Addressing oral health inequalities in Malawi: The MalDent project mission of ‘oral health for all’
19 Sep 2021
The College Director of Global Health, Professor Jeremy Bagg, writes about the College’s involvement in the MalDent project, establishing a degree programme for Dental Surgery in Malawi and developing an national Oral Health Policy in the country.
Director of Global Health, Professor Jeremy Bagg
Venerable Mother Toothache
Climb down from the white battlements,
Stop twisting in your yellow fingers
The fourfold rope of nerves
So wrote the English poet John Heath-Stubbs in his piece ‘A Charm against the Toothache’ in 1954. As many of us can attest from personal experience, dental pain can be excruciating and, if untreated, can have serious or even life threatening consequences. This poses a serious challenge in Malawi whose population of 19.5 million citizens is currently served by only 43 dentists, most of whom work in private practice in the cities, even though more than 80% of the population live in rural villages and have little disposable income.
The provision of dental care in rural areas falls largely to dental therapists, of whom there are approximately 100 in public service, but this very small workforce, which is often poorly resourced, cannot begin to address the treatment needs. As a result, most Malawians have no access to professional dental care, but the limited available oral health survey data indicate a very large burden of untreated oral and dental disease. It was against this backdrop that in 2016 Dr Mwapatsa Mipando, then the Principal of the University of Malawi College of Medicine, reached out to the University of Glasgow (UofG) for advice on establishing a Bachelor of Dental Surgery degree programme, so that Malawi could begin to train its own dentists. That was the beginning of a close partnership between the two organisations that became the MalDent Project (www.themaldentproject.com).
The MalDent Project is a collaboration between the Kamuzu University of Health Sciences (KUHeS -formerly the University of Malawi College of Medicine) and the University of Glasgow Dental School, generously funded by Scottish Government International Development. However, from the outset it has been a crosssectoral multi-stakeholder enterprise, and our College is a named partner on the grant funding awarded by Scottish Government. Furthermore, it was the College’s Global Health Group which kindly funded the flights for my first ever visit to Malawi in 2017 to scope the work that would be required to deliver a dental degree programme.
It rapidly became clear that establishing a Bachelor of Dental Surgery (BDS) degree programme in isolation would be futile if work were not undertaken in parallel to develop an Oral Health Policy for the country at Government level, which would ensure that there was a framework within which newly qualified dentists could apply their clinical and leadership skills. Furthermore, it would be critical that the policy pursued vigorously an oral disease prevention agenda, as championed by the World Health Organisation. This is especially important in low-income countries since delivery of operative dental treatment requires complex equipment and is very expensive.
Joint working between 2017 and 2019 allowed the creation of a BDS curriculum that was designed to deliver dentists who were “globally competent and locally relevant”, to quote the words of Dr Mipando. Following approval by the University of Malawi Senate in March 2019, the first ever cohort of BDS students enrolled in the new programme in August 2019. At the time of writing, there are now students enrolled on both the BDS 1 and BDS 2 courses together with 26 students in the Foundation Year ready to join BDS 1 in the next academic session. This total of 52 dental students is greater than the number of dentists in the country. The MalDent Project has established a staffing strategy for the new course, provides support with delivery of teaching as the programme is developing and has worked with industrial and charity partners (including the College’s HOPE Foundation) to enhance the clinical facilities in the Dental Department at Kamuzu Central Hospital. It has also established a small Scottish charity called MalDent Student Aid (www.maldentstudentaid.org) to raise money for a dental student hardship fund administered by KUHeS.
In a related programme of work, the MalDent Project is also funding the design, by a consortium led by John McAslan Partners, of a building on the Blantyre campus of KUHeS which will accommodate dental student clinical training and provide generic teaching space for students across all healthcare programmes on site. The curriculum contains a significant oral disease prevention component which links closely with the second major strand of work to develop a national Oral Health Policy and Implementation Strategy for Malawi. Following a two-day workshop in Lilongwe in February 2020, organised jointly by the Ministry of Health, KUHeS, University of Glasgow and WHO Africa, an Oral Health Policy Task Force was established by the Ministry of Health including members from the Ministry, KUHeS, WHO Africa and the University of Glasgow. It has been meeting fortnightly on Zoom, completing a Concept Paper, Situation Analysis and Narrative Review to inform the policy writing. The Policy is close to completion and imminent presentation to the Minister and Principal Secretary for Health, who will sign it off before an official launch later his Summer. To inform the implementation of the policy, a third strand of work aims to establish a programme for prevention of dental disease in children, based upon the principles of Scotland’s very successful Childsmile model, but adapted to the Malawian situation. Development of the programme is supported by an under-pinning research project to evaluate models of delivery, with particular emphasis on supervised tooth brushing with fluoride toothpaste in schools. This work is being undertaken by a Malawian PhD student, funded by the MalDent Project and the Borrow Foundation, who is co-supervised by staff from the School of Public Health & Family Medicine at KUHeS and the Community Oral Health Research Group at the University of Glasgow. Following the appropriate proof of concept work, the prevention programme will be integrated as part of the implementation of Malawi’s new Oral Health Policy. Linked to this work is a planned national child oral health survey to be undertaken in conjunction with the Ministry of Health, that will establish a baseline understanding of the level of dental disease among Malawian schoolchildren, against which the impact of any interventions can be measured.
A chronological description of the programme since its inception is available at www.themaldentproject.com
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