Top-down, bottom-up strategy for oral health development: A case in Malawi

Non-profit organizations and service delivery initiatives have attempted to meet oral health needs in areas of the world with little or no access to care. Traditionally, many such charitable oral health services have been ad hoc operations with poorly designed program evaluations; little is known of their effectiveness, efficiency, or sustainability. In recent years, the FDI and the WHO have published guidelines for oral health interventions in the developing world. These guidelines define program objectives that include more than service delivery, alone. The guidelines also include the promotion of measurable health outcomes, sustainable health education, social responsibility among local caregiver, empowerment to control health determinants, and increasing health care providers. In response to this, members of faculty of the Harvard School of Dental Medicine Department of Oral Health Policy and Epidemiology have designed a comprehensive international oral health program for Sub-Saharan African Nations using published guidelines. A program for Malawi has been recently piloted and is the focus of this presentation. The program's general design includes a ‘top-down' inter-university development exchange to promote the highest level of oral health education. A ‘bottom-up' component develops oral health interventions from a grassroots level. These strategies come together for a third tier, eventually bringing local professionals to remote training sites. Program evaluation using short-term, middle, and long-term outcomes have been designed. Process and output indicators are also used to evaluate the program's process and implementation. The comprehensive design and evaluation of the top-down, bottom-up strategy are valuable models for international oral health programs.