One of the original aims of the MalDent Project had been to develop a National Oral Health Policy for Malawi. This aim has been achieved and the policy was launched by the Ministry of Health in April 2022. Publication of the policy was an important landmark, but as with all policies the impact is only realised when the policy is translated into action. With that in mind, an implementation meeting had been held in Lilongwe in November 2022, resulting in the development of an action plan.
An important component of the policy and action plan is the establishment of a child oral health improvement programme. Several relevant work streams have been underway over the past three years, which have provided valuable information that could underpin such a programme. The next stage was to hold a workshop with key stakeholders, to facilitate an exchange of information and views that would feed into the creation of a child oral health improvement programme.
Earlier this year, agreement was reached with the key stakeholders in both Malawi and the UK that a workshop would be held in Malawi on 15th and 16th May, 2024. On Monday 13th May, Lorna Macpherson, Lisa Taylor, David Conway and I set off from the UK to join the meeting.
Whilst long, as always, the journey was uneventful. We were met at Kamuzu International Airport by a driver from Kamuzu University of Health Sciences. We made a detour into Lilongwe to pick up Drs Peter Chimimba and Linda Nyondo-Mipando, then headed to Chikho Hotel in Mponela, where the workshop was to be held.
On arrival, we were met by our friends Nigel and Vicky Milne of Smileawi, who had travelled out from the UK a few days earlier. We enjoyed dinner together before turning in for an early night, ahead of the meeting the next day.
DAY 1
We were up early on the Wednesday morning to prepare the meeting room for the delegates and to check the technicalities of the AV system. The room was ideal for our two-day event, with one half set up for the lecture presentations on Day 1 and the back half an open area that we could set up for the small group work on Day 2
The Ministry of Health had asked Dr Peter Chimimba to chair Day 1 of the workshop. After welcoming those present, Peter read a short speech, prepared by Dr Nitta Chinyama Nayeja, Deputy Director of Clinical Services at the Ministry of Health, wishing us a successful event.
After Peter had completed the introductory formalities, I gave a very short summary of the MalDent Project activities to date. This provided some general context for the workshop, illustrating that work on child oral health improvement is an important part of a jigsaw of activities aimed at improving oral health for all members of the population.
We were delighted that Maureen Maguza-Tembo, Deputy Director for School Health, Nutrition and HIV & AIDS in the Malawi Government Ministry of Education, had agreed to deliver the keynote lecture covering Malawi’s school health and nutrition guidelines.
This high-level presentation at the beginning of the day was extremely valuable in setting a policy context for us from the perspective of the Ministry of Education.
Following this excellent keynote lecture, Dr Chimimba invited Professor Lorna Macpherson to introduce the report on Malawi’s first national child oral health survey that had been undertaken in October 2023. This would be a double-act presentation with Dr Lisa Taylor who, with Nigel and Vicky Milne, had participated in the planning and fieldwork for the survey.
Lorna gave the first segment of the presentation:
She provided background information on the global scale of oral disease, the low priority it has been afforded and the more recent recognition of its importance, for example the WHO Global Oral Health Action Plan 2023-2030, and the establishment of a Lancet Commission on Oral Health, of which Lorna is a member:
Lorna described the survey design, based on WHO Pathfinder methodology, which had been put together in partnership between the Malawian and UK team members. Lorna then handed over to Lisa who gave a fully illustrated presentation on the training and calibration that was delivered for the UK team and nine Malawian dental therapists who undertook the survey. Lisa also provided valuable insights into the execution of the survey itself, during which 2941 children were examined, and cited some lessons learned for any future survey.
Lorna returned to the lectern to present the survey results, first for the six-year-olds …
… then for the 12-year-olds:
These findings from the survey, showing high levels of untreated dental caries in both six- and 12-year-olds, provided objective evidence of the scale of the problem and the importance of work to establish a caries prevention programme for Malawian children. Lorna concluded the presentation, before a break in proceedings for coffee and discussion.
The second session of the morning began with a presentation by Professor David Conway.
David provided an overview of the importance of upstream interventions and the outcome of a review of systematic reviews of caries prevention measures in childhood. The latter was a piece of work that had been initiated by Ronald Manjomo, a PhD student at Kamuzu University of Health Sciences, who very sadly died of COVID. David dedicated his presentation to the memory of Ronald.
David provided an extensive overview of the multiple interventions that have been examined across the globe for caries prevention in children. He included a very clear description of upstream interventions …
… some of which included the following:
He then proceeded to discuss the overview of systematic reviews, the outcome of which was summarised in two slides:
The next speaker was Associate Professor Linda Nyondo-Mipando, who presented a preliminary situation analysis based on data collected by a group of Masters in Public Health students at Kamuzu University of Health Sciences. Linda is supervising one of the seven students who are undertaking projects linked to the MalDent Project. The students’ work is focused on identifying how well the existing infrastructure in Malawi, such as school facilities, would support specific child oral health interventions of the type described by David in the previous presentation.
Linda is a health services research subject expert and her talk highlighted some of the challenges that will have to be overcome as we develop the child oral health improvement programme:
Linda’s presentation brought the morning’s proceedings to a close and we had a very enjoyable lunch break.
After lunch, we had a session of four pre-recorded presentations. The first of these was from Dr. Yuka Makino, the WHO Technical Officer for Africa. Yuka is a good friend of the MalDent Project and was a member of the task force that prepared Malawi’s National Oral Health Policy. We have always ensured that MalDent Project initiatives align with WHO recommendations for the African Region.
Yuka gave an excellent overview which, like Lorna’s introductory comments earlier in the day, highlighted the significant impact of oral disease on the world’s population, particularly in low- and middle-income countries. The costs of treatment, as well as the productivity losses due to oral disease, are both very high:
The statistics Yuka quoted for the African Region illustrated how important it is to push a disease prevention agenda:
In keeping with Yuka’s presentation, integration of oral health into general health systems, and recognition that oral diseases are an integral part of the Non Communicable Disease agenda, are essential components of Malawi’s National Oral Health Policy, including initiatives aimed at child oral health improvement.
Prior to the meeting at Mponela, Yuka had alerted us to a WHO and UNICEF collaboration entitled “Well-Child and Adolescent Care Visits: Programmatic Direction”. The programme is being overseen by Dr Anne Rerimoi, a paediatrician and epidemiologist who is currently based in Liverpool, UK. Lorna, Yuka and I had a very useful Zoom call with Anne in April:
The package provides guidance on scheduled child and adolescent well-care visits – seventeen interactions from birth through the teenage years. Oral health assessments are already included at some of the visits.
Anne kindly provided a pre-recorded presentation, which we were able to share with the workshop delegates:
There was a special relevance to our workshop programme, because Malawi is one of the countries that has been chosen to pilot the scheme. It provides, therefore, a potential opportunity for us to link our plans for a child oral health improvement programme with introduction of the new WHO/UNICEF package, helping to realise the vision of the both programmes:
This is an extremely exciting opportunity and we look forward to continuing our discussions with Anne and the team.
In addition to these two pre-recorded presentations we also showed a module of the free online OpenWHO course ‘Oral Health Training Course for Community Health Workers in Africa’. Yuka had mentioned this course in her talk and we recommended it to those present as a valuable teaching aid:
The final pre-recorded presentation had been kindly prepared by Dr Andrew Paterson, a key member of the MalDent Project team. He described the cascade training programme developed by Bridge2Aid, Smileawi, ProDental CPD and the Dental Association of Malawi, through which dental therapists in the Northern Region of Malawi had been trained to deliver teaching on oral health to community volunteers. The latter, termed Oral Health Promoters, were then equipped to deliver oral health messages within their communities. We would hear more about this later in the day from Vicky Milne of Smileawi, together with a dental therapist and an Oral Health Promoter involved in the programme.
Just before the afternoon tea break we headed down to the hotel entrance for the obligatory group photo:
The final session commenced with a presentation by Mr. Fred Sambani, the Country Director of Teethsavers International in Malawi. He started by showing a video, which you can view here.
Fred went on to describe the work of Teethsavers International, which is a non-profit organisation that focuses on promoting oral health among children in developing countries. As we work together to develop an oral health improvement programme for children in Malawi, it is important that we do so in a collaborative fashion and ensure that those who are already involved in this work are fully engaged.
Our final scheduled speaker for the day was Ms. Maria Soko from Water Aid Malawi, who gave an excellent presentation on the work of the charity in primary schools and early childhood centres. Her talk included a number of top tips for working in schools, some of which were potentially applicable to our own plans for child oral health improvement, such as use of nudges and visual reminders:
We are very keen to investigate the possibility of joining up handwashing, nutrition and toothbrushing in some small-scale feasibility programmes in schools and are delighted that Water Aid is willing to collaborate with us in this endeavour.
Maria’s presentation brought the official programme for Day 1 to a close. However, the delegates present included Mr Edwin Mhango, a dental therapist from Mzimba North and an Oral Health Promoter, Mr Emmanuel Msofi, from the same district. They had both been involved in the project described by Andrew Paterson in his pre-recorded talk earlier in the day and had brought with them some photographs and oral health teaching aids that were provided through the project. We were, therefore, delighted to provide a bonus presentation for delegates from Edwin and Emmanuel. Smileawi was a main partner in the project, providing funding from Scottish Government which they had received pre-COVID, and linking in the therapists with whom Smileawi have been working for many years in Northern Malawi. It was very appropriate, therefore, that Vicky Milne introduced the presentation:
Edwin gave an excellent and positive account of the project from his perspective, together with some of the challenges that dental therapists like himself face on a daily basis.
Edwin and Emmanuel then jointly demonstrated the teaching aids that had been provided through the project and which were suitable for use in very rural areas:
Finally, Emmanuel spoke about his own involvement and experiences in the project as an Oral Health Promoter.
This had been a really valuable addition to the day’s proceedings, providing a very authentic viewpoint of the Oral Health Promoter project from a ‘user’ perspective.
Peter closed the day’s proceedings, thanking all the speakers and whetting everyone’s appetite for the small group discussions that would follow on Day 2, when delegates would have opportunity to contribute to the development of a child oral health improvement plan:
The enthusiasm in the room was evident from the small groups who continued chatting, even after the session had been closed. Dr Ayid Shepard, Oral Health Coordinator at the Ministry of Health, and Dr Lilian Maliro from the Ministry of Health, both had a chat with Edwin and Emmanuel …
… and other groups continued discussions …
… before some of us met for an extended conversation over a drink:
This informal discussion before dinner, which included colleagues from the Ministry of Health, Ministry of Education, WASH, Kamuzu University of Health Sciences, Smileawi and the University of Glasgow, was extremely interesting and very valuable – a perfect way to end Day 1.
DAY 2
Whereas Day 1 of the workshop had comprised multiple presentations, Day 2 was completely interactive and based around three discrete small group discussion sessions. The room was ideally suited to the format and we were able to set up stations for the group work, with flip charts and Post-it notes, separate from the front of the room which retained the Day 1 layout for feedback.
Day 2 was led by David Conway. Each delegate was given a set of briefing notes which provided information presented on Day 1, to act as an aide-memoire and inform the small group discussions.
David reminded delegates about the National Oral Health Policy Implementation Workshop held in November 2022, when the Malawian oral health professionals present had developed a set of actions.
During the discussion groups at this follow-up workshop, the focus would be on child oral health, but building on the work from the meeting in 2022.
with a focus on child oral health
The first discussion group work focused on interventions in schools. The groups were each asked to identify some short-term / low-cost interventions, and some mid- / long-term interventions. This was to be initially done by each individual participant writing proposed actions on Post-it notes (one action per Post-it). These were then to be placed on a flip chart.
The chair then organised the Post-it notes in discussion with the group, identifying those which were repeats or grouped with each other, allowing agreed lists of short-term/low-cost actions and mid-/long-term actions to be defined.
The next exercise was to discuss the facilitators to implementation of each intervention in the context of Malawi, including:
- Who would need to be involved (at all levels)?
- What would be needed for it be taken forward?
- When could it be commenced?
Following this discussion of actions and facilitators, priority ranking for the list of short-term/low-cost actions and for the list of mid-/long-term actions was to be agreed.
A scribe took notes during the discussions and a rapporteur was selected for each group to feed back in the plenary session.
Once the Post-it notes started hitting the flip charts, the hubbub of discussion rapidly rose.
Each of the flip charts was photographed at the end of the session to provide a permanent record:
Once the groups had completed their discussions, everyone came together at the front of the room for the feedback session. David summarised the views expressed as they were fed in.
Following completion of the discussions on school-based interventions, the same process was repeated on two further occasions, once for Community-based Actions and finally for Policy-level Actions
The three sessions of group work were interspersed by coffee, lunch and tea breaks, during which the conversations continued.
Once all three discussion groups were complete, it fell to Lorna to extract and summarise some of the key outcomes. The discussions had been very rich and yielded a plethora of information which will be very valuable as we consider ways in which we can take the child oral health improvement programme forward.
The meeting closed with a summing up by Mr Albert Saka, Chief Education Officer in Malawi’s Ministry of Education. He started by thanking the various teams of people who had participated in the workshop. He explained that the Ministry of Education is using the schools platform to introduce health subjects, such as oral health. He praised the teachers in schools and guaranteed that if we provide them with correct information, they will teach it.
In order to progress the agenda, it needs to be presented to the Principal Secretaries for Health and Education at the respective Ministries if the work is to be taken forward with Government funds. We have objective evidence of the disease burden from the survey, which is powerful. We need to move forward in a coordinated fashion, engaging the Ministries of Health; Education; Water & Sanitation; Gender, Community Development & Social Welfare; and Local Government, Unity & Culture. There is a cross-cutting School Health Group at Government-level, and it is suggested that we establish a Child Oral Health Task Force that can feed into this Group. Multi-sectoral collaboration will be key to success.
Finally, Albert thanked all the supporting staff who had made the workshop possible and acknowledged the generous financial support of The Borrow Foundation and the Scottish Government.
The final word came from our fantastic chairperson, Dr. Peter Chimimba. Peter is the powerhouse behind so many of the MalDent Project activities and this workshop was no different. He had worn at least three different hats over the two days and with his characteristic efficiency and sense of humour had kept us all on track. He added his thanks to those of Albert and wished everyone safe travels home.
This had been a very intensive workshop but also an exceptionally useful event as we plan our next steps towards establishing an integrated child oral health improvement programme that is applicable in a Malawian context. We could not have hoped for a more successful outcome!
Acknowledgements
The workshop was made possible through generous financial support from The Borrow Foundation and Scottish Government International Development.
Thanks are due to all the speakers and to those involved in the organisation of the event.
The photographs in this post have been selected from a combined collection submitted by participants, to whom thanks are due.
Finally, many thanks are due to the delegates, who worked very hard and with great enthusiasm to provide a body of knowledge that will inform the multi-sectoral work now needed to develop a child oral health improvement programme in Malawi.
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