The relative patient costs and availability of dental services, materials and equipment in public oral care facilities in Tanzania

Although many facilities did not offer restorative services, all offered tooth extraction
services. Consequently, tooth extractions were the most common treatment provided.
The cost for all dental services was generally high. In addition, dental materials
were sporadically available and a full set of functional equipment was rarely present
in the facilities.

Cost of services is an important determinant of utilization of health services 20], 21]. This study revealed that up to 50 % of Tanzanians would need to invest financial
resources equivalent to 9 days-worth of consumption 11] in order to pay for a filling, illustrating the high cost of dental care. Previous
studies in Tanzania, Burkina Faso and Nigeria have indicated cost, and specifically
the price of services, as one of the major barriers towards utilization of oral care
services 12], 22]–25]. In Benin City, Nigeria, even among respondents with high socioeconomic status, 12 %
were unable to afford dental treatment when required 26].

In our study, the price for dental services was shown to be highly variable across
facilities. This may be due to differences in prices of services between regional
and district hospitals, as they function at different hierarchical levels in the Tanzanian
health system 27]. Nonetheless, even when assessed separately, this variation persisted within regional
and district facilities. Therefore, it is probable that dental facilities have their
prices set independently, leading to observed variations. This variability might selectively
preclude consumers with the same socioeconomic status across different geographic
locations from accessing oral care. None of the previous studies 12], 22]–25] have determined the price of dental services directly from the facilities, relying
instead on reports from the served population. Our findings confirm the conclusions
of previous studies, that the costs for dental services are considerably high.

Due to annual or even seasonal fluctuations in population income levels, the national
index of monthly financial resources for basic consumption was considered a valid
proxy for purchasing power. Besides, since this index is based on the consumption
patterns of the poorest 10–50 %, it allows for an assessment of the financial barrier
towards utilization of dental services among the poorest 11]. Utilization of dental care is reported to be dependent on ability to pay, rather
than on need of care 8], 20], 28]. Bearing in mind that about a quarter of the Tanzanian population are living in poverty
10] with many competing needs and interests, it is likely that many would postpone utilization
of dental care. Whenever they do use these services, most consumers may be expected
to opt for extraction, because of the relatively smaller resource allocation required
than for restorative work.

Dental materials and equipment availability are necessary for delivery of comprehensive
oral care 4]. In line with previous studies conducted in Eastern Africa (Tanzania, Kenya, Sudan)
this study provided further evidence of widespread shortage of dental materials and
equipment in public facilities 19], 25], 29], 30]. The finding that less than half of the facilities had any of the materials consistently
throughout the previous year means that restorative services are not available in
many facilities, even if demanded by the dental patients. Additionally, the proportion
of facilities that offer restorative services throughout the year is likely to be
smaller than currently reported due to intermittent availability of dental materials.
The government-endorsed supplier for public hospitals in Tanzania does not stock dental
materials or equipment 31]. Consequently, dental facilities throughout the country are forced to rely mostly
on private, local vendors for their supplies. Nevertheless, timeliness of material
delivery in most facilities was rated poorly, suggesting erratic and lengthy waiting
times for the supply of materials. However, budgetary sufficiency for procurement
of dental materials was favourably rated, indicating readily available financial resources.
Therefore, it appears as if either the supply of dental materials from private vendors
fails to meet demand or that procurement processes are inefficient, leading to undue
delays in obtainment of dental materials and equipment in facilities.

It is possible that equipment availability influences material availability. Essentially,
a facility does not have an incentive to purchase materials if there is no equipment
to work with, and vice versa. However, due to the cross sectional nature of the study
and the sample size involved, it was not possible to establish conclusively a causal
relationship between these factors. Furthermore, it should be noted that these findings
are from facilities within regions with zonal referral hospitals. These regions probably
have better health care infrastructure compared to other regions in the country. Therefore
these findings may be considered to give an optimistic view of the overall situation.

There is a tendency for predominantly symptom-oriented attendance for dental care
in developing countries in Africa. The major reason for dental attendance in public
facilities is due to toothache as a result of dental caries 16], 29], 32], 33]. Treatment profiles for the vast majority of the facilities in sub Saharan Africa
are highly skewed in favour of extractions as compared to fillings 29], 33]–36], similar to our findings. In accordance with previous studies indicating a high degree
of satisfaction with tooth extraction services amongst the Tanzanian population 32], 37], practitioners correspondingly reported highest competencies in this skill. However,
when compared to dental officers, other cadres working in dental facilities reported
systematically lower restorative competencies. This is likely due to “other cadres”
containing practitioners without formal training in dental care (clinical officers
and assistant medical officers), or with very basic dental training that focuses on
emergency dental care (dental therapists and dental auxiliaries). The perceived ability
of practitioners to perform a clinical procedure is an important determinant of the
kind of treatment offered to patients 38], 39]. Hence, this treatment profile is possibly a reflection of training curriculum that
places heavy emphasis on tooth extractions 40] or an indication that these practitioners operate in an environment where extractions
are the mainstay treatment offered due to limited treatment options. This is corroborated
by our findings indicating that many of the facilities do not have materials, equipment
or the skilled workforce to provide restorations.

All of the interviews were conducted by a dental practitioner, and the respondents
were aware of this. However, it is not expected that this might have led to any bias
in responding. On the contrary, it is expected that an interview with a colleague
might have encouraged them to be more forthcoming with their responses. Due to the
limited numbers of both the facilities and responding practitioners, further detailed
analyses were not possible. As a result, there remain many potential areas of interactions
that remain unexplored. Additionally, not all practitioners employed in the facilities
were interviewed; only those that were available on the day of the interview were
included. This may act as a potential source of bias in this study. Nonetheless, the
observed absenteeism is unlikely to be due to this particular research work, as the
facilities were not informed in advance. Larger samples and repeated measurements,
as well as inclusion of more regions will increase representativeness, as well as
allow for a more thorough analyses of factors associated with cost and availability
of materials and equipment. It may be interesting to conduct further studies to determine
the effective availability of dental care professionals in their respective facilities
and the regional density of private local vendors for dental materials and their effect
on availability of dental materials and equipment in facilities.