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AUTHOR (year of submission) "Full thesis title", University of Southampton, name of the University School or Department, PhD Thesis, pagination http://eprints.soton.ac.uk






By Maduwage Dileep Kumarasinghe De Silva Thesis for the degree of Doctor of Philosophy August 2012 Page | ii





Doctor of Philosophy


By Maduwage Dileep Kumarasinghe De Silva Sri Lanka is a developing South Asian country which provides free education and healthcare for all its citizens. This thesis presents a policy-oriented study, partly empirical and partly modelling, whose aim was to understand dental care provision and workforce planning, at a time where Sri Lanka‟s dental health policies appear to have failed to achieve their intended results, leading to a mismatch between supply and demand, i.e. “underemployment and unemployment” of trained dental surgeons, despite an increasing need for dental care within the population.

The first section of this thesis describes a novel method of collecting primary data on Sri Lanka‟s dental health professionals, in a challenging setting where there was no existing database. The thesis also presents a methodology to convert need for dental care to demand for care, adapting an existing model developed by the World Health Organization and the Federation Dentaire Internationale to suit the Sri Lankan setting. Finally, this section of the thesis describes a survey to identify the “timings” taken for various dental treatment modalities in Sri Lanka.

The second section of the thesis presents a System Dynamics model, which uses the data obtained from these empirical surveys, to address dental workforce planning issues in Sri Lanka. The model is then used to simulate various different scenarios, generating realistic, practical and insightful lessons for policy making. Based on the results of this model, in 2011 the Government of Sri Lanka took steps to deal with the “employment mismatch” issue by restricting the annual intake of dental students and by creating 400 new Government-funded posts over the following two years.

Page | iii Page | iv







Chapter 1: Introduction

1.1 Modern dentistry

1.2 Dental care in Sri Lanka

1.3 The problem of unemployed dental surgeons

1.4 Motivation for this research

1.5 Research questions and objectives

1.6 Research contribution

1.7 Layout of the thesis

Chapter 2: Background: supply and demand in health and dental care

2.1 Introduction

2.1.1 Health need

2.1.2 Demand for health

2.1.3 Health service market characteristics

2.1.4 Independence of supply and demand in the healthcare market

2.1.5 Dental care supply and demand

2.1.6 Demand for dental care in comparison with general health services................. 11 2.1.7 Dental Care Delivery

2.2 Healthcare systems worldwide

2.2.1 Health expenditure worldwide

2.2.2 Examples of country-specific health care spending

2.3 Dental care systems worldwide

2.3.1 Overview of global dental health services

2.3.2 Dental/oral healthcare systems and services in selected countries

Page | v

2.4 Public and private funded dental care

2.4.1 Global trends in health system financing

2.4.2 Private dental care provision

Chapter 3: Sri Lanka and its Health and Dental Care System

3.1 Sri Lanka: country profile, history, and economy

3.1.1 History: foreign invasion

3.1.2 Country profile

Sri Lanka‟s healthcare system

3.2 3.2.1 Development of the health system

3.2.2 The current healthcare system

3.2.3 Spending on health care in Sri Lanka

3.3 Sri Lankan dental services, public and private

Origin and development of „modern‟ dentistry in Sri Lanka

3.3.1 3.3.2 Expansion of public dental services in Sri Lanka

3.3.3 Publicly funded dental/oral healthcare systems and services

3.3.4 Private sector dental care in Sri Lanka

3.3.5 The Sri Lankan dental care product industry

3.4 Dental disease patterns in Sri Lanka

3.5 Dental education in Sri Lanka

Chapter 4: Literature Review

4.1 Workforce planning

4.2 Workforce planning in healthcare

4.3 Workforce Planning in Dental Care

4.3.1 Dental workforce planning techniques

4.3.2 Previous dental workforce studies of importance

Chapter 5: OR Modelling in Healthcare

5.1 Introduction

5.2 System dynamics

5.2.1 Qualitative aspects of SD

5.2.2 Quantitative aspects of SD

Page | vi 5.2.3 SD models in healthcare workforce planning

5.3 Choice of SD as a modelling approach

Chapter 6: Data Collection

6.1 Supply side

6.1.1 National-level data collection

6.1.2 Focus group discussions at district level

6.1.3 Postal questionnaire

6.1.4 Dental students survey

6.1.5 The Sri Lanka timings inquiry

6.2 Demand side

6.2.1 Secondary data from national oral health surveys

Demand for dental health care in Sri Lanka – the WHO/FDI methodology..... 81 6.2.2 Chapter 7: Results of the Empirical Studies

7.1 Results of the postal questionnaire and the mapping exercise

7.1.1 Government sector dental care provision

7.1.2 Private dental care provision by state sector-employed dental surgeons........... 88 7.1.3 Workforce profile in private sector dental care provision

7.1.4 Characteristics of private dental care provision

7.1.5 Unqualified dental practitioners

7.1.6 Dental care provision

7.1.7 Provider characteristics

7.1.8 Number of patients treated

7.1.9 Clinic staffing

7.1.10 Patient records and equipment available

7.1.11 Types of treatment provided

7.1.12 Dental Treatment Fees

7.1.13 Employment opportunities in the Ministry of Health

7.2 Results of the dental student survey

7.2.1 Demographics

7.2.2 Employment expectations

Page | vii 7.3 Demand

7.3.1 Results of the Sri Lanka Timing Inquiry

7.3.2 Treatment time calculations

7.3.3 Age group based treatment time calculation

7.3.4 Converting need to demand

7.3.5 Total dental workforce hours

Chapter 8: The System Dynamics Model

8.1 Model development

8.1.1 Model Validation

8.2 Details of the model

8.2.1 Specific employment pathways

8.2.2 Other features of the model

8.2.3 Model outputs

8.3 Use of the model

8.3.1 Results from the baseline scenario

8.3.2 Scenarios assuming changing demand

8.3.3 Graphical illustration of key results

8.3.4 Summary of model findings

8.4 Policy implications

Chapter 9: Discussion

9.1 Summary

9.2 Provision of dental care

9.2.1 Geographical distribution

9.2.2 Unqualified dental practitioners

9.2.3 Private dental care provision by state-employed dentists

9.2.4 Dental clinic staffing levels

9.2.5 Dental appointments

9.2.6 Profile of dental practitioners

9.2.7 Training and CPD

9.2.8 Dental workforce productivity

Page | viii 9.2.9 Ownership of private dental practice and clinic premises

9.2.10 Types of dental treatment provided

9.2.11 Support staff in dental clinics

9.2.12 Patient records

9.2.13 Use of dental equipment and sterilization of dental instruments

9.2.14 The future dental workforce

9.2.15 Gender issues in the dental profession

Chapter 10: Conclusion

10.1 Summary

10.2 Research Contribution

10.3 Practical impact of the research

10.4 Limitations

10.5 Further research



A1. Postal Questionnaire to all practising dentists

A2. Dental Students‟ questionnaire

A3. The Sri Lanka Timings Enquiry

A4. Stella model: code listing

A5. WHO/FDI Restorative care calculation formulae

A6. Calculation of total dentist hours

A7. Data used in the Stella model

A8. Distribution of full-time private dental clinics, by district

A9. Distribution of part-time private dental clinics, by district

A10. Distribution of unqualified practitioners, by district

A11. Population of Sri Lanka, by district

Page | ix Page | x


Figure 2.1. Global health financing

Figure 2.2.

Health expenditure as a percentage of GDP in South East Asia, 2009................. 16 Figure 2.3. Per capita health expenditure - WHO South East Asia Region in 2009............... 17 Figure 3.1. Sri Lanka

Figure 5.1 Causal loop diagram – Training of dental surgeons

Figure 5.2 Causal loop diagram - training and employment for dental surgeons

Figure 5.3 Stella diagram - training and employment for dental surgeons

Figure 7.1 Map of Sri Lanka showing the number of Department of Health employed dental surgeons in each district

Figure 7.2.

The distribution of private dental clinics/offices

Figure 7.3 Box-plot of the distribution of full-time private dental clinics/offices.

............... 92 Figure 7.4 Box-plot of the distribution of part-time private dental clinics/offices................ 92 Figure 7.5 Numbers of private dental clinics per 100,000 population, by district................ 98 Figure 7.6.

Comparison of fees between Colombo district and all other districts................. 107 Figure 7.7.

Number of dental surgeons recruited by the Ministry of Health (1995-2008).... 108 Figure 7.8. Age distribution of students

Figure 7.9 The district of university entrance-students

Figure 8.1.

Influence diagram showing dental workforce dynamics

Figure 8.2.

Career pathways in the Stella model

Figure 8.3.

Department of Health career pathway

Figure 8.4.

University staff career pathway

Figure 8.5.

Defence establishment career pathway

Figure 8.6.

Full-time private practice career pathway

Figure 8.7.

Stella graphical function showing increase over time in FT:PT ratio................ 136 Figure 8.8. Stella graphical function showing increase over time in foreign-qualified dentists entering FT practice

Figure 8.9.

Locum part-time private practice career pathway

Figure 8.10.

Screenprint of the entire Stella model

Figure 8.11.

Number of dentists awaiting government employment, and waiting time....... 151 Figure 8.12 Supply and demand for dental care, scenario G

Figure 8.13 Dental surgeon to population ratios

Page | xi Figure 8.14 Full-time equivalent dental surgeons

Figure 8.15 Number of dental surgeons in MOH and established full and part-time private practices

Page | xii


Table 2.1 Health care financing trends by country income level

Table 2.2.

Health professional training institutes by WHO region

Table 2.3.

Number of dentists by WHO region

Table 2.4 Number of dental surgeons per 100,000 population

Table 3.1.

Health expenditure indicators in Sri Lanka-2009

Table 3.2.

Distribution of school dental therapists (SDTs)

Table 3.3.

Dental disease trends in Sri Lanka, 1984-2003

Table 3.4.

Number of dental surgeons graduating from the University of Peradeniya........... 46 Table 5.1. Conceptual differences between DES and SD

Table 6.1.

Need-demand conversion factors in the WHO/FDI model

Table 6.2.

The three demand scenarios tested in the system dynamics model

Table 7.1 Provincial distribution of state sector-employed dental surgeons in 2008.

............. 86 Table 7.2.

Participation in part-time private dental care provision by state sector.................. 88 Table 7.3 The provincial distribution of private dental clinics/offices

Table 7.4.

The district distribution of private dental clinics/offices

Table 7.5 Distribution of Unqualified Dental Practitioner clinics

Table 7.6.

Correlation between the distribution of „legitimate‟ clinics and UDP clinics........ 96 Table 7.7 Private dental clinic density

Table 7.8.

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