0.01
DMFT
(Var. [2])
1.86
3.99
2.88
2.01
1.92
1.87
1.81
1.20
1.66
0.86
15-year-olds
DT
MT
(Var. [3]) (Var. [4])
0.29
1.34
0.92
2.65
0.32
2.48
0.64
1.08
0.09
1.73
0.22
1.57
0.11
1.04
0.08
1.00
0.10
1.31
0.05
0.78
FT
(Var. [5])
0.23
0.42
0.07
0.28
0.09
0.08
0.65
0.11
0.24
0.03
Restoration fraction (Variable [6])
This variable was predetermined and represents the fraction of the
dmft/DMFT which can be saved through preventive procedures. The values
used in this model are:
d)
•
Age 4 to 5: 0.5
•
Age 6 to 15: 0.6
New fillings : Teeth (NFT) (Variable [7])
The NFT ratio was calculated by applying the formula:
Restoration fraction x Predicted dmft or DMFT
e)
Mean replacement period in years for a restoration (Variable [8])
This variable was predetermined and a value of fifteen years was used in this
model.
f)
Replacement fillings : Teeth (RFT) (Variable [9])
The RFT ratio was calculated by applying the formula:
(Age intervals x NFT) / (2 x Mean replacement period in years for a
restoration)
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g)
Ratio of surfaces / Teeth (Variable [10])
This variable was predetermined and a value of 1.5 was used in this model.
h)
Sealants, arresting care and remineralisation (Variable [11])
This variable was calculated by applying the formula:
(1 – Restoration fraction) x Predicted dmft or DMFT
i)
New fillings : Surfaces (NFS) (Variable [12])
The NFS ratio was calculated by applying the formula:
NFT x Ratio of surfaces / Teeth
j)
Replacement fillings : Surfaces (RFS) (Variable [13])
The RFS ratio was calculated by applying the formula:
RFT x Ratio of surfaces / Teeth
k)
Extraction (Variable [14])
This variable is represented by the predicted mt or MT (Variable [4]).
5.2.2 Treatment time requirements (Variable Group (B))
a)
Group Preventive Care (Variables [15] to [17])
The number of group preventive care sessions as well as the time per session
was predetermined. A single group preventive session in each of the 4- to 5and 6- to 15-year-old cohorts (Variable [15]) of fifteen minutes duration
(Variable [16]) was used in this model.
The time required for group preventive care (Variable [17]) was calculated by
applying the formula:
Number of Group Preventive Care sessions x Time per Group Preventive
Care session
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b)
Individual Preventive Care (Variables [18] to [20])
The number of individual preventive care sessions as well as the time per
session was predetermined. For this study no individual preventive care was
included for the 4- to 5-year-old cohort.
Four sessions (Variable [18]) of
fifteen minutes each (Variable [19]) over the duration of the 6- to 15-year-old
cohort (10 years) were used in this model.
The time required for individual preventive care (Variable [20]) was calculated
by applying the formula:
Number of Individual Preventive Care sessions x Time per Individual
Preventive Care session
c)
Arresting care (Variables [21] and [22])
Variable [21] was predetermined and a value of 5 minutes required per fissure
sealant was used in this model.
Arresting care (Variable [22]) was calculated by applying the formula:
Sealants, arresting care and remineralisation variable x Time per fissure
sealant
d)
Periodontal care (Variables [23] to [26])
Severity of periodontal disease for 15-year-old children in South Africa as
determined in the 1999-2002 NCOHS (Department of Health, 2003b) was
used in the calculations for periodontal care for the 6- to 15-year-old cohort
only as it was assumed that no periodontal care would be required for the 4to 5-year-old cohort.
The mean number of sextants with bleeding and
calculus are presented in Table 45. The mean national values were used for
Gauteng as periodontal disease was not included in the survey for this
province.
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In this model the sum of the mean number of sextants with bleeding and
calculus were regarded as being in need of a prophylaxis treatment (Variable
[23]).
This study does recognise the limitations of the use of CPI data in human
resources planning as reported in the literature (Manji and Sheiham, 1986;
Page and Morrison, 1994).
Table 45: Mean number of sextants with bleeding and calculus in 15-year-old
South African children (Department of Health, 2003b)
Province
Weighted national mean
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Mean number of sextants
Total sextants in
Bleeding Calculus
need of scaling
3.31
2.17
1.14
3.27
1.84
1.43
2.3
0.85
1.45
2.88
2.62
0.26
3.95
2.96
0.99
3.57
2.23
1.34
3.31
2.17
1.14
2.57
1.47
1.1
1.97
1.22
0.75
4.41
2.43
1.98
Variables [24] and [25] were predetermined and values of two sessions of
periodontal care over the duration of the 6- tot 15-year-old cohort and five
minutes required for each sextant in need of scaling were used in this model.
Periodontal care (prophylaxis only) (Variable [26]) was calculated by applying
the formula:
Mean number of sextants in need of scaling x Time per scaling per sextant x
Number of scaling sessions
e)
Surgical care (Variables [27] to [29])
It was assumed that 60 minutes would be required to cover surgical care for
trauma, impaction and other oral surgery (Variable [28]) over the duration of
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each of the 4- to 5- and 6- to 15-year-old age cohorts (World Health
Organization/Fédération Dentaire Internationale, 1989).
The following values were assumed for the percentage of children in need of
surgical care (Variable [27]):
•
Age 4 to 5: 1%
•
Age 6 to 15: 10%
Surgical care (Variable [29]) was calculated by applying the formula:
% in need of Surgical Care x Time for Surgical Care
f)
Restorative care for new and replacement fillings (Variables [30] to [32])
The WHO/FDI model assumes that fifteen minutes are required for either a
new or a replacement restoration (Variable [30]). The following formulas were
applied:
•
Restorative care for new fillings (NFS) (Variable [31]):
NFS x Time per restoration
•
Restorative care for replacement fillings (RFS) (Variable [32]):
RFS x Time per restoration
g)
Extractions (Variables [33] and [34])
The WHO/FDI model assumes that 7.5 minutes are required per extraction
(Variable [33]). Time for extractions was calculated by applying the formula:
Extraction variable x Time per extraction
h)
Total minutes of need per cohort (Variable [35])
This variable was calculated by adding the time required for preventive (group
and individual), arresting, periodontal, surgical and restorative care as well as
extractions.
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i)
Total minutes of need per year (Variables [36] to [38])
This variable was calculated by applying the formula:
Total minutes of need per cohort / Age intervals
By assuming that the oral hygienist would be responsible for delivering the
preventive, arresting and periodontal care and the dental therapist/dentist the
surgical care, restorative care and extractions, total minutes of need per year
were calculated separately for each of the total human resources (Variable
[36]), oral hygienists (Variable [37]) and dental therapists/dentists (Variable
[38]) by applying the formula above for those procedures for which the oral
hygienist and dental therapist/dentist are responsible.
j)
Minutes of demand per year (Variables [39] and [40])
Table 46 provides information on the utilization of oral health services by
South African adults aged 20 to 64 as determined in the 1988/89 NOHS
(Department of Health, 1994).
A weighted national mean value was
calculated from this data using the 2006 South African mid-year population
estimates (Statistics South Africa, 2006). A weighted mean service utilization
value of 25.7% for those having visited a dentist/dental clinic within the last 12
months was used for both the 4- to 5- and 6- to 15-year-old cohorts (Variable
[39]).
Table 46: Utilization of services based on time elapsed since previous visit to a
dentist or dental clinic for the South African adult population (Department of
Health, 1994)
Time elapsed since last visit
Within 12 months
> 1 year ago
Do not know
Never
Percentage utilization of services by population group
(% of population)
Asian
Black
Coloured White
Weighted national mean
(2.46%) (79.47%)
(8.86%)
(9.21%)
59.9
26.7
21.5
31.5
25.7
49.3
37.4
64.9
48.9
49.7
2.9
2.2
4.5
2.7
5.3
22.1
0.5
3.9
26.9
13.5
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Minutes of demand per year were calculated for the each of the total human
resources (Variable [40]), oral hygienists (Variable [41]) and dental
therapists/dentists (Variable [42]) by applying the formula:
Total minutes of need per year x % Demand
5.2.3 Human resources calculations (Variable Group (C))
a)
Working year (Variables [43] and [44])
For the purpose of this model a working year (Variable [43]) was considered
as 40 hours per week for 44 weeks (1,760 hours).
In this model this value was converted to minutes (Variable [44]) for
calculating the human resources required.
b)
Human resources to population ratio (Variables [45] to [47])
This variable was calculated for the each of the total human resources
(Variable [45]), oral hygienists (Variable [46]) and dental therapists/dentists
(Variable [47]) by applying the formula:
Working year in minutes / Minutes of demand per year
c)
Population size (Variable [48])
This variable was calculated from the 2006 South African mid-year population
estimates (Statistics South Africa, 2006). Table 47 presents the values used
in this model.
d)
Number of human resources required (Variables [49] to [54])
The number of human resources required was calculated for the each of the
total human resources (Variable [49]), oral hygienists (Variable [50]) and
dental therapists/dentists (Variable [51]) by applying the formula:
Population size / Human resources : population ratio
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The ratio of dental therapists to dentists of 5:1 and dental therapists/dentists
to dental assistants of 1:1.5 as described in Table 12 (p 63) (Department of
Health, 1999) were applied to the results to separately calculate the number
of dentists (Variable [52]), dental therapists (Variable [53]), and dental
assistants (Variable [54]) required.
Table 47: 2006 South African mid-year population estimates for the 4- to 5- and
6- to 15-year-old age cohorts (Statistics South Africa, 2006)
Province
Total population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
47,390,800
4,745,500
910,500
7,051,500
2,958,800
9,731,800
9,211,200
3,858,200
3,252,500
5,670,800
4- to 5-year-olds
n
%
2,035,320 4.29
182,980 3.86
38,600 4.24
312,260 4.43
119,940 4.05
440,360 4.52
348,300 3.78
167,900 4.35
151,180 4.65
273,800 4.83
6- to 15-year-olds
n
%
10,087,080 21.28
869,340 18.32
186,540 20.49
1,700,100 24.11
607,120 20.52
2,235,140 22.97
1,472,640 15.99
798,240 20.69
751,980 23.12
1,465,980 25.85
4- to 15-year-olds
n
%
12,122,400 25.57
1,052,320 22.18
225,140 24.73
2,012,360 28.54
727,060 24.57
2,675,500 27.49
1,820,940 19.77
966,140 25.04
903,160 27.77
1,739,780 30.68
5.2.4 Impact of the implementation of water fluoridation
Estimated caries reductions as a result of the implementation of water
fluoridation of 10%, 30% and 50%, were applied to the dmft/DMFT values
(Variables [2] to [5]) to indicate the impact that this would have on the required
human resources.
Results of the human resources required to deliver the minimum package of
oral care to the 4- to 5- and 6- to 15-year-old cohorts with and without the
impact of water fluoridation as calculated with the WHO/FDI model are
presented in Section 5.4 (p 149).
5.3
A “Service Targets Method” model to calculate human
resources
This approach involves the setting of targets for the production and delivery of
specific health services followed by converting these into human resources
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requirements by means of staffing and productivity standards. This method
attempts to strike a balance between needs and wants of the population,
available technology and what can be delivered (Hall, 1978).
Based on need and demand the service target for the model described in this
section is to deliver the minimum package of oral care to 4- to 15-year-old
children with appropriate oral health human resources where the oral
hygienist would be responsible for delivering the group prevention, periodontal
care (prophylaxis only), topical fluoride application and fissure sealants and
the dental therapist/dentist the restorative care and extractions.
Similar to the approach used for the WHO/FDI model, for the purpose of this
study, this model also assumes that the public oral health services would not
be held responsible for delivering the minimum package of oral care to
children older than fifteen.
The calculation of oral health human resources requirements with this model
consisted of three steps:
1. Convert treatment need to time required to complete treatment;
2. Convert time required to complete treatment need to demand time to
complete treatment; and
3. Convert demand time to complete treatment to human resources required.
Table 48 presents the input variables to calculate the human resources
required to deliver the minimum package of oral care to the 4- to 15-year-old
cohort with a “Service Target Method” model.
Each variable has been
allocated a unique number (in a square bracket) which indicates where it is
used in the different formulas.
Microsoft Excel software was used to computerise this model. An example of
the model applied to the 4- to 15-year-old age cohort is presented in
Annexure 5.
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Table 48: A “Service Targets Method” model to calculate human resources
needed to deliver the minimum package of oral care
Variable
Formula
(A) Minutes of need
[1] Population size
[2] Treatment need
[3] Treatment time per procedure
[1] x [2] x [3]
[4] Time to complete each treatment need type
[5] Total time to complete treatment need
[5] / [1]
[6] Per capita time to complete treatment need
[4] / [5] x 100
[7] % of total time for each treatment need type
[6] x [7] / 100
[8] Per capita time of each treatment need type
(B) Minutes of demand
[9] % Demand (utilization)
[10] Minutes of demand per person per year
[6] x [9] / 100
(C) Human resources calculations
[11] Working year (hours)
[11] x 60 minutes
[12] Working year (minutes)
[12] / [10]
[13] Human resource : population ratio
[1] / [13]
[14] Number of human resources required
5.3.1 Minutes of need (Variable Group (A))
a)
Population size (Variable [1])
The 2006 South African mid-year population estimates by age and sex
(national and per province) were used in this model (Statistics South Africa,
2006).
Since these population estimates are presented in five year age
intervals, the mean values for each interval were used to calculate the
population estimates for the 4- to 15-year-old cohort.
A population estimate
for the 6- to 15-year-old age cohort was used to calculate the human
resources for prophylaxis since this procedure was not included in this model
for the 4- to 5-year-olds.
Population size values used in this model are
presented in Table 47 (p 142).
b)
Treatment need (Variable [2])
Percentage treatment need and mean number of teeth in need of treatment
as reported in Chapter 4 (Table 31, p 110 and Table 32, p 111) for 4- to 5-, 6-,
12- and 15-year-olds were used to calculate a mean weighted value for the 4to 15-year-old cohort on a national as well as a provincial level for each of the
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nine South African provinces. The mean national value was used for Gauteng
and Limpopo as survey data for these two provinces were not available.
Similar to the model described in Chapter 4 to calculate the per capita cost to
deliver the minimum package or oral care as well as the WHO/FDI human
resources model described in a previous section of this chapter, it was
assumed that no periodontal care would be required for the 4- to 5-year-old
cohort. Data for 15-year-old children in South Africa as determined in the
1999-2002 NCOHS (Department of Health, 2003b) and reported as the
percentage of sextants (prevalence) and the mean number of sextants
(severity) with the highest score being either healthy or bleeding was used in
this model for the 6- to 15-year-old age cohort (See Table 33, p 114). The
mean national values were used for Gauteng as periodontal disease was not
included in the survey for 15-year-olds for this province.
An oral examination and bitewing radiographs were excluded from the
calculations in this model as these procedures were not included in the
WHO/FDI model either. The mean weighted treatment need values used in
this model are presented in Table 49.
Table 49: Treatment need as a percentage of the population or mean number
of teeth/sextants for the 4- to 15-year-old age cohort
Prophylaxis
Province
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Mean no.
of sextants
3.31
3.27
2.3
2.88
3.95
3.57
3.31
2.57
1.97
4.41
Topical fluoride
application
% of
population
5.39
2.46
2.36
6.66
5.21
6.32
5.39
5.79
5.24
5.39
Fissure
sealant
Mean no.
of teeth
0.80
1.80
0.31
0.07
1.13
0.94
0.80
0.29
0.05
0.80
1 surface
restoration
Mean no.
of teeth
0.39
0.56
0.93
0.29
0.54
0.29
0.39
0.25
0.48
0.39
>1 surface
restoration
Mean no.
of teeth
0.20
0.36
0.81
0.14
0.13
0.18
0.20
0.11
0.24
0.20
Extraction
Mean no.
of teeth
0.29
0.50
0.77
0.37
0.28
0.26
0.29
0.07
0.33
0.29
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Chapter 5
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c)
Treatment time per procedure (Variable [3])
Treatment times used for this model were based on those of the WHO/FDI
human resources model, except for topical fluoride application. These are:
•
Group prevention: Four sessions of fifteen minutes each over twelve age
intervals between the ages of 4 to 15
•
Prophylaxis: Two prophylaxis treatment sessions for the 6- to 15-year-old
cohort based on five minutes per sextant in need of a scaling over ten age
intervals
•
Topical fluoride application: Three fluoride applications of ten minutes
each at ages 6, 12 and 15 over twelve age intervals. These ages were
chosen to coincide with the eruption of the first and second permanent
molars at a stage when mineralisation of the enamel has not been fully
completed. A final topical fluoride application is provided at age fifteen,
the last age for which it is assumed the minimum package of oral care
would be provided.
•
Fissure sealants: Five minutes per sealant
•
Restorations (one or more than one surface): Fifteen minutes per
restoration
•
Extractions: 7.5 minutes per extraction
The treatment times used in this model are summarised in Table 50.
Table 50: Treatment times used in the “Service Targets Method” model
Procedure
Group prevention
Prophylaxis
Topical fluoride application
Fissure sealant
1 surface restoration
More than 1 surface restoration
Extraction
Estimated time per year (minutes)
4 sessions x 15 minutes each / 12 age intervals = 5 minutes per year
2 sessions x 5 minutes per sextant / 10 age intervals = 1 minute per year
3 applications x 10 minutes each / 12 age intervals = 2.5 minutes per year
5 minutes per sealant
15 minutes per restoration
15 minutes per restoration
7.5 minutes per extraction
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d)
Time to complete each treatment need type (Variable [4])
For each of the treatment need types the time to complete treatment for the
specific procedure was calculated by applying the formula:
Population size x Treatment need x Treatment time per procedure
e)
Total time to complete treatment need (Variable [5])
Total time to complete treatment need was calculated by adding all times
required to complete each of the treatment need types which are part of the
minimum package or oral care.
f)
Per capita time to complete treatment need (Variable [6])
This variable was calculated by applying the formula:
Total time to complete treatment need / Population size
g)
Percentage of total time for each treatment need type (Variable [7])
The time to complete each treatment need type was expressed as a
percentage of the total time to address treatment need by applying the
formula:
Time to complete each treatment need type / Total time to complete treatment
need x 100
h)
Per capita time of each treatment need type (Variable [8])
The time for each treatment need type was converted to a per capita time by
applying the formula:
Per capita time to complete treatment need x % of total time for each
treatment need type
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Chapter 5
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5.3.2 Minutes of demand (Variable Group (B))
Similar to the WHO/FDI model a mean weighted service utilization value of
25.7% (Variable [9]) for those having visited a dentist or dental clinic within the
last 12 months (see Table 46, p 140) was used in this model.
Minutes of demand per person per year (Variable [10]) was calculated by
applying the formula:
Per capita time to complete treatment need x % Demand
5.3.3 Human resources calculations (Variable Group (C))
a)
Working year (Variables [11] and [12])
For the purpose of this study a working year (Variable [11]) was considered as
40 hours per week for 44 weeks (1,760 hours).
This value was converted to minutes (Variable [12]) for calculating the human
resources required with this model.
b)
Human resources to population ratio (Variable [13])
This variable was calculated by applying the formula:
Working year in minutes / Minutes of demand per person per year
c)
Number of human resources required (Variable [12])
This variable was calculated by applying the formula:
Population size / Human resources : population ratio
The number of required oral hygienists was calculated based on the minutes
of demand per person per year to deliver prevention, prophylaxis, fissure
sealants and fluoride applications.
The number of required dental
therapists/dentists was calculated based on the minutes of demand per
person per year to deliver restorations and extractions.
Similar to the WHO/FDI model the ratios of dental therapists to dentists (5:1)
and dental therapists/dentists to dental assistants (1:1.5) as described in
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Table 12 (p 63) (Department of Health, 1999) were applied to the results to
separately determine the number of dental therapists, dentists and dental
assistants required.
5.3.4 Impact of the implementation of water fluoridation
Estimated caries reductions as a result of the implementation of water
fluoridation of 10%, 30% and 50%, were applied to the treatment need values
to indicate the impact that this would have on the required human resources
to deliver the minimum package of oral care.
Results of the human resources required for the 4- to 15-year-old cohort with
and without the impact of water fluoridation as calculated with the “Service
Targets Method” model are presented in the next section.
5.4
Results
5.4.1 Background information
For both the WHO/FDI and “Service Targets Method” models results are
presented for the 4- to 15-year-old age cohort using oral health status and
treatment need data for dental caries and periodontal disease (bleeding and
calculus only) from the 1999-2002 NCOHS (Department of Health, 2003b)
combined with a mean weighted demand/utilization of services of 25.7% (See
Table 46, p 140).
Based on anticipated caries reductions as a result of the implementation of
water fluoridation of 10%, 30% and 50%, caries prevalence values for the
WHO/FDI model and treatment need for dental caries values for the “Service
Targets Method” model were adjusted accordingly to indicate the impact that
this would have on the required human resources to deliver the minimum
package of care.
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For both models the total number of human resources required is indicated on
a national as well as a provincial level. It was assumed that the oral hygienist
would be responsible for delivering the group prevention, prophylaxis, topical
fluoride application and fissure sealants and the dental therapist/dentist for the
restorative care and extractions.
5.4.2 Total human resources
Table 51 presents the human resources required as calculated with the two
models without the introduction of water fluoridation as well as assuming a
10%, 30% or 50% reduction in caries prevalence after its introduction. Please
note that dental assistants are not included in the total human resources
required column.
In general on both the national and all provincial levels the number of human
resources required as calculated with the WHO/FDI model was less than
calculated with the “Service Targets Method” model.
Table 52 presents the difference between the calculations for the two models
for the total human resources requirements to deliver the minimum package
of care.
Figure 11 and Figure 12 present the required human resources on a national
level without water fluoridation and with an estimated caries reduction of 10%,
30% and 50% after its introduction as calculated with the WHO/FDI and
“Service Targets Method” models.
___________________________________________________________________
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150
Table 51: Summary of human resources requirements for 4- to 15-year-old
South African children calculated with the WHO/FDI and “Service Targets
Method” models
Estimated
caries
reduction
No water
fluoridation
10%
30%
50%
No water
fluoridation
10%
30%
50%
No water
fluoridation
10%
30%
50%
No water
fluoridation
10%
30%
50%
No water
fluoridation
10%
30%
50%
Total human
resources (excl.
Dental Assistants)
WHO/
STM
FDI
Dental
Therapists/
Dentists
WHO/
STM
FDI
National
Oral
Hygienists
WHO/
FDI
STM
183
Dentists
Dental
Therapists
Dental
Assistants
WHO/
FDI
STM
WHO/
FDI
STM
WHO/
FDI
STM
510
679
327
352
327
31
54
153
272
275
490
491
453
415
634
544
454
325
320
315
339
166
294
315
133
229
290
100
163
Western Cape
28
22
17
49
38
27
139
111
83
245
191
136
250
200
149
441
343
245
63
88
31
43
45
5
8
27
38
49
68
60
53
45
81
68
54
30
29
28
41
30
41
36
23
32
31
17
23
Northern Cape
5
4
3
7
5
4
25
19
14
34
26
19
44
35
26
61
48
34
10
22
6
5
17
1
3
4
15
6
26
10
9
8
20
17
13
6
6
5
5
4
4
4
16
3
12
2
9
Eastern Cape
1
1
0
3
2
1
3
3
2
13
10
7
6
5
3
24
18
13
91
84
54
39
45
6
7
31
37
56
67
87
79
71
79
70
60
53
52
51
39
38
38
34
40
27
31
20
22
Free State
6
4
3
7
5
4
28
22
17
34
26
19
51
40
30
60
47
34
33
47
21
25
22
2
4
10
18
18
33
31
29
26
44
37
31
21
20
20
24
11
20
22
8
15
20
6
11
KwaZulu-Natal
2
1
1
3
3
2
9
7
5
16
13
9
16
13
10
29
23
16
33
4
37
No water
114
142
74
84
fluoridation
10%
109
133
73
80
30%
101
115
72
74
50%
93
97
71
68
Note: STM = “Service Targets Method” model
12
40
59
7
10
33
49
60
88
36
29
22
53
41
29
6
5
4
9
7
5
30
24
18
44
34
24
54
43
33
79
62
44
___________________________________________________________________
Chapter 5
151
Table 51: (continued)
Estimated
caries
reduction
No water
fluoridation
10%
30%
50%
No water
fluoridation
10%
30%
50%
No water
fluoridation
10%
30%
50%
Total human
resources (excl.
Dental Assistants)
WHO/
STM
FDI
Dental
Therapists/
Dentists
WHO/
STM
STM
FDI
Gauteng
Oral
Hygienists
WHO/
FDI
74
102
49
52
71
66
61
95
81
68
48
48
47
33
35
32
31
29
25
Dentists
Dental
Therapists
Dental
Assistants
WHO/
FDI
STM
WHO/
FDI
STM
WHO/
FDI
49
4
8
21
41
38
74
51
23
47
18
43
14
North West
44
34
25
4
3
2
7
6
4
19
15
11
37
29
20
34
27
21
66
52
37
24
21
14
2
2
8
12
14
21
33
29
26
24
24
23
20
9
13
19
7
10
19
5
7
Mpumalanga
1
1
1
2
2
1
7
6
4
11
8
6
13
11
8
19
15
11
33
45
22
15
29
2
5
10
24
18
44
32
30
27
42
36
30
22
21
21
15
15
15
26
21
15
2
1
1
4
3
2
9
7
5
22
17
12
16
13
10
40
31
22
11
47
2
8
9
39
17
70
10
9
7
42
33
23
2
1
1
7
5
4
9
7
6
35
27
20
16
13
10
63
49
35
9
12
11
9
6
Limpopo
No water
60
101
49
55
fluoridation
10%
59
95
49
53
30%
57
82
48
49
50%
55
69
48
46
Note: STM = “Service Targets Method” model
It is clear from Table 51 and both Figure 11 and Figure 12, irrespective of
whether the WHO/FDI or the “Service Targets Method” model were used for
the calculations, that oral hygienists represent the majority of oral health
human resources required to deliver the minimum package of oral care to 4to 15-year-old children.
___________________________________________________________________
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152
Table 52: Difference between human resources requirements for 4- to 15-yearold South African children calculated with the WHO/FDI and “Service Targets
Method” models
Estimated
caries
reduction
Total
(excl. Dental Assistants)
WHO/FDI
STM
National
No water fluoridation
510
679
10%
491
634
30%
453
544
50%
415
454
Western Cape
No water fluoridation
63
88
10%
60
81
30%
53
68
50%
45
54
Northern Cape
No water fluoridation
10
22
10%
10
20
30%
9
17
50%
8
13
Eastern Cape
No water fluoridation
91
84
10%
87
79
30%
79
70
50%
71
60
Free State
No water fluoridation
33
47
10%
31
44
30%
29
37
50%
26
31
KwaZulu-Natal
No water fluoridation
114
142
10%
109
133
30%
101
115
50%
93
97
Gauteng
No water fluoridation
74
102
10%
71
95
30%
66
81
50%
61
68
North West
No water fluoridation
33
35
10%
32
33
30%
31
29
50%
29
26
Mpumalanga
No water fluoridation
33
45
10%
32
42
30%
30
36
50%
27
30
Limpopo
No water fluoridation
60
101
10%
59
95
30%
57
82
50%
55
69
Note: STM = “Service Targets Method” model
Difference
169
143
91
39
25
21
15
9
12
10
8
5
7
8
9
11
14
13
8
5
28
24
14
4
28
24
15
7
2
1
2
3
12
10
6
3
41
36
25
14
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Chapter 5
153
N o w a te r flu o rid a tio n
1 0 % ca rie s re d u c tio n
28
31
139
153
327
O ral h ygien is ts
D en tal th erapists
325
D en tis ts
3 0 % ca rie s re d u c tio n
O ral h ygien ists
D en tal th erapis ts
5 0 % ca rie s re d u c tio n
22
17
83
111
320
O ral h ygien is ts
D en tis ts
D en tal th erapis ts
315
D en tis ts
O ral h ygien is ts
D en tal th erapis ts
D en tis ts
Figure 11: National human resources requirements calculated with the
WHO/FDI model for delivering the minimum package of oral care to 4- to 15year-old South African children
N o w a te r flu o rid a tio n
1 0 % c a rie s re d u c tio n
54
49
352
339
245
272
O ral h ygien ists
D en tal th erapis ts
D en tis ts
3 0 % c a rie s re d u c tio n
O ral h ygien is ts
O ral h ygien is ts
D en tis ts
5 0 % c a rie s re d u c tio n
38
191
D en tal th erapis ts
27
136
315
D en tal th erapis ts
290
D en tis ts
O ral h ygien is ts
D en tal th erapis ts
D en tis ts
Figure 12: National human resources requirements calculated with the
“Service Targets Method” model for delivering the minimum package of oral
care to 4- to 15-year-old South African children
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Chapter 5
154
5.4.3 Oral hygienists
Table 53 presents the requirements for oral hygienists to deliver the minimum
package of care as calculated with the WHO/FDI and “Service Targets
Method” models. Requirements on a national and provincial level are also
expressed as a percentage of the total number of human resources required.
For the WHO/FDI model, oral hygienists represent more than 50% of the total
human resources required to deliver the minimum package of oral care to 4to 15-year-olds. Although less oral hygienists are required when the “Service
Targets Method” model was used, for the majority of provinces it still
represents more than 50% of the total human resources required.
With both models, as the anticipated caries reduction due to the
implementation of water fluoridation increases, the proportion of oral
hygienists in relation to the need for dentists and dental therapists increases
(see Table 54).
5.4.4 Dental therapists and dentists
Table 54 presents the requirements for dental therapists and dentists to
deliver the minimum package of care as calculated with the WHO/FDI and
“Service Targets Method” models. Requirements on a national and provincial
level are also expressed as a percentage of the total number of human
resources required.
Dental therapists represent approximately 30 to 40% and dentists less than
10% of the total human resources required to deliver the restorative care and
extraction components of the minimum package of oral care to 4- to 15-yearold children.
Table 54 clearly illustrates the reduced need for both dental therapists and
dentists as the anticipated level of caries reduction increases due to the
introduction of water fluoridation.
___________________________________________________________________
Chapter 5
155
Table 53: Requirements for oral hygienists for 4- to 15-year-old South African
children using the WHO/FDI and “Service Targets Method” models
Estimated
caries
reduction
Total
(excl Dental Assistants)
WHO/FDI
STM
National
679
634
544
454
Western Cape
No water fluoridation
63
88
10%
60
81
30%
53
68
50%
45
54
Northern Cape
No water fluoridation
10
22
10%
10
20
30%
9
17
50%
8
13
Eastern Cape
No water fluoridation
91
84
10%
87
79
30%
79
70
50%
71
60
Free State
No water fluoridation
33
47
10%
31
44
30%
29
37
50%
26
31
KwaZulu-Natal
No water fluoridation
114
142
10%
109
133
30%
101
115
50%
93
97
Gauteng
No water fluoridation
74
102
10%
71
95
30%
66
81
50%
61
68
North West
No water fluoridation
33
35
10%
32
33
30%
31
29
50%
29
26
Mpumalanga
No water fluoridation
33
45
10%
32
42
30%
30
36
50%
27
30
Limpopo
No water fluoridation
60
101
10%
59
95
30%
57
82
50%
55
69
Note: STM = “Service Targets Method” model
No water fluoridation
10%
30%
50%
510
491
453
415
Oral Hygienists
n
WHO/FDI
% of total
n
STM
% of total
327
325
320
315
64.1
66.2
70.6
75.9
352
339
315
290
51.8
53.5
57.9
63.9
31
30
29
28
49.2
50.0
54.7
62.2
43
41
36
31
48.9
50.6
52.9
57.4
6
6
6
5
60.0
60.0
66.7
62.5
5
5
4
4
22.7
25.0
23.5
30.8
54
53
52
51
59.3
60.9
65.8
71.8
39
39
38
38
46.4
49.4
54.3
63.3
21
21
20
20
63.6
67.7
69.0
76.9
25
24
22
20
53.2
54.5
59.5
64.5
74
73
72
71
64.9
67.0
71.3
76.3
84
80
74
68
59.2
60.2
64.3
70.1
49
48
48
47
66.2
67.6
72.7
77.0
52
51
47
43
51.0
53.7
58.0
63.2
24
24
24
23
72.7
75.0
77.4
79.3
21
20
19
19
60.0
60.6
65.5
73.1
22
22
21
21
66.7
68.8
70.0
77.8
15
15
15
15
33.3
35.7
41.7
50.0
49
49
48
48
81.7
83.1
84.2
87.3
55
53
49
46
54.5
55.8
59.8
66.7
___________________________________________________________________
Chapter 5
156
Table 54: Requirements for dental therapists and dentists for 4- to 15-year-old
South African children using the WHO/FDI and “Service Targets Method”
models
Estimated
caries
reduction
Total
(excl Dental
Assistants)
WHO/FDI
STM
No water fluoridation
10%
30%
50%
510
491
453
415
679
634
544
454
No water fluoridation
10%
30%
50%
63
60
53
45
88
81
68
54
No water fluoridation
10%
30%
50%
10
10
9
8
22
20
17
13
No water fluoridation
10%
30%
50%
91
87
79
71
84
79
70
60
No water fluoridation
10%
30%
50%
33
31
29
26
47
44
37
31
No water fluoridation
10%
30%
50%
114
109
101
93
142
133
115
97
No water fluoridation
10%
30%
50%
74
71
66
61
102
95
81
68
No water fluoridation
10%
30%
50%
33
32
31
29
35
33
29
26
No water fluoridation
10%
30%
50%
33
32
30
27
45
42
36
30
No water fluoridation
10%
30%
50%
60
59
57
55
101
95
82
69
Dental Therapists
WHO/FDI
% of
n
total
National
153
30.0
139
28.3
111
24.5
83
20.0
Western Cape
27
42.9
25
41.7
19
35.8
14
31.1
Northern Cape
4
40.0
3
30.0
3
33.3
2
25.0
Eastern Cape
31
34.1
28
32.2
22
27.8
17
23.9
Free State
10
30.3
9
29.0
7
24.1
5
19.2
KwaZulu-Natal
33
28.9
30
27.5
24
23.8
18
19.4
Gauteng
21
28.4
19
26.8
15
22.7
11
18.0
North West
8
24.2
7
21.9
6
19.4
4
13.8
Mpumalanga
10
30.3
9
28.1
7
23.3
5
18.5
Limpopo
9
15.0
9
15.3
7
12.3
6
10.9
STM
% of
n
total
Dentists
WHO/FDI
% of
n
total
STM
% of
n
total
272
245
191
136
40.1
38.6
35.1
30.0
31
28
22
17
6.1
5.7
4.9
4.1
54
49
38
27
8.0
7.7
7.0
5.9
38
34
26
19
43.2
42.0
38.2
35.2
5
5
4
3
7.9
8.3
7.5
6.7
8
7
5
4
9.1
8.6
7.4
7.4
15
13
10
7
68.2
65.0
58.8
53.8
1
1
1
0
10.0
10.0
11.1
0.0
3
3
2
1
13.6
15.0
11.8
7.7
37
34
26
19
44.0
43.0
37.1
31.7
6
6
4
3
6.6
6.9
5.1
4.2
7
7
5
4
8.3
8.9
7.1
6.7
18
16
13
9
38.3
36.4
35.1
29.0
2
2
1
1
6.1
6.5
3.4
3.8
4
3
3
2
8.5
6.8
8.1
6.5
49
44
34
24
34.5
33.1
29.6
24.7
7
6
5
4
6.1
5.5
5.0
4.3
10
9
7
5
7.0
6.8
6.1
5.2
41
37
29
20
40.2
38.9
35.8
29.4
4
4
3
2
5.4
5.6
4.5
3.3
8
7
6
4
7.8
7.4
7.4
5.9
12
11
8
6
34.3
33.3
27.6
23.1
2
1
1
1
6.1
3.1
3.2
3.4
2
2
2
1
5.7
6.1
6.9
3.8
24
22
17
12
53.3
52.4
47.2
40.0
2
2
1
1
6.1
6.3
3.3
3.7
5
4
3
2
11.1
9.5
8.3
6.7
39
35
27
20
38.6
36.8
32.9
29.0
2
2
1
1
3.3
3.4
1.8
1.8
8
7
5
4
7.9
7.4
6.1
5.8
___________________________________________________________________
Chapter 5
157
5.5
Discussion
5.5.1 Introduction
An appropriate workforce to address the oral health needs and demands of
the South African population has been described in a number of publications,
research reports, policy documents and position papers.
An overview of
major decisions and recommendation in this regard was presented in Chapter
2 (see Section 2.2.4, p 39).
The majority of reports on human resources in South Africa have highlighted
the inequitable distribution between urban and rural on the one side and the
private and public sectors on the other.
Recent reports and publication
suggested more appropriately trained human resources, for example the
NHRP proposed annual productions for the various members of the oral
health team (Department of Health, 2006a). In doing so it recognised that
consideration had to be given to mobility of health professionals to and from
the private sector, migration overseas and other attrition factors.
Three studies have been conducted in South Africa over the past number of
years investigating human resources required for oral health. Booyens (1994)
applied the WHO/FDI needs model (World Health Organization/Fédération
Dentaire Internationale, 1989) to the 1988/89 NOHS data (Department of
Health, 1994).
This study concluded that more oral hygienists should be
trained to address the need for more primary preventive dental services.
Van Wyk (1996) developed a model to determine the future human resource
needs for optimal health care for the total population of South Africa where the
actual demand for services was used as a point of departure. This study
concluded that the levels of human resources required for 2011 would be
difficult to attain and a programme of optimal fluoridation was suggested as an
absolute necessity to address oral health to the population of South Africa.
Kissoon-Singh (2001) also used the WHO/FDI needs based model (World
Health Organization/Fédération Dentaire Internationale, 1989) and the basic
___________________________________________________________________
Chapter 5
158
oral health care package (Department of Health, 2001a) to plan human
resources for oral health care for KwaZulu-Natal. This study concluded that
there was a gross shortage of oral health personnel to meet the oral health
needs of this province.
For this study the WHO/FDI human resources planning model (World Health
Organization/Fédération Dentaire Internationale, 1989) and a “Service
Targets Method” model were used to calculate the oral health human
resources required for the delivery of the minimum package of oral care to 4to 15-year-old children.
In both models total human resources and the
number of oral hygienists and dentists/dental therapists were calculated
separately. Both approaches assumed that the public oral health services
would not be responsible for delivering the minimum package of oral care to
children older than fifteen and that the oral hygienist would be responsible for
delivering the preventive care (group and individual), topical fluoride
application,
fissure
sealants
and
periodontal
care
and
the
dental
therapist/dentist the restorative care and extractions.
To illustrate the possible impact of the implementation of water fluoridation on
the number of oral health human resources required, treatment need
expressed as a percentage of the population or the mean number of teeth in
need of treatment (see Table 31, p 110 and Table 32, p 111) were adjusted
accordingly based on assumed caries reductions of 10%, 30% and 50%
which were applied to both the water fluoridation model and calculating the
cost of delivering the minimum package or oral care as well.
Considering the low caries prevalence observed from the 1999-2002 NCOHS
(Department of Health, 2003b), only results for an anticipated 30% caries
reduction due to the implementation of water fluoridation compared to no
water fluoridation will be discussed.
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Chapter 5
159
5.5.2 Oral health human resources required on a national level
In general on both the national and all provincial levels the number of human
resources required as calculated with the WHO/FDI model is less than the
numbers calculated with the “Service Targets Method” model (see Table 51, p
151).
The WHO/FDI model calculates that without the impact of water
fluoridation 510 oral health workers would be required to deliver the minimum
package of care to 4- to 15-year-olds compared to 679 with the “Service
Targets Method” model. Similarly at a 30% anticipated caries reduction the
number required would be 453 with the WHO/FDI model and 544 with the
“Service Targets Method” model.
A possible explanation for this is that the WHO/FDI model places a big
emphasis on prevention and control of disease, maintenance of health and
high quality restorative care whereas the “Service Targets Method” model
converts treatment need based on demand to FTE with all types of treatment
need considered as equal. For both models similar treatment times were
used for the calculations. The WHO/FDI model also requires DMFT data,
whereas the “Service Targets Method” model requires treatment need. Both
these datasets used in this study are from the 1999-2002 NCOHS
(Department of Health, 2003b). It can be argued that treatment need in this
survey might have been overestimated leading to more oral health workers
required as calculated with the “Service Targets Method” model.
It is clear from Table 51 (p 151) and both Figure 11 and Figure 12 (p 154),
irrespective of whether the WHO/FDI or the “Service Targets Method” models
were used for the calculations, that oral hygienists represent the majority of
oral health human resources required to deliver the minimum package of oral
care to 4- to 15-year-old children. This is not surprising as the minimum
package or oral care adopts a much more preventative approach, yet still
takes into consideration that active disease needs to be addressed as well
through restorative procedures and extractions.
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When the impact of the introduction of water fluoridation is taken into
consideration at an anticipated caries reduction of 30%, the impact is much
larger on the number of dentists and dental therapists required compared to
oral hygienists. With the WHO/FDI model (see Figure 11, p 154), compared
to when no water fluoridation has been introduced, the number of dentists
decrease from 31 to 22 (29%) and the number of dental therapists from 153 to
111 (27.5%), whereas the number of oral hygienists only decrease from 327
to 320 (2.1%). Similarly, with the “Service Targets Method” (see Figure 12, p
154), the number of dentists decrease from 54 to 38 (29.6%) and the number
of dental therapists from 272 to 191 (29.8%), whereas the number of oral
hygienists decrease from 352 to 315 (10.5%). This can be explained by water
fluoridation impacting on the number of restorations and extractions required,
whereas it has little impact on the required number of fissure sealants and
topical fluoride applications and no impact on group prevention and
prophylaxis. These procedures are all provided by oral hygienists.
When results are studied by the type of oral health worker, due to the
emphasis op prevention in both models used in this study, oral hygienists
represent more than 50% of oral health human resources required to deliver
the minimum package of oral care to 4- to 15-year-old children (see Table 53,
p 156). Dental therapists represent approximately 30 to 40% and dentists
less than 10% of the total human resources required to deliver the restorative
care and extraction components of the minimum package of oral care (see
Table 54, p 157).
The decreased need for oral health human resources as a result of the
implementation of water fluoridation, based on an anticipated 30% reduction
in dental caries, can be expressed as a monetary value by using the
remuneration paid to a senior oral hygienist, senior dental therapist and a
community service dentist employed in the public service as on 1 July 2006
(Department of Public Service and Administration, 2006).
The average
annual basic salary for both a senior oral hygienist and senior dental therapist
appointed on Level 7 in the public service is R106,700. If 30% is added to the
basic salary for benefits such as pension, medical insurance and bonuses,
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this amounts to R138,700 per annum. The average salary for a community
service dentist, including scarce skills allowance, overtime payment, pension,
medical insurance and bonuses is R259,000 per annum.
If the mean value of the reduction in the required human resources between
those calculated with the WHO/FDI and “Service Targets Method” models is
used, 12.5 less dentists (9 with the WHO/FDI and 16 with the “Service
Targets Method” model), 61.5 less dental therapists (42 with the WHO/FDI
and 81 with the “Service Targets Method” model) and 22 less oral hygienists
(7 with the WHO/FDI and 37 with the “Service Targets Method” model) would
be required to deliver the minimum package of oral care to 4- to 15-year-olds
at an anticipated 30% caries reduction due to the implementation of water
fluoridation. This converts to an annual saving in salary of R3,237,500 for
dentists, R8,530,050 for dental therapists and R3,051,400 for oral hygienists.
The total annual saving in salaries alone for all oral health human resources
combined would be R14,818,950 per year.
5.5.3 Oral health human resources required on a provincial level
Population size and treatment need are the two determining variables in
calculating human resources in both models. The great variation between
provinces for the total number of human resources required as well as the
different types of oral health workers can therefore be explained based on
these.
The 2006 South African mid-year population estimates indicate the
largest 4- to 15-year-old population to be in KwaZulu-Natal (2.7 million),
followed by the Eastern Cape (2 million), Gauteng (1.8 million) and Limpopo
(1.7 million) (Statistics South Africa, 2006).
Reports on the 1999-2002
NCOHS highlight the higher caries prevalence in provinces such as the
Western and Northern Cape with North West province recording some of the
lowest caries prevalence rates (Department of Health, 2003b; Van Wyk et al.,
2004).
This is reflected in higher treatment needs for the Western and
Northern Cape as well.
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According to both the WHO/FDI and “Service Targets Method” models,
without the impact of water fluoridation, KwaZulu-Natal would require the
highest number of human resources (114 and 142 respectively), followed by
the Eastern Cape (91 and 84) and Gauteng (74 and 102) (see Table 52, p
153). The lowest number of human resources to implement the minimum
package of oral care without the impact of water fluoridation are the Northern
Cape (10 and 22), North West (33 and 35), Mpumalanga (33 and 45) and the
Free State (33 and 47). Similar results are found for the number of oral
hygienists required (see Table 54, p 157).
For dentists and dental therapists combined the largest number are required
for KwaZulu-Natal (40 and 59), Eastern Cape (37 and 45), Western Cape (33
and 45) and Gauteng (25 and 49). The lowest number of dentists and dental
therapist are needed in the Northern Cape (4 and 17), North West (9 and 14),
Limpopo (11 and 47) and Free State (12 and 22) (see Table 51, p 151). This
can be explained mainly by the difference in caries prevalence for these
provinces.
5.6
Summary
This chapter presented the WHO/FDI and “Service Targets Method” models,
results and discussion to calculate the oral health human resources required
for the implementation of the minimum package of oral care to 4- to 15-yearold children, taking into account different scenarios for caries reduction
achieved through water fluoridation.
In general on both the national and all provincial levels the number of human
resources required as calculated with the WHO/FDI model is less than
calculated with the “Service Targets Method” model.
For both models oral hygienists represent more than 50% of the total oral
health human resources required to deliver the minimum package of oral care
to 4- to 15-year-old children.
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Dental therapists represent approximately 30 to 40% and dentists less than
10% of the total human resources required to deliver the restorative care and
extraction components of the minimum package of oral care.
The conclusions and recommendations from this study linked to water
fluoridation and delivering the basic package of oral care as well as the impact
on the required number of oral health human resources will be discussed in
Chapter 6.
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CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS
6.1
Conclusions
6.1.1 Cost evaluation of the implementation of water fluoridation in South
Africa
Decision makers in dental public health should continuously decide on which
community-based preventive procedures utilise limited resources optimally.
Due to its ease of implementation and equity associated with the artificial
fluoridation of public water supplies, it remains the first choice to expose the
public to the protective effect of fluoride.
Worldwide declines in dental caries and low caries prevalence in both
developed and developing countries, including South Africa, has led to the
cost-effectiveness of water fluoridation being questioned, especially in smaller
communities and towns.
White et al. (1989) identified ten variables related to the cost of water
fluoridation.
These include political costs (referenda and campaigning),
number of employees (labour cost), choice of chemicals (chemical cost), cost
of equipment and instrumentation, annual operational cost (electricity, rent,
insurance, shared space), maintenance (annual cost of testing equipment,
length of usefulness and replacement cost), natural fluoride content of
drinking water, the optimal level of fluoride in drinking water suggested for a
country, number of injection sites and cost of installation and consulting
engineers’ fees.
A model to determine the per capita cost, cost-effectiveness and cost-benefit
of the implementation of water fluoridation for seventeen major metropolitan
cities, towns and water boards from all nine South African provinces was
presented in Chapter 3. This model addressed eight of the ten variables
suggested by White et al. (1989). Regulations for the implementation of water
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fluoridation for South Africa make provision for consultation with and informing
the public (Republic of South Africa, 2000). It is therefore fair to assume that
political costs for South Africa will be limited to public communication without
referenda. A National Fluoridation Survey conducted in 1998 indicated that
the majority of respondents (61.9%) agreed that fluoride should be added to
water, 9% disagreed with the remaining 29.1% unsure. (Chikte and Brand,
1999; Chikte and Brand, 2000; Chikte et al., 2000).
Operational costs such as electricity, rent, insurance and shared space was
not included in the model, but it can be assumed that this would have
represented only a small portion of the total operational cost.
When this model was applied to seventeen major metropolitan cities, towns
and water boards from all nine South African provinces, results clearly show
that despite a low prevalence of dental caries in South African children,
artificial fluoridation of drinking water remains the community-based
preventive measure of choice for South Africa.
The average per capita cost
for all municipalities and water providers is R2.08 per annum, which is
extremely low compared to the cost other fluoride vehicles. Other additional
benefits of artificially fluoridated water include that it is equitable and passive
without direct interaction with a dental provider required.
Results of this study also clearly show that cost-effectiveness and cost-benefit
at an anticipated 30% reduction in caries levels as a result of the introduction
of water fluoridation is highly favourable. Even at an anticipated 10% caries
reduction level, cost-benefit only approached or slightly exceeded a ratio of
0.8 for three municipalities.
Two previous South African studies described the economics of water
fluoridation for Gauteng. Smalberger (1998) calculated the per capita cost for
Gauteng (based on information supplied by Rand Water in 1995) as R0.11 for
poor households and R2.40 for affluent households. At an estimated caries
reduction of 25%, saving per person per year varied from R11.70 to
R26.60. Based on information supplied between 1998 and 2000, Van Wyk et
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al. (2001) calculated the per capita cost for Gauteng as R0.73 and costeffectiveness and cost-benefit at an anticipated caries reduction of 30%
as R6.58 and 0.07 respectively, compared to this study where the per capita
cost for Gauteng (Rand Water) was calculated as R2.06 and costeffectiveness and cost-benefit at an anticipated caries reduction of 30%
as R34.18 and 0.2 respectively. Reasons for the difference between the Van
Wyk et al. (2001) and this study is a decline in caries prevalence (DMFT for
15-year-olds of 3.3 used by Van Wyk et al. (2001) compared to 1.81 for the
current study) and the impact of inflation.
The model presented in this study does not take into account the impact of
water fluoridation on physical, social and emotional well-being or changes in
quality of life as a result of its introduction. An increase in the number of
caries free teeth and declines in caries incidence will without doubt have a
positive outcome on these indicators. These include cosmetic advantages of
caries free unrestored teeth, reduced discomfort associated with dental
treatment, reduction in the number of dental visits and the associated loss of
employment time and absenteeism from school or work to have the treatment
performed.
The WHO in collaboration with the FDI and the IADR hosted a global
consultation on “Oral Health through Fluoride” from 17-19 November 2006. A
declaration from this consultation reaffirmed the efficiency, cost-effectiveness
and safety of the daily use of optimal fluoride and that access to fluoride for
dental health formed part of the basic human right to health (Fédération
Dentaire Internationale, 2006).
6.1.2 Cost evaluation of delivering the minimum package of oral care to South
African children
Adoption of the PHC approach and reducing the incidence of common oral
diseases through a minimum package of care, water fluoridation, and
reduction of the consumption of refined sugar were identified as the main
principles to address oral health (Republic of South Africa, 1997b). The South
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African National Oral Health Strategy (Department of Health, 2005) listed the
provision of appropriate disease prevention and health promotion measures
based on the minimum package of care on a district level.
According to the 1999-2002 NCOHS (Department of Health, 2003b; Van Wyk
et al., 2004) dental caries is more severe in the primary dentition compared to
the permanent dentition.
Although caries levels for 12-year-olds range
between very low and low according to the WHO classification (Barmes,
1977), high levels of untreated caries in all provinces is of major concern.
The population under fifteen years of age in South Africa is around 14.3
million which is approximately 32% of the total population (Statistics South
Africa, 2003).
The introduction of water fluoridation to major metropolitan areas and larger
towns will impact on the number of caries lesions.
Restorative dentistry
should be simpler as lesions will develop slower and be smaller.
In the
majority of cases these will be limited to occlusal surfaces as regular
exposure to fluoride protects mainly the smooth surfaces of the tooth. This
will impact on the human resources required to address especially dental
caries.
A model to express the delivery of the minimum package of oral health care
as a per capita cost was presented in Chapter 4. This model was applied to
4- to 5-, 6-, 12- and 15-year-olds based on treatment need data from the
1999-2002 NCOHS (Department of Health, 2003b; Van Wyk et al., 2004)
which was converted to a cost by applying the 2006 NRPL (Council for
Medical Schemes, 2006) and UPFS (Gauteng Provincial Government, 2005)
treatment fees on a national level as well as for all nine South African
provinces.
To illustrate the possible impact of the implementation of water fluoridation on
the cost of delivering the minimum package or oral care, treatment need was
adjusted accordingly based on assumed caries reductions of 10%, 30% and
50% as a result of the introduction of water fluoridation.
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At an anticipated caries reduction of 30% where the cost of an oral
examination and bitewing radiographs were excluded, per capita cost for
delivering the minimum package of oral care ranges from R133.45 for 4- to 5year-olds to R227.10 for 6-year-olds with the cost of restorations and
extractions as the major contributor.
Results varied greatly between provinces with those provinces where the
highest treatment need exists (Western and Northern Cape) presenting with
the highest per capita cost of delivering the minimum package of care. At an
anticipated 30% caries reduction due to water fluoridation these were
calculated as R215.56 for the Northern Cape and R285.28 for the Western
Cape.
6.1.3 Oral health human resources needs for South African children
The four approaches to human resources planning are the human resources
to population ratio, health needs, health demands approach and the service
targets approach (Hall, 1978). The WHO/FDI model translates need into FTE
of oral health personnel required to provide a calculated level of care based
on
time
estimates
for
each
treatment
type
(World
Health
Organization/Fédération Dentaire Internationale, 1989). This model makes
provision for modifying factors such as demand.
Human resources planning for oral health in South Africa has received a lot of
attention. This was reviewed in Chapter 2 (see Section 2.2.4, p 39). Despite
several committees and commissions reporting on oral health, very few have
been taken seriously and only a limited number of recommendations have
been implemented.
Since 1994 three postgraduate studies and reports into human resources for
the new South Africa have been published. Booyens (1994) reported on
human resources needed to deliver primary preventive services. A modified
version of the WHO/FDI human resources model was used in this study. Van
Wyk (1996) reported on human resources needed based on the principles of
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supply and demand taking into consideration modifying factors, treatment
needs and trends. Kissoon-Singh (2001) reported on a human resources plan
for oral health care for the province of KwaZulu-Natal. The WHO/FDI human
resources model was used for the calculations.
A new debate on human resources planning for oral health was triggered with
the publication of the NHRP for South Africa (Department of Health, 2006a)
building on recommendations from the Pick report (Pick et al., 2001).
The Pick report used computer simulation models developed by the WHO and
historical information from registers of the statutory councils to project supply
of a number of health workers, including oral health, over a thirty year period
to 2029 using different demographic assumptions (Pick et al., 2001). The
report suggested the creation of a single dental auxiliary to replace the oral
hygienist and dental therapist, a downward revision of the annual intake of
dental students, dental assistants in underserved areas should receive a one
year training by dentists to perform simple procedures such as the ART and
the scope of the dental therapist should be expanded to include placement
and removal of sutures and removable orthodontic appliances and care of
wounds and finally a projected requirement for 2029 of 6,413 dentists and 435
oral hygienists.
The NHRP for Health for South Africa provided a framework to guide all
stakeholders to ensure an adequate workforce in partnership with government
(Department of Health, 2006a).
The NHRP proposed an annual production
of 120 dental practitioners by 2008, 600 dental therapists by 2009,
maintaining current levels of dental technicians, 150 oral hygienists by 2009
and 300 dental assistants by 2008. In a response to the NHRP the editor of
the SADJ on behalf of the SADA
(Campbell, 2006) criticised the
recommendation made for dentists, but welcomed the suggested increase in
the production of oral hygienists. It furthermore expressed concern on the
suggested number of dental therapists to be trained, especially since current
facilities are only equipped to train 300 dentists/dental therapists per year.
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In this study the WHO/FDI human resources planning model (World Health
Organization/Fédération Dentaire Internationale, 1989) and a “Service
Targets Method” model were used to calculate oral health human resources
required for the delivery of the minimum package of oral care to 4- to 15-yearold. In both models total human resources and the number of oral hygienists
and dentists/dental therapists were calculated separately. Both approaches
assumed that the public oral health services would not be responsible for
delivering the minimum package of oral care to children older than fifteen and
that the oral hygienist would be responsible for delivering the preventive
(group and individual), topical fluoride application, fissure sealants and
periodontal care and the dental therapist/dentist the restorative care and
extractions.
Without the impact of water fluoridation taken into consideration, the number
of human resources required to deliver the minimum package of oral care was
calculated as 510 with the WHO/FDI model (327 oral hygienists, 31 dentists
and 153 dental therapists) and 679 with the “Service Targets Method” (352
oral hygienists, 54 dentists and 272 dental therapists).
When an anticipated caries reduction of 30% is taken into consideration with
the introduction of water fluoridation, the impact is much larger on the number
of dentists and dental therapists required compared to oral hygienists. With
the WHO/FDI model, compared to when no water fluoridation has been
introduced, the number of dentists decrease from 31 to 22 (29%) and the
number of dental therapists from 153 to 111 (27.5%), whereas the number of
oral hygienists decrease from 327 to 320 (2.1%). Similarly, with the “Service
Targets Method”, the number of dentists decrease from 54 to 38 (29.6%) and
the number of dental therapists from 272 to 191 (29.8%), whereas the number
of oral hygienists decrease from 352 to 315 (10.5%). This can be explained
by water fluoridation impacting on the number of restorations and extractions
required, whereas it has little impact on the required number of fissure
sealants and topical fluoride applications and no impact on group prevention
and prophylaxis. These procedures are all provided by oral hygienists.
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When this decreased need for oral health human resources is expressed as a
monetary value by using the remuneration paid to a senior oral hygienist,
senior dental therapist and a community service dentist employed in the
public service as on 1 July 2006 (Department of Public Service and
Administration, 2006), it converts to an annual saving of R3,237,500 for
dentists, R8,530,050 for dental therapists and R3,051,400 for oral hygienists.
The total annual saving in salaries alone for all oral health human resources
to deliver the minimum package of oral care to 4- to 15-year-olds at an
anticipated 30% caries reduction due to the implementation of water
fluoridation would be R14,818,950.
Although this study was limited to calculating the number of human resources
required to deliver the minimum package of oral care to 4- to 15-year-olds
only, the results would support an increase in the training of oral hygienists to
be employed in mainly the public sector.
The majority of restorative
procedures and extractions required as part of the minimum package of oral
care can be provided by a dental therapist.
As of 30 March 2007, 961 oral hygienists, 456 dental therapists and 4,792
dentists were registered with the HPCSA (Health Professions Council of
South Africa, 2007). It would require 35% or oral hygienists and between
34% and 60% of dental therapists currently registered with the HPCSA to
deliver the minimum package of oral care to 4- to 15-year-old children.
In terms of the Medical, Dental and Supplementary Health Service
Professions Amendment Act, 1997 (Act 89 of 1997) (Republic of South Africa,
1997a), one year of CCS in the public sector was introduced for dentists in
July 2000. These numbers should be sufficient to address that component of
the minimum package of oral care where a dentist is required.
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6.2
Recommendations
Despite declines in caries incidence worldwide, artificial fluoridation of drinking
water is still regarded as a viable public health measure. Public health
professionals at a national, provincial and local level need to enhance their
promotion of fluoride and commit the necessary resources for equipment,
personnel and training.
Currently no artificially fluoridated water scheme exists in South Africa,
despite a Commission of Inquiry into water fluoridation recommending the
fluoridation of public water supplies to the optimal fluoride concentration
(Republic of South Africa, 1966) and regulations for the introduction of water
fluoridation in South Africa which were promulgated on 8 September 2000
(Republic of South Africa, 2000) which compel water providers to fluoridate
public water supplies. These regulations were repealed with the repealing of
the Health Act of 1977 and have been amended and will follow the normal
legal process for approval (Smit, 2007).
This study confirms that in view of a low per capita cost, favourable costeffectiveness and cost-benefit ratios, which will result in huge savings in the
cost of treatment, artificial fluoridation of drinking water remains a feasible
community-based preventive option for South Africa, even if only a 10%
caries reduction as a result of its introduction is achieved.
Evidence exists
that fluoridation has the effect of reducing the dental caries disparities
between different socio-economic status groups (Burt, 2002), which on its
own is a major reason, especially for South Africa, to seriously consider its
introduction.
It is strongly recommended that the NFC should use this model and the
results from this investigation to convince water providers and local authorities
about the benefits of this measure, provided that the national and provincial
Departments of Health, who will be the main beneficiaries of improved oral
health, make available resources to municipalities and water providers to
subsidise its introduction.
The national Department of Health should also
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launch an information campaign to inform the public of all aspects of the
artificial fluoridation of drinking water.
Water fluoridation does not only lead to improved oral health, but will also
result in a change in need and demand for oral health services which will
translate to a decrease in human resource requirements.
Although the introduction of water fluoridation will impact on caries incidence,
caries will still develop. It is strongly recommended that all provinces should
actively pursue the introduction of the suggested minimum package of oral
care to all children aged younger than fifteen to address especially the large
untreated caries component. Appropriate modes of delivery, such as mobile
oral health units and equipment, must be investigated to deliver the service to
as wide a community as possible in the most cost-effective way. Per capita
cost of delivering the minimum package of care will be reduced as a result of
the impact of water fluoridation.
To deliver the minimum package of oral care according to the White Paper for
the Transformation of Health Services in South Africa (Republic of South
Africa, 1997b), will require the creation of a number of posts as well as
incentives to attract especially oral hygienists to the public service.
The
recommendations from the NHRP to increase the number of oral hygienists
(Department of Health, 2006a) is supported by this study.
This study does
not recommend an increase in the training of the number of dental therapists,
or the suggested creation of a single dental auxiliary to replace the oral
hygienist and dental therapist. The minimum package of oral care places
great emphasis on preventive services for which an oral health worker
dedicated to prevention, such as an oral hygienist, already exists.
A change in regulations in 1993 to allow dental therapists to enter the private
sector and open their own practices, combined with poor salaries and limited
career opportunities were listed as the main reasons for dental therapists
resigning in large numbers from the public service (Prinsloo, 1994).
This
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decision and its impact remains controversial and especially the SADA has
made its view on this clear on a number of occasions.
A position paper on dental therapists (South African Dental Association, 2000)
recommended an immediate moratorium on the training of dental therapist
until all key stakeholders have debated this issue. It also urged the HPCSA
to rescind the decision to allow dental therapists to practice independently as
this was seen as not to be in the best interest of the public sector, especially
since the intention was that dental therapists be employed in this sector. In
response to the NHRP, the SADA once again called for meaningful
negotiations with all stakeholders to address the future of the dental therapy
profession (Campbell, 2006).
Results from this study clearly illustrate an urgent need for dental therapists in
the public service.
Until adequate numbers of oral hygienists have been
trained and the future of dental therapists investigated, it is recommended that
CCS be expanded to include both oral hygienists and dental therapists with
the primary objective of focusing on the delivery of the minimum package of
care to children younger than fifteen.
When training institutions, in
collaboration with the Department of Health and professional bodies, decide
on the appropriate numbers to be trained, the envisaged introduction of water
fluoridation and its subsequent impact on caries levels should always be
taken into account.
A summary of the recommendations from this study are presented in Table
55.
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Table 55: Summary of recommendations from this study
Cost evaluation of the implementation of water fluoridation in South Africa:
• In view of a low per capita cost, favourable cost-effectiveness and cost-benefit
ratios as well as the effect of reducing the dental caries disparities between
different socio-economic status groups, water fluoridation remains a viable option
for South Africa, even if only a 10% caries reduction as a result of its introduction
is achieved;
• The NFC should use this model and the results from this investigation to
convince water providers and local authorities about the benefits of this measure;
• The national and provincial Departments of Health, who will be the main
beneficiaries of improved oral health, should make available resources to
municipalities and water providers to subsidise its introduction; and
• The national Department of Health should launch an information campaign to
inform the public of all aspects of the artificial fluoridation of drinking water.
Cost evaluation of delivering the minimum package of oral care to South
African children:
• All provinces should actively pursue the introduction of the minimum package of
oral care to all children aged younger than fifteen to address especially the large
untreated caries component; and
• Appropriate modes of delivery such as mobile oral health units and equipment
must be investigated to deliver the service to as wide a community as possible in
the most cost-effective way.
Oral health human resources needs for South African children:
• The creation of a number of posts as well as incentives to attract especially oral
hygienists to the public service will be required to deliver the minimum package of
oral care;
• An increase in the number of oral hygienists trained;
• To ensure a focus on preventive services the creation of a single dental auxiliary
to replace the oral hygienist and dental therapist is not supported;
• Meaningful negotiations with all stakeholders to address the future of the dental
therapy profession and attracting this profession back to the public sector is
urgently required;
• CCS be expanded to include both oral hygienists and dental therapists with the
primary objective of focusing on the delivery of the minimum package of care to
children younger than fifteen; and
• The possible impact of the introduction of water fluoridation on human resources
should always be considered in planning the number of oral health professionals
to be trained.
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Company.
Wright, J. C., Bates, M. N., Cutress, T. and Lee, M. 2001. The cost-effectiveness of fluoridating water
supplies in New Zealand. Australian & New Zealand Journal of Public Health, 25, 170-178.
Zietsman, S. 1991. Spatial variation of fluorosis and fluoride content of water in an endemic area in
Bophuthatswana. Journal of the Dental Association of South Africa, 46, 11-15.
___________________________________________________________________
Bibliography
186
ANNEXURES
ANNEXURE 1: PER CAPITA COST, COST-EFFECTIVENESS AND
COST-BENEFIT OF THE IMPLEMENTATION OF WATER
FLUORIDATION
FOR
THE
CITY
OF
TSHWANE
METROPOLITAN MUNICIPALITY (PRETORIA)
Category A: >700 Ml/day
Category B: <700; >100 Ml/day
Category C: <100 Ml/day
Chemical name
Chemical formula
Molecular mass
[a] Available fluoride
[b] Purity
Note: Data is needed for all shaded fields
City
Category
Tshwane (Pretoria)
Category A
Fluorosilicic acid
H2SiF6
144.08
79.1%
40.0%
Variable
(A) CHEMICAL COST:
[1] Daily water purification rate (litre per day)
[2] Natural fluoride content of water (mg F/litre)
[3] Adjustment of fluoride level to (mg F/litre)
[4] Fluoride needed per day (metric tonne)
[5] Fluoride needed per year (metric tonne)
[6] Chemical needed per year (metric tonne)
[7] Cost of chemical (Rand per metric tonne)
[8] Percentage handling fee by agent
[9] Delivery cost (metric tonne)
[10] Total delivery cost of chemical
(A) Cost of chemical per year
(B) LABOUR COST:
[11] Average operator salary
[12] Number of operators needed
[13] Annual operator salary for number of operators needed
[14] Number of hours needed per operator per day
(B) Annual labour cost for number of hours needed per day
(C) MAINTENANCE COST:
[15] Capital cost per Mega litre of water processed
[16] Percentage cost of buildings and storage
[17] Cost of buildings and storage
[18] Percentage cost of mechanical and electrical plant
[19] Cost of mechanical and electrical plant
[20] Total capital cost
[21] Percentage
(C) Maintenance cost: % of total capital cost
Formula
[1]x([3]-[2])/(1 x 109)
[4]x365
[5]/([a]*[b])
[7]+([7]x[8]/100)+[9]
[6]*[10]
[11]x[12]
[13]/8x[14]
[1]/1,000,000*[15]*[16]/100
[1]/1,000,000*[15]*[18]/100
[17]+[19]
[20]x[21]/100
Value
722,000,000
0.20
0.7
0.36
131.77
416.45
R7,044.00
12.5
R180.00
R8,104.50
R3,375,124.66
R255,162.87
6
R1,561,596.77
1
R195,199.60
R8,750.00
21
R1,326,675.00
79
R4,990,825.00
R6,317,500.00
2.4
R151,620.00
___________________________________________________________________
Annexure 1
187
Variable
(D) OPPORTUNITY COST:
[22] Prime Overdraft Rate of Banks
(D) Opportunity cost: % of total capital cost
(E) CAPITAL DEPRECIATION:
[23] Years for building and storage
[24] Capital depreciation of buildings and storage
[25] Years for mechanical and electrical plant
[26] Capital depreciation of mechanical and electrical plant
(E) Total capital depreciation per annum
(F) OPERATING COST:
Chemical cost + Labour cost + Maintenance cost
(G) TOTAL COST:
Opportunity cost + Capital depreciation + Operating cost
(H) PER CAPITA COST:
[27] Population served by water provider
[28] Per capita cost for total population
[29] Percentage of population younger than 15 years
[30] Population served by water scheme younger than 15 years
[31] Per capita cost younger than 15 years
(I) CARIES DATA
[32] DMFT
[33] Age for DMFT score
[34] DMFT increment per year
Formula
[20]x[22]/100
[17]/[23]
[19]/[25]
[24]+[26]
Value
11.5
R726,512.50
15
R88,445.00
8
R623,853.13
R712,298.13
(A)+(B)+(C)
R3,721,944.26
(D)+(E)+(F)
R5,160,754.88
(G)/[27]
[27]x[29]/100
(G)/[30]
2,100,000
R2.46
26.46
555,660
R9.29
[32]/([33]-6)
Variable
Formula
Value
(J) COST-EFFECTIVENESS (the cost per person per year to save 1 DMFT)
[35] Decrease in caries incidence (%)
10
30
[36] Decrease in DMFT per child per year
[35]/100x[34]
0.02
0.06
[28]/[36]
(J) Cost-effectiveness for total population
R122.20
R40.73
(J) Cost-effectiveness for population younger
[31]/[36]
R461.81
R153.94
than 15 years
(K) COST-BENEFIT RATIO (the cost of implementation of water fluoridation divided by savings in cost of
treatment)
[37] Cost of a 2 surface amalgam restoration
R155.90
[38] Cost of a 2 surface anterior resin restoration
R174.60
[39] Cost of a 2 surface posterior resin restoration
R186.20
[40] Average cost of a 2 surface restoration
([37]+[38]+[39])/3
R172.23
[28]/([36]x[40])
(K) Cost-benefit ratio for total population
0.71
0.24
(K) Cost-benefit ratio for population younger than
[31]/([36]x[40])
2.68
0.89
15 years
___________________________________________________________________
Annexure 1
188
1.81
15
0.20
50
0.10
R24.44
R92.36
0.14
0.54
ANNEXURE 2: DETAILED INFORMATION ON WATER PROVIDERS
Classification of water providers:
• Category A: Water purification rate of more than 700 Mega litre per day
•
Category B: Water purification rate of less than 700 and more than 100 Mega
litres per day
•
Category C: Water purification rate of less than 100 Mega litres per day
Number of plant superintendents required:
• Water purification rate of more than 250 Mega litre per day: 4 plant
superintendents
•
Water purification rate between 100 and 249 Mega litre per day: 3 plant
superintendents
•
Water purification rate between 50 and 99 Mega litre per day: 2 plant
superintendents
•
Water purification rate less than 50 Mega litre per day: 1 plant superintendent
•
Water purification rate less than 1 Mega litre per day: Assumed that
superintendents from other plants service this plant
Salary adjustments:
Information on salaries of plant superintendents was supplied in 2004. Adjustments
for 2005 and 2006 were based on the annual salary adjustments recommended by
the Department of Public Service and Administration for post levels 1 to 12
(Department of Public Service and Administration, 2005; Department of Public
Service and Administration, 2006):
•
2005: 4.6% adjustment of 2004 salary rates
•
2006: 5.3% adjustment of 2005 salary rates
___________________________________________________________________
Annexure 2
189
Category A water providers:
• Cape Town
Plant
Faure
Blackheath
Wemmershoek
Voëlvlei
Steenbras
Witzands
Kloof Nek
Somerset West
Brooklands
Albion Spring
Constantia Nek
Total
•
Current production
(Ml/day)
188.3
190
195.3
154
86.2
17.1
12.4
2.1
2.7
1.1
1.1
850.3
3,350,000
Plant
superintendents
3
3
3
3
2
1
1
Same team as Faure
1
Unmanned
1
18
Salary (2006)
R558,237.42
R558,237.42
R558,237.42
R558,237.42
R372,158.28
R186,079.14
R186,079.14
R186,079.14
R186,079.14
R3,349,424.49
Umgeni Water
Plant
Midmar
D.V. Harris
Durban Heights
Wiggins
Hazelmere
Amanzimtoti
Mtwalumi
Craigie Burn
Umzinto
Umbumbulu
Ixopo
Total
•
Population served
Current production
(Ml/day)
250
45
613
120
30
25
4
4
12
2.5
2
1,107.5
Population served
800,000
150,000
1,750,000
500,000
40,000
75,000
15,000
15,000
60,000
10,000
7,000
3,422,000
Plant
superintendents
4
1
4
3
1
1
1
1
1
1
1
19
Salary (2006)
R1,101,438.00
R275,359.50
R1,101,438.00
R826,078.50
R220,287.60
R220,287.60
R220,287.60
R220,287.60
R220,287.60
R220,287.60
R220,287.60
R4,846,327.20
Durban/Pietermaritzburg combined
Plant
Midmar
D.V. Harris
Durban Heights
Wiggins
Hazelmere
Amanzimtoti
Total
Current production
(Ml/day)
250
45
613
120
30
25
1,083
Population served
800,000
150,000
1,750,000
500,000
40,000
75,000
3,315,000
Plant
superintendent
4
1
4
3
1
1
14
Salary (2006)
R1,101,438.00
R275,359.50
R1,101,438.00
R826,078.50
R220,287.60
R220,287.60
R3,744,889.20
___________________________________________________________________
Annexure 2
190
•
Durban
Plant
Current production
Salary (2006)
Population served
superintendent
(Ml/day)
R660,862.80
2.4
150
Midmar (60%)
R165,215.70
0.6
27
D.V. Harris (60%)
R1,101,438.00
4
613
Durban Heights
R826,078.50
3
120
Wiggins
R220,287.60
1
30
Hazelmere
R220,287.60
1
25
Amanzimtoti
R200,000.00
1
4
Craigie Burn
R200,000.00
1
2.5
Umbumbulu
Total
971.5
3,064,624
14
R3,594,170.20
Note: 60% of water processed by the Midmar and D.V. Harris plants (Umgeni Water) is supplied to
Durban, therefore Durban is responsible for 60% of the cost of superintendents for these plants
Plant
•
Rand Water
Plant
Current production
(Ml/day)
Vereeniging
Zuikerbosch
Total
•
Population served
3,558
12,000,000
Plant
superintendent
4
4
8
Salary (2006)
R1,101,438.00
R1,101,438.00
R2,202,876.00
Johannesburg
Plant
Salary (2006)
superintendent
1.44
R396,517.68
Vereeniging (36%)
1.44
R396,517.68
Zuikerbosch (36%)
Total
1,280
3,225,608
2.88
R793,035.36
Note: 36% of water processed by the Vereeniging and Zuikerbosch plants (Rand Water) is supplied
to Johannesburg, therefore Johannesburg is responsible for 36% of the cost of superintendents for
these plants
Plant
•
Current production
(Ml/day)
Population served
Tshwane (Pretoria)
Current
Population
Plant
Salary (2006)
Plant
production
served
superintendent
(Ml/day)
R250,638.83
1
40
Rietvlei
R501,277.65
2
60
Temba
R501,277.65
2
60
Roodeplaat
Unmanned
65
Fonteine, Grootfontein, Sterkfontein
R308,402.64
1.12
497
Rand Water (14%)
Total
722
2,100,000
6.12
R1,561,596.77
Note: 14% of water processed by Rand Water is supplied to Tshwane, therefore Tshwane is
responsible for 14% of the cost of superintendents for these plants
___________________________________________________________________
Annexure 2
191
Category B water providers:
• Port Elizabeth
Plant
Linton
Loerie
Churchill
Elandsjagt
Groendal
Springs
Nooitgedacht
Total
•
Population served
1,200,000
Plant
superintendent
1
2
2
2
1
Unmanned
2
10
Salary (2006)
R201,563.15
R403,126.31
R403,126.31
R403,126.31
R201,563.15
R403,126.31
R2,015,631.54
Amatola Water
Plant
Sandile
Laing
Nahoon
Peddie
Binfield Park
Wesley Coastal
Mascincedane
Debe Nek
Rooikrantz
Pleasant View
Dabi
Upper Mnyameni
Glenmore
Upper Gxulu
Total
•
Current production
(Ml/day)
11
65
70
65
15
6
50
282
Current production
(Ml/day)
18
27.3
33.7
6.56
4.8
4.3
2.2
1.5
1.2
0.75
0.72
0.56
0.5
0.11
102.2
Population served
1,210,286
Plant
superintendent
1
1
1
1
1
1
1
1
1
9
Salary (2006)
R132,172.56
R132,172.56
R132,172.56
R132,172.56
R132,172.56
R132,172.56
R132,172.56
R132,172.56
R132,172.56
R1,189,553.04
Pietermaritzburg
Plant
Current production
Salary (2006)
Population served
superintendents
(Ml/day)
1.6
R440,575.20
Midmar (40%)
100
0.4
R110,143.80
D.V. Harris (40%)
18
Total
118
500,000
2
R550,719.00
Note: 40% of water processed by the Midmar and D.V. Harris plants (Umgeni Water) is supplied to
Pietermaritzburg, therefore Pietermaritzburg is responsible for 40% of the cost of superintendents for
these plants
Plant
___________________________________________________________________
Annexure 2
192
•
Bloem Water
Current production
(Ml/day)
120
30
5
4
2.2
1
3.5
165.7
Plant
Welbedacht
Rustfontein
Groothoek
Bethulie
Gariep
Philippolis
Sterkspruit
Total
•
Population served
600,000
330,000
25,000
24,000
4,000
4,000
40,000
1,027,000
Plant
superintendents
3
1
1
1
1
1
1
9
Salary (2006)
R712,178.80
R237,392.93
R237,392.93
R237,392.93
R237,392.93
R237,392.93
R237,392.93
R2,136,536.39
Bloemfontein
Plant
Current production
Salary (2006)
Population served
superintendents
(Ml/day)
Welbedacht (88%)
105.6
528,000
2.64
R626,717.34
Rustfontein (4%)
1.2
13,200
0.04
R9,495.72
Total
106.8
541,200
2.68
R636,213.06
Note: 88% of water processed by the Welbedacht and 4% of the Rustfontein plants (Bloem Water) is
supplied to Bloemfontein, therefore Bloemfontein is responsible for 88% and 4% of the cost of
superintendents for these plants
Plant
•
Kimberley
Plant
Riverton
Ritchie
Total
Current production
(Ml/day)
128
1.7
129.7
Population served
223,000
Plant
superintendents
3
1
4
Salary (2006)
R454,607.52
R151,535.84
R606,143.36
Category C water providers:
• Buffalo City (East London)
Plant
Sandile
Laing
Nahoon
Total
•
Current production
(Ml/day)
18
27.3
33.7
79
Population served
677,379
Plant
superintendents
1
1
1
3
Salary (2006)
R132,172.56
R132,172.56
R132,172.56
R396,517.68
Botshabelo
Plant
Current production
Salary (2006)
Population served
superintendents
(Ml/day)
Rustfontein (93%)
27.9
306,900
0.93
R200,442.90
Note: 93% of water processed by the Rustfontein plant (Bloem Water) is supplied to Botshabelo,
therefore Botshabelo is responsible for 93% of the cost of superintendents for these plants
Plant
___________________________________________________________________
Annexure 2
193
•
Mafikeng
Plant
Mmabatho
Mafikeng
Total
•
Population served
170,000
Plant
superintendents
1
1
2
Salary (2006)
R137,679.75
R137,679.75
R275,359.50
Nelspruit
Plant
Nelspruit
Matsulu
Total
•
Current production
(Ml/day)
10
27
37
Current production
(Ml/day)
28
14
42
Population served
35,000
60,000
95,000
Plant
superintendents
1
1
2
Salary (2006)
R132,172.56
R132,172.56
R264,345.12
Polokwane
Plant
Polokwane
Seshego
Houtrivierdam
Molepodam
Chuenespoortdam
Total
Current production
(Ml/day)
16
2
3
2
1
24
Population served
47,565
70,991
53,600
28,400
200,556
Plant
superintendents
1
1
1
1
1
5
Salary (2006)
R109,477.43
R109,477.43
R109,477.43
R109,477.43
R109,477.43
R547,387.15
___________________________________________________________________
Annexure 2
194
ANNEXURE 3: PER CAPITA COST OF DELIVERING THE MINIMUM
PACKAGE OF ORAL CARE TO THE 15-YEAR-OLD AGE
COHORT
Anticipated % caries reduction due to water fluoridation
Variable:
[1]
[2]
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
100
100
100
100
100
100
100
100
100
100
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
100
100
100
100
100
100
100
100
100
100
Mean no
of sextants
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
3.31
3.27
2.30
2.88
3.95
3.57
3.31
2.57
1.97
4.41
% needing
care
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
57.67
85.20
62.20
49.70
66.60
59.00
47.10
31.30
44.90
24.10
0
NRPL 2006
Examination/bitewings included
[3]; [4]
[7]
[8]
Examination
Fee code: 8101
% of
Per capita
Fee: R103.50
total
cost
R102,216,600.00
19.23
R103.50
R8,795,430.00
12.98
R103.50
R1,773,990.00
16.40
R103.50
R18,083,520.00
23.87
R103.50
R6,421,140.00
17.04
R103.50
R22,331,160.00
20.51
R103.50
R14,427,900.00
19.60
R103.50
R7,967,430.00
26.60
R103.50
R7,410,600.00
21.31
R103.50
R15,005,430.00
18.98
R103.50
Bitewings
Fee code: 8112
% of
Per capita
Fee: R41.90
total
cost
R82,760,880.00
15.57
R83.80
R7,121,324.00
10.51
R83.80
R1,436,332.00
13.27
R83.80
R14,641,536.00
19.32
R83.80
R5,198,952.00
13.80
R83.80
R18,080,688.00
16.61
R83.80
R11,681,720.00
15.87
R83.80
R6,450,924.00
21.53
R83.80
R6,000,080.00
17.25
R83.80
R12,149,324.00
15.36
R83.80
Prophylaxis
Fee code: 8159
% of
Per capita
Fee: R124.90
total
cost
R92,760,132.48
17.45
R93.92
R8,883,919.67
13.12
R104.54
R1,389,370.11
12.84
R81.06
R18,374,568.58
24.25
R105.17
R4,835,248.70
12.83
R77.94
R19,510,658.98
17.92
R90.43
R13,093,117.12
17.79
R93.92
R6,441,917.34
21.50
R83.68
R6,099,016.88
17.53
R85.18
R14,124,241.56
17.86
R97.42
Consultation
Examination/bitewings excluded
[3]; [4]
[7]
[8]
Fee code: 8159
Fee: R124.90
R92,760,132.48
R8,883,919.67
R1,389,370.11
R18,374,568.58
R4,835,248.70
R19,510,658.98
R13,093,117.12
R6,441,917.34
R6,099,016.88
R14,124,241.56
% of
total
26.76
17.14
18.26
42.69
18.55
28.50
27.57
41.46
28.54
27.20
Per capita
cost
R93.92
R104.54
R81.06
R105.17
R77.94
R90.43
R93.92
R83.68
R85.18
R97.42
___________________________________________________________________
Annexure 3
195
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
9.20
3.30
2.00
7.20
3.80
10.80
9.20
12.30
12.40
9.20
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
1.48
3.38
0.13
0.03
2.23
1.55
1.48
0.52
0.14
1.48
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.83
1.60
1.31
0.63
1.30
0.60
0.83
0.44
0.92
0.83
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.30
0.54
0.73
0.14
0.27
0.29
0.30
0.12
0.31
0.30
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.21
0.48
0.41
0.29
0.17
0.19
0.05
0.05
0.15
0.27
Topical fluoride application
Fee code: 8161
% of
Per capita
Fee: R63.60
total
cost
R5,776,935.88
1.09
R5.85
R178,356.02
0.26
R2.10
R21,802.08
0.20
R1.27
R800,077.82
1.06
R4.58
R149,938.27
0.40
R2.42
R1,482,012.29
1.36
R6.87
R815,416.02
1.11
R5.85
R602,199.14
2.01
R7.82
R564,666.24
1.62
R7.89
R848,056.06
1.07
R5.85
Fissure sealant
Fee code: 8163
% of
Per capita
Fee: R41.90
total
cost
R61,069,345.81
11.49
R61.84
R12,018,597.63
17.74
R141.43
R95,748.05
0.88
R5.59
R207,686.53
0.27
R1.19
R5,807,895.63
15.41
R93.62
R14,008,984.86
12.87
R64.93
R8,619,954.24
11.71
R61.84
R1,687,710.73
5.63
R21.92
R411,350.78
1.18
R5.75
R8,964,999.75
11.34
R61.84
One surface restoration
Average fee:
% of
Per capita
R138.60
total
cost
R113,474,632.01
21.35
R114.90
R18,867,774.29
27.85
R222.03
R3,106,788.30
28.71
R181.26
R15,311,062.74
20.21
R87.63
R11,212,125.87
29.76
R180.72
R17,947,652.44
16.49
R83.18
R16,016,974.18
21.76
R114.90
R4,692,539.27
15.66
R60.96
R9,148,725.26
26.30
R127.78
R16,658,112.75
21.07
R114.90
Two or more surface restoration
Average fee:
% of
Per capita
R202.99
total
cost
R60,201,310.27
11.32
R60.96
R9,289,359.05
13.71
R109.31
R2,548,482.42
23.55
R148.69
R5,141,229.16
6.79
R29.43
R3,393,542.95
9.01
R54.70
R12,844,263.60
11.80
R59.53
R8,497,430.79
11.55
R60.96
R1,857,557.07
6.20
R24.13
R4,472,217.81
12.86
R62.46
R8,837,571.85
11.18
R60.96
Extraction
Fee code: 8201
% of
Per capita
Fee: R63.60
total
cost
R13,331,004.56
2.51
R13.50
R2,581,287.82
3.81
R30.38
R447,496.09
4.14
R26.11
R3,211,447.93
4.24
R18.38
R660,545.95
1.75
R10.65
R2,659,704.33
2.44
R12.33
R443,292.00
0.60
R3.18
R256,729.73
0.86
R3.34
R675,724.25
1.94
R9.44
R2,489,596.56
3.15
R17.17
Fee code: 8161
Fee: R63.60
R5,776,935.88
R178,356.02
R21,802.08
R800,077.82
R149,938.27
R1,482,012.29
R815,416.02
R602,199.14
R564,666.24
R848,056.06
% of
total
1.67
0.34
0.29
1.86
0.58
2.16
1.72
3.88
2.64
1.63
Per capita
cost
R5.85
R2.10
R1.27
R4.58
R2.42
R6.87
R5.85
R7.82
R7.89
R5.85
Fee code: 8163
Fee: R41.90
R61,069,345.81
R12,018,597.63
R95,748.05
R207,686.53
R5,807,895.63
R14,008,984.86
R8,619,954.24
R1,687,710.73
R411,350.78
R8,964,999.75
% of
total
17.62
23.19
1.26
0.48
22.29
20.47
18.15
10.86
1.92
17.27
Per capita
cost
R61.84
R141.43
R5.59
R1.19
R93.62
R64.93
R61.84
R21.92
R5.75
R61.84
Average fee:
R138.60
R113,474,632.01
R18,867,774.29
R3,106,788.30
R15,311,062.74
R11,212,125.87
R17,947,652.44
R16,016,974.18
R4,692,539.27
R9,148,725.26
R16,658,112.75
% of
total
32.74
36.41
40.83
35.57
43.03
26.22
33.73
30.20
42.81
32.08
Per capita
cost
R114.90
R222.03
R181.26
R87.63
R180.72
R83.18
R114.90
R60.96
R127.78
R114.90
Average fee:
R202.99
R60,201,310.27
R9,289,359.05
R2,548,482.42
R5,141,229.16
R3,393,542.95
R12,844,263.60
R8,497,430.79
R1,857,557.07
R4,472,217.81
R8,837,571.85
% of
total
17.37
17.93
33.49
11.94
13.02
18.76
17.89
11.95
20.93
17.02
Per capita
cost
R60.96
R109.31
R148.69
R29.43
R54.70
R59.53
R60.96
R24.13
R62.46
R60.96
Fee code: 8201
Fee: R63.60
R13,331,004.56
R2,581,287.82
R447,496.09
R3,211,447.93
R660,545.95
R2,659,704.33
R443,292.00
R256,729.73
R675,724.25
R2,489,596.56
% of
total
3.85
4.98
5.88
7.46
2.53
3.89
0.93
1.65
3.16
4.79
Per capita
cost
R13.50
R30.38
R26.11
R18.38
R10.65
R12.33
R3.18
R3.34
R9.44
R17.17
___________________________________________________________________
Annexure 3
196
Variable:
[1]
[5]
[6]
[5]
[6]
All procedures
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Total per
capita cost
R538.27
R797.08
R631.27
R433.67
R607.34
R504.57
R527.95
R389.15
R485.79
R545.44
Total expense
R531,590,841.02
R67,736,048.49
R10,820,009.05
R75,771,128.77
R37,679,389.38
R108,865,124.50
R73,595,804.35
R29,957,007.29
R34,782,381.23
R79,077,332.53
Treatment need group
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
Total per
capita cost
R350.97
R609.78
R443.97
R246.37
R420.04
R317.27
R340.65
R201.85
R298.49
R358.14
Total expense
R346,613,361.02
R51,819,294.49
R7,609,687.05
R43,046,072.77
R26,059,297.38
R68,453,276.50
R47,486,184.35
R15,538,653.29
R21,371,701.23
R51,922,578.53
%
Rand
National
34.80
17.45
12.57
35.18
100.0
R187.30
R93.92
R67.69
R189.35
R538.27
Western Cape
26.76
19.29
53.95
100.0
R93.92
R67.69
R189.35
R350.97
23.50
13.12
18.01
45.38
100.0
R187.30
R104.54
R143.53
R361.71
R797.08
Northern Cape
17.14
23.54
59.32
100.0
R104.54
R143.53
R361.71
R609.78
29.67
12.84
1.09
56.40
100.0
R187.30
R81.06
R6.86
R356.05
R631.27
Eastern Cape
18.26
1.54
80.20
100.0
R81.06
R6.86
R356.05
R443.97
43.19
24.25
1.33
31.23
100.0
R187.30
R105.17
R5.77
R135.44
R433.67
Free State
42.69
2.34
54.97
100.0
R105.17
R5.77
R135.44
R246.37
30.84
12.83
15.81
40.52
100.0
R187.30
R77.94
R96.03
R246.07
R607.34
KwaZulu-Natal
18.55
22.86
58.58
100.0
R77.94
R96.03
R246.07
R420.04
28.50
22.63
48.87
100.0
R90.43
R71.80
R155.04
R317.27
27.57
19.87
52.56
100.0
R93.92
R67.69
R179.04
R340.65
37.12
17.92
14.23
30.73
100.0
R187.30
R90.43
R71.80
R155.04
R504.57
Gauteng
35.48
17.79
12.82
33.91
100.0
R187.30
R93.92
R67.69
R179.04
R527.95
%
Rand
___________________________________________________________________
Annexure 3
197
North West
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
Variable:
[1]
[2]
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
100
100
100
100
100
100
100
100
100
100
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
100
100
100
100
100
100
100
100
100
100
Mean no
of sextants
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
3.31
3.27
2.30
2.88
3.95
3.57
3.31
2.57
1.97
4.41
48.13
21.50
7.64
22.72
100.0
R187.30
R83.68
R29.75
R88.42
R389.15
Mpumalanga
41.46
14.74
43.81
100.0
R83.68
R29.75
R88.42
R201.85
38.56
17.53
2.81
41.10
100.0
R187.30
R85.18
R13.63
R199.67
R485.79
Limpopo
28.54
4.57
66.90
100.0
R85.18
R13.63
R199.67
R298.49
34.34
17.86
12.41
35.39
100.0
R187.30
R97.42
R67.69
R193.03
R545.44
27.20
18.90
53.90
100.0
R97.42
R67.69
R193.03
R358.14
UPFS 2006 (H2)
Examination/bitewings included
[3]; [4]
[7]
[8]
Examination
Fee code: 0924
% of
Per capita
Fee: R40.00
total
cost
R39,504,000.00
18.23
R40.00
R3,399,200.00
12.41
R40.00
R685,600.00
16.34
R40.00
R6,988,800.00
21.79
R40.00
R2,481,600.00
16.22
R40.00
R8,630,400.00
19.10
R40.00
R5,576,000.00
19.41
R40.00
R3,079,200.00
25.80
R40.00
R2,864,000.00
20.82
R40.00
R5,799,200.00
19.62
R40.00
Bitewings
Fee code: 0914
% of
Per capita
Fee: R15.00
total
cost
R29,628,000.00
13.67
R30.00
R2,549,400.00
9.31
R30.00
R514,200.00
12.25
R30.00
R5,241,600.00
16.34
R30.00
R1,861,200.00
12.16
R30.00
R6,472,800.00
14.33
R30.00
R4,182,000.00
14.56
R30.00
R2,309,400.00
19.35
R30.00
R2,148,000.00
15.61
R30.00
R4,349,400.00
14.72
R30.00
Prophylaxis
Fee code: 0924
% of
Per capita
Fee: R40.00
total
cost
R29,707,008.00
13.71
R30.08
R2,845,130.40
10.39
R33.48
R444,954.40
10.60
R25.96
R5,884,569.60
18.35
R33.68
R1,548,518.40
10.12
R24.96
R6,248,409.60
13.83
R28.96
R4,193,152.00
14.60
R30.08
R2,063,064.00
17.28
R26.80
R1,953,248.00
14.20
R27.28
R4,523,376.00
15.31
R31.20
Examination/bitewings excluded
[3]; [4]
[7]
[8]
Fee code: 0924
Fee: R40.00
R29,707,008.00
R2,845,130.40
R444,954.40
R5,884,569.60
R1,548,518.40
R6,248,409.60
R4,193,152.00
R2,063,064.00
R1,953,248.00
R4,523,376.00
% of
total
20.13
13.27
14.85
29.66
14.13
20.78
22.11
31.50
22.34
23.31
Per capita
cost
R30.08
R33.48
R25.96
R33.68
R24.96
R28.96
R30.08
R26.80
R27.28
R31.20
___________________________________________________________________
Annexure 3
198
% needing
care
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
57.67
85.20
62.20
49.70
66.60
59.00
47.10
31.30
44.90
24.10
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
9.20
3.30
2.00
7.20
3.80
10.80
9.20
12.30
12.40
9.20
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
1.48
3.38
0.13
0.03
2.23
1.55
1.48
0.52
0.14
1.48
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.83
1.60
1.31
0.63
1.30
0.60
0.83
0.44
0.92
0.83
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.30
0.54
0.73
0.14
0.27
0.29
0.30
0.12
0.31
0.30
Consultation
Average fee:
% of
Per capita
R57.50
total
cost
R32,751,801.19
15.11
R33.16
R4,163,170.20
15.20
R48.99
R613,012.10
14.61
R35.77
R4,993,060.80
15.57
R28.58
R2,375,821.80
15.53
R38.30
R7,319,658.00
16.20
R33.93
R3,775,300.50
13.14
R27.08
R1,385,447.55
11.61
R18.00
R1,848,533.00
13.44
R25.82
R2,009,060.35
6.80
R13.86
Topical fluoride application
Fee code: 0924
% of
Per capita
Fee: R40.00
total
cost
R3,633,293.01
1.68
R3.68
R112,173.60
0.41
R1.32
R13,712.00
0.33
R0.80
R503,193.60
1.57
R2.88
R94,300.80
0.62
R1.52
R932,083.20
2.06
R4.32
R512,840.26
1.79
R3.68
R378,741.60
3.17
R4.92
R355,136.00
2.58
R4.96
R533,368.59
1.80
R3.68
Fissure sealant
Fee code: 0914
% of
Per capita
Fee: R15.00
total
cost
R21,862,534.30
10.09
R22.14
R4,302,600.58
15.71
R50.63
R34,277.34
0.82
R2.00
R74,350.79
0.23
R0.43
R2,079,198.91
13.59
R33.51
R5,015,149.71
11.10
R23.24
R3,085,902.47
10.74
R22.14
R604,192.39
5.06
R7.85
R147,261.62
1.07
R2.06
R3,209,427.12
10.86
R22.14
One surface restoration
Fee code: 0921
% of
Per capita
Fee: R45.00
total
cost
R36,842,412.99
17.00
R37.30
R6,125,900.74
22.37
R72.09
R1,008,697.50
24.04
R58.85
R4,971,124.27
15.50
R28.45
R3,640,300.61
23.79
R58.68
R5,827,159.88
12.90
R27.01
R5,200,316.29
18.11
R37.30
R1,523,551.71
12.76
R19.79
R2,970,365.34
21.59
R41.49
R5,408,478.16
18.30
R37.30
Two or more surface restoration
Fee code: 0921
% of
Per capita
Fee: R45.00
total
cost
R13,345,848.52
6.16
R13.51
R2,059,330.24
7.52
R24.23
R564,965.45
13.46
R32.96
R1,139,743.73
3.55
R6.52
R752,304.39
4.92
R12.13
R2,847,406.40
6.30
R13.20
R1,883,770.03
6.56
R13.51
R411,796.27
3.45
R5.35
R991,432.60
7.21
R13.85
R1,959,174.89
6.63
R13.51
Average fee:
R57.50
R32,751,801.19
R4,163,170.20
R613,012.10
R4,993,060.80
R2,375,821.80
R7,319,658.00
R3,775,300.50
R1,385,447.55
R1,848,533.00
R2,009,060.35
% of
total
22.19
19.42
20.46
25.17
21.68
24.34
19.91
21.16
21.14
10.35
Per capita
cost
R33.16
R48.99
R35.77
R28.58
R38.30
R33.93
R27.08
R18.00
R25.82
R13.86
Fee code: 0924
Fee: R40.00
R3,633,293.01
R112,173.60
R13,712.00
R503,193.60
R94,300.80
R932,083.20
R512,840.26
R378,741.60
R355,136.00
R533,368.59
% of
total
2.46
0.52
0.46
2.54
0.86
3.10
2.70
5.78
4.06
2.75
Per capita
cost
R3.68
R1.32
R0.80
R2.88
R1.52
R4.32
R3.68
R4.92
R4.96
R3.68
Fee code: 0914
Fee: R15.00
R21,862,534.30
R4,302,600.58
R34,277.34
R74,350.79
R2,079,198.91
R5,015,149.71
R3,085,902.47
R604,192.39
R147,261.62
R3,209,427.12
% of
total
14.81
20.07
1.14
0.37
18.97
16.68
16.27
9.23
1.68
16.54
Per capita
cost
R22.14
R50.63
R2.00
R0.43
R33.51
R23.24
R22.14
R7.85
R2.06
R22.14
Fee code: 0921
Fee: R45.00
R36,842,412.99
R6,125,900.74
R1,008,697.50
R4,971,124.27
R3,640,300.61
R5,827,159.88
R5,200,316.29
R1,523,551.71
R2,970,365.34
R5,408,478.16
% of
total
24.97
28.58
33.67
25.06
33.22
19.38
27.42
23.27
33.97
27.87
Per capita
cost
R37.30
R72.09
R58.85
R28.45
R58.68
R27.01
R37.30
R19.79
R41.49
R37.30
Fee code: 0921
Fee: R45.00
R13,345,848.52
R2,059,330.24
R564,965.45
R1,139,743.73
R752,304.39
R2,847,406.40
R1,883,770.03
R411,796.27
R991,432.60
R1,959,174.89
% of
total
9.04
9.61
18.86
5.75
6.87
9.47
9.93
6.29
11.34
10.10
Per capita
cost
R13.51
R24.23
R32.96
R6.52
R12.13
R13.20
R13.51
R5.35
R13.85
R13.51
___________________________________________________________________
Annexure 3
199
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Variable:
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
[1]
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.21
0.48
0.41
0.29
0.17
0.19
0.05
0.05
0.15
0.27
Extraction
Fee code: 0921
% of
Fee: R45.00
total
R9,432,314.55
4.35
R1,826,382.89
6.67
R316,624.59
7.55
R2,272,250.90
7.09
R467,367.42
3.05
R1,881,866.27
4.17
R313,650.00
1.09
R181,648.40
1.52
R478,106.78
3.48
R1,761,507.00
5.96
[5]
All procedures
Per capita
cost
R9.55
R21.49
R18.47
R13.01
R7.53
R8.72
R2.25
R2.36
R6.68
R12.15
[6]
Total per
capita cost
R219.43
R322.23
R244.81
R183.54
R246.62
R209.38
R206.05
R155.07
R192.12
R203.84
Total expense
R216,707,212.56
R27,383,288.66
R4,196,043.38
R32,068,693.68
R15,300,612.33
R45,174,933.07
R28,722,931.56
R11,937,041.92
R13,756,083.34
R29,552,992.11
Treatment need group
%
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
15.11
31.90
13.71
11.77
27.51
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
15.20
21.72
10.39
16.12
36.56
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
14.61
28.59
10.60
1.14
45.05
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
15.57
38.14
18.35
1.80
26.14
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
15.53
28.38
10.12
14.21
31.76
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
16.20
33.43
13.83
13.16
23.37
100.0
Rand
National
R33.16
R70.00
R30.08
R25.82
R60.37
R219.43
Western Cape
R48.99
R70.00
R33.48
R51.95
R117.81
R322.23
Northern Cape
R35.77
R70.00
R25.96
R2.80
R110.29
R244.81
Eastern Cape
R28.58
R70.00
R33.68
R3.31
R47.98
R183.54
Free State
R38.30
R70.00
R24.96
R35.03
R78.34
R246.62
KwaZulu-Natal
R33.93
R70.00
R28.96
R27.56
R48.93
R209.38
Fee code: 0921
Fee: R45.00
R9,432,314.55
R1,826,382.89
R316,624.59
R2,272,250.90
R467,367.42
R1,881,866.27
R313,650.00
R181,648.40
R478,106.78
R1,761,507.00
[5]
% of
total
6.39
8.52
10.57
11.45
4.27
6.26
1.65
2.77
5.47
9.08
Per capita
cost
R9.55
R21.49
R18.47
R13.01
R7.53
R8.72
R2.25
R2.36
R6.68
R12.15
[6]
Total per
capita cost
R149.43
R252.23
R174.81
R113.54
R176.62
R139.38
R136.05
R85.07
R122.12
R133.84
Total expense
R147,575,212.56
R21,434,688.66
R2,996,243.38
R19,838,293.68
R10,957,812.33
R30,071,733.07
R18,964,931.56
R6,548,441.92
R8,744,083.34
R19,404,392.11
%
Rand
22.19
R33.16
20.13
17.28
40.40
100.0
R30.08
R25.82
R60.37
R149.43
19.42
R48.99
13.27
20.60
46.71
100.0
R33.48
R51.95
R117.81
R252.23
20.46
R35.77
14.85
1.60
63.09
100.0
R25.96
R2.80
R110.29
R174.81
25.17
R28.58
29.66
2.91
42.26
100.0
R33.68
R3.31
R47.98
R113.54
21.68
R38.30
14.13
19.84
44.35
100.0
R24.96
R35.03
R78.34
R176.62
24.34
R33.93
20.78
19.78
35.10
100.0
R28.96
R27.56
R48.93
R139.38
___________________________________________________________________
Annexure 3
200
Variable:
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
13.14
33.97
14.60
12.53
25.76
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
11.61
45.14
17.28
8.23
17.73
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
13.44
36.43
14.20
3.65
32.28
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
6.80
34.34
15.31
12.66
30.89
100.0
[1]
[2]
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
100
100
100
100
100
100
100
100
100
100
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
100
100
100
100
100
100
100
100
100
100
Mean no
of sextants
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
3.31
3.27
2.30
2.88
3.95
3.57
3.31
2.57
1.97
4.41
Gauteng
R27.08
R70.00
R30.08
R25.82
R53.07
R206.05
North West
R18.00
R70.00
R26.80
R12.77
R27.50
R155.07
Mpumalanga
R25.82
R70.00
R27.28
R7.02
R62.01
R192.12
Limpopo
R13.86
R70.00
R31.20
R25.82
R62.97
R203.84
UPFS 2006 (HG)
Examination/bitewings included
[3]; [4]
[7]
[8]
Examination
Fee code: 0924
% of
Per capita
Fee: R81.00
total
cost
R79,995,600.00
18.62
R81.00
R6,883,380.00
12.68
R81.00
R1,388,340.00
16.87
R81.00
R14,152,320.00
22.43
R81.00
R5,025,240.00
16.57
R81.00
R17,476,560.00
19.53
R81.00
R11,291,400.00
19.92
R81.00
R6,235,380.00
26.07
R81.00
R5,799,600.00
21.32
R81.00
R11,743,380.00
19.60
R81.00
Bitewings
Fee code: 0914
% of
Per capita
Fee: R33.00
total
cost
R65,181,600.00
15.17
R66.00
R5,608,680.00
10.34
R66.00
R1,131,240.00
13.74
R66.00
R11,531,520.00
18.27
R66.00
R4,094,640.00
13.50
R66.00
R14,240,160.00
15.91
R66.00
R9,200,400.00
16.23
R66.00
R5,080,680.00
21.24
R66.00
R4,725,600.00
17.37
R66.00
R9,568,680.00
15.97
R66.00
Prophylaxis
Fee code: 0924
% of
Per capita
Fee: R81.00
total
cost
R60,156,691.20
14.00
R60.91
R5,761,389.06
10.62
R67.80
R901,032.66
10.95
R52.57
R11,916,253.44
18.88
R68.20
R3,135,749.76
10.34
R50.54
R12,653,029.44
14.14
R58.64
R8,491,132.80
14.98
R60.91
R4,177,704.60
17.47
R54.27
R3,955,327.20
14.54
R55.24
R9,159,836.40
15.29
R63.18
19.91
R27.08
22.11
18.98
39.01
100.0
R30.08
R25.82
R53.07
R136.05
21.16
R18.00
31.50
15.01
32.33
100.0
R26.80
R12.77
R27.50
R85.07
21.14
R25.82
22.34
5.75
50.78
100.0
R27.28
R7.02
R62.01
R122.12
10.35
R13.86
23.31
19.29
47.05
100.0
R31.20
R25.82
R62.97
R133.84
Examination/bitewings excluded
[3]; [4]
[7]
[8]
Fee code: 0924
Fee: R81.00
R60,156,691.20
R5,761,389.06
R901,032.66
R11,916,253.44
R3,135,749.76
R12,653,029.44
R8,491,132.80
R4,177,704.60
R3,955,327.20
R9,159,836.40
% of
total
21.15
13.79
15.77
31.84
14.78
21.91
23.46
33.15
23.72
23.73
Per capita
cost
R60.91
R67.80
R52.57
R68.20
R50.54
R58.64
R60.91
R54.27
R55.24
R63.18
___________________________________________________________________
Annexure 3
201
% needing
care
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
57.67
85.20
62.20
49.70
66.60
59.00
47.10
31.30
44.90
24.10
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
9.20
3.30
2.00
7.20
3.80
10.80
9.20
12.30
12.40
9.20
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
1.48
3.38
0.13
0.03
2.23
1.55
1.48
0.52
0.14
1.48
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.83
1.60
1.31
0.63
1.30
0.60
0.83
0.44
0.92
0.83
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.30
0.54
0.73
0.14
0.27
0.29
0.30
0.12
0.31
0.30
Consultation
Average fee:
% of
Per capita
R87.00
total
cost
R49,554,899.20
11.54
R50.18
R6,299,057.52
11.61
R74.12
R927,513.96
11.27
R54.11
R7,554,718.08
11.97
R43.24
R3,594,721.68
11.85
R57.94
R11,074,960.80
12.38
R51.33
R5,712,193.80
10.08
R40.98
R2,096,242.38
8.76
R27.23
R2,796,910.80
10.28
R39.06
R3,039,795.66
5.07
R20.97
Topical fluoride application
Fee code: 0924
% of
Per capita
Fee: R81.00
total
cost
R7,357,418.34
1.71
R7.45
R227,151.54
0.42
R2.67
R27,766.80
0.34
R1.62
R1,018,967.04
1.61
R5.83
R190,959.12
0.63
R3.08
R1,887,468.48
2.11
R8.75
R1,038,501.54
1.83
R7.45
R766,951.74
3.21
R9.96
R719,150.40
2.64
R10.04
R1,080,071.40
1.80
R7.45
Fissure sealant
Fee code: 0914
% of
Per capita
Fee: R33.00
total
cost
R48,097,575.46
11.20
R48.70
R9,465,721.28
17.44
R111.39
R75,410.16
0.92
R4.40
R163,571.73
0.26
R0.94
R4,574,237.61
15.08
R73.73
R11,033,329.37
12.33
R51.14
R6,788,985.44
11.98
R48.70
R1,329,223.25
5.56
R17.27
R323,975.56
1.19
R4.52
R7,060,739.66
11.79
R48.70
One surface restoration
Fee code: 0921
% of
Per capita
Fee: R90.00
total
cost
R73,684,825.98
17.15
R74.61
R12,251,801.48
22.58
R144.17
R2,017,395.00
24.51
R117.70
R9,942,248.53
15.76
R56.90
R7,280,601.21
24.00
R117.35
R11,654,319.77
13.02
R54.02
R10,400,632.59
18.35
R74.61
R3,047,103.42
12.74
R39.58
R5,940,730.69
21.84
R82.97
R10,816,956.33
18.06
R74.61
Two or more surface restoration
Fee code: 0921
% of
Per capita
Fee: R90.00
total
cost
R26,691,697.04
6.21
R27.03
R4,118,660.48
7.59
R48.47
R1,129,930.90
13.73
R65.92
R2,279,487.45
3.61
R13.05
R1,504,608.78
4.96
R24.25
R5,694,812.81
6.36
R26.39
R3,767,540.06
6.65
R27.03
R823,592.55
3.44
R10.70
R1,982,865.20
7.29
R27.69
R3,918,349.77
6.54
R27.03
Average fee:
R87.00
R49,554,899.20
R6,299,057.52
R927,513.96
R7,554,718.08
R3,594,721.68
R11,074,960.80
R5,712,193.80
R2,096,242.38
R2,796,910.80
R3,039,795.66
% of
total
17.42
15.08
16.24
20.19
16.94
19.17
15.78
16.63
16.77
7.88
Per capita
cost
R50.18
R74.12
R54.11
R43.24
R57.94
R51.33
R40.98
R27.23
R39.06
R20.97
Fee code: 0924
Fee: R81.00
R7,357,418.34
R227,151.54
R27,766.80
R1,018,967.04
R190,959.12
R1,887,468.48
R1,038,501.54
R766,951.74
R719,150.40
R1,080,071.40
% of
total
2.59
0.54
0.49
2.72
0.90
3.27
2.87
6.08
4.31
2.80
Per capita
cost
R7.45
R2.67
R1.62
R5.83
R3.08
R8.75
R7.45
R9.96
R10.04
R7.45
Fee code: 0914
Fee: R33.00
R48,097,575.46
R9,465,721.28
R75,410.16
R163,571.73
R4,574,237.61
R11,033,329.37
R6,788,985.44
R1,329,223.25
R323,975.56
R7,060,739.66
% of
total
16.91
22.66
1.32
0.44
21.56
19.10
18.75
10.55
1.94
18.29
Per capita
cost
R48.70
R111.39
R4.40
R0.94
R73.73
R51.14
R48.70
R17.27
R4.52
R48.70
Fee code: 0921
Fee: R90.00
R73,684,825.98
R12,251,801.48
R2,017,395.00
R9,942,248.53
R7,280,601.21
R11,654,319.77
R10,400,632.59
R3,047,103.42
R5,940,730.69
R10,816,956.33
% of
total
25.91
29.33
35.32
26.57
34.32
20.18
28.73
24.18
35.63
28.02
Per capita
cost
R74.61
R144.17
R117.70
R56.90
R117.35
R54.02
R74.61
R39.58
R82.97
R74.61
Fee code: 0921
Fee: R90.00
R26,691,697.04
R4,118,660.48
R1,129,930.90
R2,279,487.45
R1,504,608.78
R5,694,812.81
R3,767,540.06
R823,592.55
R1,982,865.20
R3,918,349.77
% of
total
9.39
9.86
19.78
6.09
7.09
9.86
10.41
6.53
11.89
10.15
Per capita
cost
R27.03
R48.47
R65.92
R13.05
R24.25
R26.39
R27.03
R10.70
R27.69
R27.03
___________________________________________________________________
Annexure 3
202
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Variable:
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
[1]
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
987,600
84,980
17,140
174,720
62,040
215,760
139,400
76,980
71,600
144,980
Treatment
need
0.21
0.48
0.41
0.29
0.17
0.19
0.05
0.05
0.15
0.27
Extraction
Fee code: 0921
% of
Fee: R90.00
total
R18,864,629.10
4.39
R3,652,765.79
6.73
R633,249.18
7.69
R4,544,501.79
7.20
R934,734.84
3.08
R3,763,732.54
4.21
R0.00
0.00
R363,296.79
1.52
R956,213.56
3.52
R3,523,014.00
5.88
[5]
All procedures
Per capita
cost
R19.10
R42.98
R36.95
R26.01
R15.07
R17.44
R0.00
R4.72
R13.35
R24.30
[6]
Total per
capita cost
R434.98
R638.60
R480.27
R361.17
R488.97
R414.71
R406.68
R310.73
R379.89
R413.24
Total expense
R429,584,936.31
R54,268,607.16
R8,231,878.65
R63,103,588.07
R30,335,493.01
R89,478,373.21
R56,690,786.22
R23,920,174.73
R27,200,373.40
R59,910,823.22
Treatment need group
%
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
11.54
33.79
14.00
12.91
27.76
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
11.61
23.02
10.62
17.86
36.90
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
11.27
30.61
10.95
1.25
45.93
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
11.97
40.70
18.88
1.87
26.57
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
11.85
30.06
10.34
15.71
32.04
100.0
Rand
National
R50.18
R147.00
R60.91
R56.15
R120.74
R434.98
Western Cape
R74.12
R147.00
R67.80
R114.06
R235.62
R638.60
Northern Cape
R54.11
R147.00
R52.57
R6.02
R220.57
R480.27
Eastern Cape
R43.24
R147.00
R68.20
R6.77
R95.96
R361.17
Free State
R57.94
R147.00
R50.54
R76.81
R156.67
R488.97
Fee code: 0921
Fee: R90.00
R18,864,629.10
R3,652,765.79
R633,249.18
R4,544,501.79
R934,734.84
R3,763,732.54
R0.00
R363,296.79
R956,213.56
R3,523,014.00
[5]
% of
total
6.63
8.74
11.09
12.14
4.41
6.52
0.00
2.88
5.73
9.13
Per capita
cost
R19.10
R42.98
R36.95
R26.01
R15.07
R17.44
R0.00
R4.72
R13.35
R24.30
[6]
Total per
capita cost
R287.98
R491.60
R333.27
R214.17
R341.97
R267.71
R259.68
R163.73
R232.89
R266.24
Total expense
R284,407,736.31
R41,776,547.16
R5,712,298.65
R37,419,748.07
R21,215,613.01
R57,761,653.21
R36,198,986.22
R12,604,114.73
R16,675,173.40
R38,598,763.22
%
Rand
17.42
R50.18
21.15
19.50
41.93
100.0
R60.91
R56.15
R120.74
R287.98
15.08
R74.12
13.79
23.20
47.93
100.0
R67.80
R114.06
R235.62
R491.60
16.24
R54.11
15.77
1.81
66.18
100.0
R52.57
R6.02
R220.57
R333.27
20.19
R43.24
31.84
3.16
44.81
100.0
R68.20
R6.77
R95.96
R214.17
16.94
R57.94
14.78
22.46
45.82
100.0
R50.54
R76.81
R156.67
R341.97
___________________________________________________________________
Annexure 3
203
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
12.38
35.45
14.14
14.44
23.60
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
10.08
36.15
14.98
13.81
24.99
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
8.76
47.31
17.47
8.76
17.70
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
10.28
38.70
14.54
3.83
32.65
100.0
UPFS consultation
Examination/bitewings
Prophylaxis
Topical F app/Dental sealant
Curative/Extraction
5.07
35.57
15.29
13.59
30.48
100.0
KwaZulu-Natal
R51.33
R147.00
R58.64
R59.89
R97.85
R414.71
Gauteng
R40.98
R147.00
R60.91
R56.15
R101.64
R406.68
North West
R27.23
R147.00
R54.27
R27.23
R55.00
R310.73
Mpumalanga
R39.06
R147.00
R55.24
R14.57
R124.02
R379.89
Limpopo
R20.97
R147.00
R63.18
R56.15
R125.94
R413.24
19.17
R51.33
21.91
22.37
36.55
100.0
R58.64
R59.89
R97.85
R267.71
15.78
R40.98
23.46
21.62
39.14
100.0
R60.91
R56.15
R101.64
R259.68
16.63
R27.23
33.15
16.63
33.59
100.0
R54.27
R27.23
R55.00
R163.73
16.77
R39.06
23.72
6.26
53.25
100.0
R55.24
R14.57
R124.02
R232.89
7.88
R20.97
23.73
21.09
47.30
100.0
R63.18
R56.15
R125.94
R266.24
___________________________________________________________________
Annexure 3
204
ANNEXURE 4: THE WORLD HEALTH ORGANIZATION/FéDéRATION
DENTAIRE
INTERNATIONAL
HUMAN
RESOURCES
PLANNING MODEL: NATIONAL REQUIREMENTS TO DELIVER
THE MINIMUM PACKAGE OF ORAL CARE TO 4- TO 15-YEAROLD SOUTH AFRICAN CHILDREN
Note: Data is needed for all shaded fields
0
National
Anticipated % caries reduction due to water fluoridation
Variable
Formula
Value
4- to 56- to 15year-olds
year-olds
(A) RESTORATIVE CARE, ARRESTING CARE AND EXTRACTIONS
[1] Number of age intervals
2
10
[2] Predicted dmft or DMFT
2.44
1.86
[3] Predicted dt or DT
1.95
1.34
[4] Predicted mt or MT
0.35
0.29
[5] Predicted ft or FT
0.16
0.23
[6] Restoration fraction
0.50
0.60
[7] New fillings : Teeth (NFT)
[6] x [2]
1.22
1.12
[8] Mean replacement period in years for a restoration
15
15
[9] Replacement fillings : Teeth (RFT)
([1] x [7]) / (2 x [8])
0.08
0.37
[10] Ratio Surfaces / Teeth
1.50
1.50
[11] Sealants, arresting care and remineralisation
(1 - [6]) x [2]
1.22
0.74
[12] New fillings : Surfaces (NFS)
[7] x [10]
1.83
1.67
[13] Replacement fillings : Surfaces (RFS)
[9] x [10]
0.12
0.56
[14] Extraction
[4]
0.35
0.29
(B) TREATMENT TIME REQUIREMENTS
[15] Number of Group Preventive Care sessions
1
1
[16] Time per Group Preventive Care session
15
15
[15] x [16]
[17] Group Preventive Care (minutes)
15
15
[18] Number of Individual Preventive Care sessions
0
4
[19] Time per Individual Preventive Care session
15
15
[18] x [19]
[20] Individual Preventive Care (minutes)
0
60
[21] Time per fissure sealant
5
5
[11] x [21]
[22] Arresting Care (minutes)
6.10
3.72
[23] Mean number of sextants in need of scaling
0
3.31
[24] Time per scaling per sextant
5
5
[25] Number of scaling sessions
0
2
[23] x [24] x [25]
[26] Periodontal Care (prophylaxis only) (minutes)
0.00
33.10
[27] % in need of Surgical Care
1
10
[28] Time for Surgical Care
60
60
[27] / 100 x [28]
[29] Surgical Care (minutes)
0.60
6.00
[30] Time per restoration (new or replacement)
15
15
[12] x [30]
[31] Restorative Care for new fillings (NFS)
27.45
25.11
(minutes)
___________________________________________________________________
Annexure 4
205
[32] Restorative Care for replacement fillings (RFS)
(minutes)
[33] Time per extraction
[34] Extraction (minutes)
[35] Total minutes of need per cohort
Total minutes of need per year:
[36] For total human resources
[37] For Oral Hygienists
[38] For Dental Therapists/Dentists
[39] % Demand (utilization)
Minutes of demand per year:
[40] For total human resources
[41] For Oral Hygienists
[42] For Dental Therapists/Dentists
(C) HUMAN RESOURCES CALCULATIONS
[43] Working year (hours)
[44] Working year (minutes)
Human resources : population ratio:
[45] For total human resources
[46] For Oral Hygienists
[47] For Dental Therapists/Dentists
[48] Population size
Number of human resources required:
[49] Total human resources
[50] Oral Hygienist
[51] Dental Therapist/Dentist
[52] Dentists
(Ratio 1 Dentist : 5 Dental Therapists)
[53] Dental Therapists
(Ratio 1 Dentist : 5 Dental Therapists)
[54] Dental Assistants
(Ratio 1 Dental Therapist/Dentist : 1.5 Dental
Assistants)
[13] x [30]
1.83
8.37
7.5
2.63
53.61
7.5
2.18
153.48
[35] / [1]
([17]+[20]+[22]+[26])/[1]
([29]+[31]+[32]+[34])/[1]
26.80
10.55
16.25
25.7
15.35
11.18
4.17
25.7
[36] x [39] /100
[37] x [39] /100
[38] x [39] /100
6.90
2.72
4.18
3.95
2.88
1.07
[43] x 60
1760
105,600
1760
105,600
[44] / [40]
[44] / [41]
[44] / [42]
15,307
38,887
25,243
2,035,320
26,731
36,689
98,489
10,087,080
[48] / [45]
[48] / [46]
[48] / [47]
[51] / 6
133
52
81
13
377
275
102
17
[51] / 6 x 5
67
85
[51] x 1.5
121
154
[14] x [33]
[17]+[20]+[22]+
[26]+[29]+[31]+
[32]+[34]
Summary for 4-15-year-olds
Total human resources
Oral Hygienist
Dental Therapist/Dentist
Dentists (Ratio 1 Dentist : 5 Dental Therapists)
Dental Therapists (Ratio 1 Dentist : 5 Dental Therapists)
Dental Assistants (Ratio 1 Dentist/Dental Therapist : 1.5 Dental Assistants)
510
327
183
31
153
275
___________________________________________________________________
Annexure 4
206
ANNEXURE 5: A “SERVICE TARGETS METHOD” MODEL FOR
HUMAN
RESOURCES
PLANNING:
REQUIREMENTS
TO
DELIVER THE MINIMUM PACKAGE OF ORAL CARE TO 4- TO
15-YEAR-OLD SOUTH AFRICAN CHILDREN
Treatment times
Procedure
Unit
Group prevention
Prophylaxis
Topical fluoride
Fissure sealant
1 surface restoration
> 1 surface restoration
Extraction
15 min/session
5 min/sextant
10 min/application
5 min/sealant
15 min/restoration
15 min/restoration
7.5 min/extraction
Time/year
(minutes)
5
1
2.5
5
15
15
7.5
Anticipated % caries reduction due to water fluoridation
Variable:
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Mean no
of sextants
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
[1]
0
[2]
[3]; [4]
Group prevention
Pop est
Treatment Time (minutes):
2006
need
5
12,122,400
100
60,612,000
1,052,320
100
5,261,600
225,140
100
1,125,700
2,012,360
100
10,061,800
727,060
100
3,635,300
2,675,500
100
13,377,500
1,820,940
100
9,104,700
966,140
100
4,830,700
903,160
100
4,515,800
1,739,780
100
8,698,900
Prophylaxis (6- to 15-year-olds only)
Pop est
Treatment Time (minutes):
2006
need
1
33,388,235
10,087,080
3.31
869,340
3.27
2,842,742
186,540
2.30
429,042
1,700,100
2.88
4,896,288
607,120
3.95
2,398,124
2,235,140
3.57
7,979,450
1,472,640
3.31
4,874,438
798,240
2.57
2,051,477
751,980
1.97
1,481,401
1,465,980
4.41
6,464,972
[7]
% of total
21.78
14.52
12.37
29.26
18.97
22.92
21.85
33.86
24.61
20.90
% of total
11.99
7.85
4.72
14.24
12.51
13.67
11.70
14.38
8.07
15.53
[8]
Per capita
time
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
Per capita
time
2.75
2.70
1.91
2.43
3.30
2.98
2.68
2.12
1.64
3.72
___________________________________________________________________
Annexure 5
207
% of
population
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Topical fluoride application
Treatment
Time (minutes):
need
2.5
1,633,613
5.39
2.46
64,777
2.36
13,299
6.66
335,237
5.21
94,710
6.32
422,689
5.39
245,390
5.79
139,944
5.24
118,296
5.39
234,452
Fissure sealant
Pop est
Treatment
Time (minutes):
2006
need
5
48,610,096
12,122,400
0.80
1,052,320
1.80
9,475,528
225,140
0.31
353,615
2,012,360
0.07
738,925
727,060
1.13
4,092,552
2,675,500
0.94
12,511,220
1,820,940
0.80
7,301,860
966,140
0.29
1,417,279
903,160
0.05
214,101
1,739,780
0.80
6,976,413
One surface restoration
Pop est
Treatment
Time (minutes):
2006
need
15
70,509,367
12,122,400
0.39
1,052,320
0.56
8,897,698
225,140
0.93
3,153,394
2,012,360
0.29
8,631,649
727,060
0.54
5,937,590
2,675,500
0.29
11,627,754
1,820,940
0.39
10,591,412
966,140
0.25
3,670,124
903,160
0.48
6,523,249
1,739,780
0.39
10,119,348
Two or more surface restoration
Pop est
Treatment
Time (minutes):
2006
need
15
37,042,650
12,122,400
0.20
1,052,320
0.36
5,761,429
225,140
0.81
2,723,977
2,012,360
0.14
4,131,874
727,060
0.13
1,468,714
2,675,500
0.18
7,199,957
1,820,940
0.20
5,564,281
966,140
0.11
1,650,123
903,160
0.24
3,291,093
1,739,780
0.20
5,316,279
Pop est
2006
12,122,400
1,052,320
225,140
2,012,360
727,060
2,675,500
1,820,940
966,140
903,160
1,739,780
% of total
0.59
0.18
0.15
0.97
0.49
0.72
0.59
0.98
0.64
0.56
% of total
17.46
26.15
3.89
2.15
21.35
21.43
17.52
9.94
1.17
16.76
% of total
25.33
24.56
34.66
25.10
30.98
19.92
25.42
25.73
35.54
24.31
% of total
13.31
15.90
29.94
12.01
7.66
12.33
13.35
11.57
17.93
12.77
Per capita
time
0.13
0.06
0.06
0.17
0.13
0.16
0.13
0.14
0.13
0.13
Per capita
time
4.01
9.00
1.57
0.37
5.63
4.68
4.01
1.47
0.24
4.01
Per capita
time
5.82
8.46
14.01
4.29
8.17
4.35
5.82
3.80
7.22
5.82
Per capita
time
3.06
5.47
12.10
2.05
2.02
2.69
3.06
1.71
3.64
3.06
___________________________________________________________________
Annexure 5
208
Mean no
of teeth
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Variable:
Pop est
2006
12,122,400
1,052,320
225,140
2,012,360
727,060
2,675,500
1,820,940
966,140
903,160
1,739,780
[1]
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
12,122,400
1,052,320
225,140
2,012,360
727,060
2,675,500
1,820,940
966,140
903,160
1,739,780
Variable:
[1]
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
Pop est
2006
12,122,400
1,052,320
225,140
2,012,360
727,060
2,675,500
1,820,940
966,140
903,160
1,739,780
[11] Working year (hours)
[12] Working year (minutes)
Extraction
Treatment
Time (minutes):
need
7.5
26,557,573
0.29
0.50
3,925,098
0.77
1,298,181
0.37
5,597,501
0.28
1,537,717
0.26
5,257,246
0.29
3,989,288
0.07
505,536
0.33
2,208,525
0.29
3,811,484
[5]
All procedures
Total time
(minutes)
278,353,534
36,228,872
9,097,208
34,393,273
19,164,708
58,375,816
41,671,369
14,265,182
18,352,464
41,621,849
[5]
[6]
All procedures
Need
Total time Per capita time
(minutes)
(minutes)
278,353,534
22.96
36,228,872
34.43
9,097,208
40.41
34,393,273
17.09
19,164,708
26.36
58,375,816
21.82
41,671,369
22.88
14,265,182
14.77
18,352,464
20.32
41,621,849
23.92
[9]
Per capita
time
2.19
3.73
5.77
2.78
2.11
1.96
2.19
0.52
2.45
2.19
[6]
% of total
9.54
10.83
14.27
16.27
8.02
9.01
9.57
3.54
12.03
9.16
Per capita time
(minutes)
22.96
34.43
40.41
17.09
26.36
21.82
22.88
14.77
20.32
23.92
[10]
Demand
% demand Per capita time
(utilization)
(minutes)
25.74
5.91
25.74
8.86
25.74
10.40
25.74
4.40
25.74
6.78
25.74
5.62
25.74
5.89
25.74
3.80
25.74
5.23
25.74
6.16
1,760
105,600
___________________________________________________________________
Annexure 5
209
Variable:
21.78
11.99
5.00
2.75
[10]
Demand:
Per capita time
(Minutes)
National
1.29
0.71
18.05
4.14
1.07
98970.17
122
48.18
11.06
2.85
37078.84
327
100.00
22.96
17864.43
679
Dental therapist/
Dentist
Total
14.52
7.85
5.00
2.70
82040.33
151847.56
13
7
Oral hygienist
Oral hygienist
26.33
9.07
2.33
45246.29
23
Oral hygienist
51.30
17.66
4.55
23227.41
45
100.00
34.43
11914.90
88
Dental therapist/
Dentist
Total
Group prevention
Prophylaxis
Topical F app/
Dental sealant
12.37
4.72
5.00
1.91
82040.33
215253.51
3
1
Oral hygienist
Oral hygienist
4.03
1.63
0.42
251701.40
1
Oral hygienist
Curative/Extraction
78.88
31.87
8.20
12870.48
17
100.00
40.41
10151.77
22
Dental therapist/
Dentist
Total
Group prevention
Prophylaxis
Topical F app/
Dental sealant
29.26
14.24
5.00
2.43
82040.33
168591.67
25
12
Oral hygienist
Oral hygienist
3.12
0.53
0.14
768480.97
3
Oral hygienist
Curative/Extraction
53.39
9.12
2.35
44957.92
45
100.00
17.09
24001.01
84
18.97
12.51
5.00
3.30
4.40
Free State
1.29
0.85
Dental therapist/
Dentist
Total
82040.33
124364.38
9
6
Oral hygienist
Oral hygienist
21.85
5.76
1.48
71225.82
10
Oral hygienist
46.67
12.30
3.17
33345.31
22
100.00
26.36
15562.00
47
Dental therapist/
Dentist
Total
22.92
13.67
5.00
2.98
82040.33
137540.12
33
19
Oral hygienist
Oral hygienist
22.16
4.83
1.24
84854.04
32
Oral hygienist
41.26
9.00
2.32
45567.63
59
100.00
21.82
5.62
18800.50
142
% of total
Group prevention
Prophylaxis
Topical F app/
Dental sealant
Curative/Extraction
Group prevention
Prophylaxis
Topical F app/
Dental sealant
Curative/Extraction
Group prevention
Prophylaxis
Topical F app/
Dental sealant
Curative/Extraction
Group prevention
Prophylaxis
Topical F app/
Dental sealant
Curative/Extraction
[6]
Need:
Per capita time
(Minutes)
5.91
Western Cape
1.29
0.70
8.86
Northern Cape
1.29
0.49
10.40
Eastern Cape
1.29
0.63
6.79
KwaZulu-Natal
1.29
0.77
[13]
HR:
population
ratio
[14]
82040.33
148933.55
148
81
Oral hygienist
Oral hygienist
Oral hygienist
HR
Required
Dental therapist/
Dentist
Total
___________________________________________________________________
Annexure 5
210
21.85
11.70
5.00
2.68
Gauteng
1.29
0.69
82040.33
153238.70
22
12
Oral hygienist
Oral hygienist
18.11
4.14
1.07
98970.17
18
Oral hygienist
48.34
11.06
2.85
37078.84
49
100.00
22.88
17924.84
102
33.86
14.38
5.00
2.12
5.89
North West
1.29
0.55
Dental
therapist/
Dentist
Total
82040.33
193183.86
12
5
Oral hygienist
Oral hygienist
10.92
1.61
0.41
254499.30
4
Oral hygienist
40.84
6.03
1.55
68027.30
14
100.00
14.77
27781.78
35
Dental
therapist/
Dentist
Total
Group prevention
Prophylaxis
Topical F app/
Dental sealant
24.61
8.07
5.00
1.64
82040.33
250086.11
11
4
Oral hygienist
Oral hygienist
1.81
0.37
0.09
1114565.36
1
Oral hygienist
Curative/Extraction
65.51
13.31
3.43
30814.42
29
100.00
20.32
20186.81
45
20.90
15.53
5.00
3.72
5.23
Limpopo
1.29
0.96
Dental
therapist/
Dentist
Total
82040.33
110388.82
21
16
Oral hygienist
Oral hygienist
17.32
4.14
1.07
98970.17
18
Oral hygienist
46.24
11.06
2.85
37078.84
47
100.00
23.92
6.16
17146.30
101
Dental
therapist/
Dentist
Total
Total
Oral
hygienists
352
43
5
39
25
84
52
21
15
55
Dentists
Dental
Therapists
272
38
15
37
18
49
41
12
24
39
Dental
Assistants
490
68
26
67
33
88
74
21
44
70
Group prevention
Prophylaxis
Topical F app/
Dental sealant
Curative/Extraction
Group prevention
Prophylaxis
Topical F app/
Dental sealant
Curative/Extraction
Group prevention
Prophylaxis
Topical F app/
Dental sealant
Curative/Extraction
Summary of
human resources
National
Western Cape
Northern Cape
Eastern Cape
Free State
KwaZulu-Natal
Gauteng
North West
Mpumalanga
Limpopo
679
88
22
84
47
142
102
35
45
101
3.80
Mpumalanga
1.29
0.42
Dental Therapists/
Dentists
327
45
17
45
22
59
49
14
29
47
54
8
3
7
4
10
8
2
5
8
___________________________________________________________________
Annexure 5
211
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