Mapping the geographic availability of public dental services in Uganda relative to ruralization and poverty of the population

INTRODUCTION

Uganda is a low-income sub-Saharan African country, with one of the lowest gross national per capita incomes in the world, at $US670.^[1] Over 80% of the population is rural^[2] and there is widespread poverty, with almost a fifth of the population living below the poverty line. Although the majority of Ugandans are classified as not poor, among these, 43% are insecure and vulnerable to falling back into poverty.^[3] Despite significant reductions in poverty during the last two decades, certain regions (e.g., North Region) are lagging behind and remain the poorest, while the West and Central Regions have made remarkable progress and their poverty rates are below the national average. For example, nearly 90% of households in Kampala – the capital city in the Central Region – are middle-class, while <1% are classified as poor. By contrast, <10% of households in the Northeast are middle-class, with nearly three-quarters of all households in the subregion living in poverty.^[3]

Uganda’s poor population experiences a greater burden of disease and yet have less access to health services, a common occurrence in other parts of the world.^[4] Geographic distance is a major barrier to health care access, especially for the poor and rural residents^[5,6] with the utilization of services from formal health facilities greatly influenced by the distance.^[7] The poor population is sometimes forced to seek care from traditional practitioners if they are located closest to their home.^[5] The use of public health facilities is highest among households in the lowest welfare quintile and reduces as the welfare quintile of household increases. Kampala, with the highest middle-class population, has previously recorded only 17% of its population as attending public health facilities, and 76% attending private health facilities. Conversely, the northeast had only 4.7% and 77% attending private and public health facilities, respectively.^[8]

Public health care in Uganda is focussed on health services which have been defined in the Uganda National Minimum Health Care Package that includes oral health care.^[9] The Ugandan Ministry of Health (MoH) operates on a budgetary allocation of only 9% of the national budget,^[10] which appears inadequate for optimal service delivery in the complex environment that is Uganda. Of this, the direct oral health-care budgetary allocation is <0.1%.^[11] Basic oral health services are free in government health units, whereas secondary and tertiary services are provided at a fee. However, due to shortages of materials, supplies, equipment and workforce, patients have to seek and pay for basic treatment elsewhere.^[11] Therefore, the burden of financing dental services is predominately borne by the patients.

Given the current organization of oral health care in Uganda, and the widespread nature of oral diseases, it is important to analyze the extent to which the population can potentially access public oral health care, assuming that other access barriers have been overcome. Therefore, this study sought to examine the geographic distribution of public oral health services in Uganda and how this distribution relates to population poverty and ruralization.

MATERIALS AND METHODS

This study was an ecological assessment of population data relative to the distribution of public dental facilities in Uganda. It involved the use of secondary data from open sources.

RESULTS

Ninety-seven districts out of the total of 112 districts (86.6%) were included in the analysis, as the remaining districts could not be contacted to obtain information on the availability of public dental services. The population in the included districts represented 89.5% of the total population of 35 million Ugandans.

Among districts with dental services, the majority (n = 42, 51%) had a single public clinic [Table 1]. The overall facility-to-population ratio was 1:170,000 people. It should be noted that the total population within the 15 districts, which had no public dental services, was 2.5 million (8.2%) [Table 2].

All districts without public services were in the North and East regions of the country. The northeast subregion was the most affected, with 71% of its population without dental services, while the eastern subregion had 15% without services [Figure 1].

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Figure 1:

Public dental services availability by district in Uganda.

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Distribution of dental public facilities and ruralization

Analysis of the ruralization and distribution of public facilities revealed that generally, the number of facilities increased with decreasing ruralization [Figure 2]. Most of the 40 districts with over 90% ruralization had none (n = 8, 20%) or one (n = 22, 55%) dental facility, while the exceptions were Kibaale and Arua districts, with four dental facilities each. Among the 38 districts with 80–90% ruralization, eight (21%) had no facilities. However, at this level of ruralization, the most outstanding number of facilities was eight in Kibaale district within the south-western subregion. Kampala subregion – enlarged to the right bottom corner [Figure 2] – was fully urbanized with 15 facilities.

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Figure 2:

Distribution of public dental clinics in relation to ruralization of districts in Uganda.

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Distribution of dental public facilities and poverty

The proportion of the population living below the poverty line was considered as the prevalence of poverty in a subregion. Districts without services were located in the four poorest subregions which are all in the eastern and northern regions. These are the eastern, Mid-north, West Nile, and northeast subregions, in the order of increasing poverty [Figure 3]. On the other hand, the highest number of dental facilities was in Kampala, where poverty of the population was the lowest.

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Figure 3:

Distribution of public dental clinics in relation to the subregional population poverty in Uganda.

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DISCUSSION

The challenges in oral health service delivery in Uganda are enormous due to inadequate funding, low prioritization, poor planning, inadequate workforce, and insufficient coordination between the central government and the local governments. The spatial analysis presents an avenue to inform and guide the decision-making and planning process by identifying geographic areas with access gaps relative to the population and its socio-demographic characteristics.

The macro-analysis of service provision before incorporating geo-data and socio-demographics revealed that the 182 public facilities in the 82 districts were providing dental services to 91.8% of the Ugandan population. This left only 8.2% of the population lacking public services in terms of availability, within the designated administrative boundaries. Unfortunately, this level of analysis does not provide the actual geographic distribution of those subpopulations most affected.^[15] Several previous studies have argued that macro-analyses which do not incorporate geographic and socio-demographic variables are not accurate and no longer necessary, given the recent developments in GIS and spatially referenced data^[16-18] that are proven to have higher acuity and accuracy.^[17-19]

In practice, macro-analyses on the availability of services are not considered very useful for meticulous planning but can be used in workforce planning and for policy discussions in some countries.^[17] In addition, these crude ratios are useful in obtaining a snapshot to compare service delivery among regions and identify the most disadvantaged subpopulations at the national level – lacking any form of services – as was revealed at this level for Uganda. The northern region and western subregion were the only areas with districts lacking public dental services.

When the 182 facilities are visualized on a map, the distribution pattern shows some urban areas as having a relative advantage, characterized by clustered clinics. This is confirmed further with the general trend of having more services in urban than rural areas – a common finding from other studies,^[17,20-24] and described as the “inverse care law.”^[25] Poor oral health continues to be higher among the rural population,^[26] further increasing the health inequalities between the rural and urban populations. Rural populations having fewer public dental services have also been demonstrated in Sri Lanka,^[27] another developing country. This phenomenon might be expected in some developed countries that have private dental services – whereby economic factors influence the location of facilities. In such cases, governments respond by providing a safety net for those who may be disadvantaged by rural and remote dwelling.^[19,20]

However, in developing countries, this does not only apply to dental services, but generally for all health care offered in the public system. In Uganda, rural areas have few formal health providers and even fewer public providers.^[4,8,28,29] Since 80% of the population resides in rural areas, this shows that the majority of the population is affected by limited or scarce health services, which has been demonstrated in a number of Ugandan studies.^[4] Therefore, the findings here that most districts in the rural areas have none, or only one facility, augments the point of the scarcity of dental services in rural Uganda.

There is no current record of the dental workforce in Uganda, but previous records in 2006, reported the dentist- to-population ratio as 1:158,000 people, with 39% of the workforce based within the capital city; Kampala.^[11] The current national oral health policy spells out that each district hospital must have a dental surgeon, and each sub- district hospital, a lower cadre public health dental officer. In addition, specialists would be trained and posted to every regional referral hospital. Unfortunately, there is no reliable information on the extent to which this policy was implemented. Although beyond the study objectives of this project, it was established that some of these public dental facilities, especially in the rural and remote districts, had several challenges, including dental workforce issues (having none, very few, or only the lower cadres, who might not be in a position to appropriately serve their catchment areas).

Unfortunately, findings revealed a very wide gap between the most and least disadvantaged subregions. Evidence of the poorest populations having no public services is highly unacceptable, but widely occurring in both developed and developing countries.^{[17,19,21,22,24,30]} The Ugandan poor is a vulnerable group in most aspects of life and with very complex relationships affecting their health outcomes.^[4,8,29] A fifth of Uganda’s population faces these health inequities because of poverty, and so does the 43% that is non-poor but vulnerable in many aspects and hence, prone to the inequities in health.^[31] Based on poverty, the lack and inadequate distribution of services in the north region (especially the northeast subregion; and eastern subregion) is a sign of social injustice – a situation that needs to be reversed.

A limitation of this study was that the poverty data analyzed were based on income poverty classified at the subregional level, a big geographic area. Socio-economic measures of the Ugandan population on a smaller area level to reduce ecological fallacy were not available.

CONCLUSIONS

This study sought to analyze the spatial distribution of public dental services in relation to the Ugandan population distribution by poverty and rurality. The findings revealed that the poorest and most rural populations had the least access to public dental services, and yet they are already vulnerable to other access barriers. Allowing such health inequities to perpetuate is an unacceptable injustice to the Ugandan population and goes against the principles of equity, on which the Ugandan constitution and all health policies are established. The evidence also shows that identifying locations of future services need to take into consideration several population socio-demographic characteristics, rather than merely using distance to a health facility as the only criterion. Therefore, it would be prudent to include GIS techniques in the planning of location for new service points. It is recommended that the relevant policymakers, stakeholders, and planners define standard criteria for access to dental services so that a clear, holistic approach is used to identify the most disadvantaged and vulnerable populations.