Health For All has become a corner-stone of public health, ever since the International Conference on Primary Healthcare and declaration of Alma Ata in 1978. Health for all is not just being free from diseases; it is a promise for the provision of basic services to every single person in the world. Right to healthcare is a basic human necessity and includes dental healthcare within its umbrella of holistic cares. ¹

One of the principles of primary health care is to provide social equity universally. The word equity refers to just and fair distribution of health care services all around the globe. ¹ There is a special emphasis on providing access, which is people’s ability to avail healthcare related services as and when they are needed. ² Access to healthcare has an important role to play in the overall health system, in reducing the burden of disease. ² Access to health care has two important geographical perspectives: 1.

Accessibility (potential of approach) – how conveniently a particular service can be approached and the means of accessing the facility; and

It is very well acknowledged that, the healthcare based resources need to be planned in a specific way that, they are utilized to the maximum. ³ They need to be located conveniently for the majority of the population to be able to access them. It is also important to accommodate for different growth rates of different geographic areas and population clusters. Some areas are dynamic and mutate, evolve and grow with time. This uneven growth rate of population clusters is straining an already stressed utility provision system. The prime objective for healthcare providers is to have an adequate road map during the establishment of new healthcare centres so that it caters to maximum number of people. ³

Given the above criteria, geographic information system (GIS) based accessibility interpretation is the most scientific and succinct method that can be used to calculate the extent to which geographical access is obtained. ^{4 , 5} In short, GIS is the ‘digitization of cartogram’. It is a modern information system with capabilities of accepting, recording, analysing, managing and presenting the spatial referenced data (that is, the data is linked to a geographic location). ⁶ It uses data that is attached to a unique location (geo-referencing) to create a multi-tier map showing individual attributes that can be superimposed. GIS allows and aids in cartographical representation and comparison of data that can be used in formulating better and focused healthcare plans. Pictorial representation of statistical data is much more lucid and easier to interpret in comparison to other formats of data representation. ⁷ Density maps/Heat maps aid in finding density of health centres, cases, vectors, risk factors, etc. Kernel density calculates the density of features in a neighbourhood and around those features, per unit area, in a raster format. It can be used with both the point and line data. ⁷

In terms of geographical extent, India enjoys the position of being the seventh largest country worldwide, with a population of 1.3 billion. In India, dental healthcare is provided by a combination of private sector and public institutions. As one of the major signatories of the United Nations (UN) charter for health, India is committed to provide basic dental health provision, starting at the level of Community Health Centres. Since the inception of India’s first dental college in Kolkata in the year 1920, it has been an uphill task to train sufficient number of dentists to meet the demands of an ever-growing population. Annual government funding for health services is meagre 1.6% of our total GDP, with no separate allocation for oral health. ⁸ With 22% of the population living below poverty line, providing basic dental health services is a mammoth task. ⁹

Coastal Karnataka includes the districts of Udupi, Dakshina Kannada and Uttara Kannada in the South Western part of India. This area has its own ethnic population and customs and boasts of a population of roughly 4.7 million, spread over an area of 18730 square kilometer. The settlements vary greatly from commercial and urban clusters of Mangalore to inaccessible villages of Dandeli. This uneven distribution of population, and living standards warrants individual surveys for planning. (GIS)-based model is been applied in other countries to estimate the number of new oral health facilities needed based on the geographical proximity or distance to nearest health care facility. ^{3 , 6 , 10}

This thorough assessment of the existing distribution of oral healthcare facilities to understand potential accessibility when planning for expansion of oral health services. We hypothesized that dentists are concentrated to areas with high population density, easy geographic access and a higher wealth distribution.

Hence, this study aimed to map and calculate objectively, spatial accessibility to the oral health care facilities in coastal districts of Karnataka state, India: Udupi, Uttara Kannada and Dakshina Kannada, and its association with population density and socio-economic conditions. Objectives were: 1.

to analyze the geographic distribution of private and public dental healthcare providers with respect to population, per-capita income and urbanization, in GIS environment;

The three coastal districts of Karnataka stretch to a length of 435 km and a width of 225 km. These Districts are further divided into administrative sub-units known as taluks. There are a total of 1807 villages in 20 Taluks of these 3 Districts. We chose administrative districts as our geographical regions, since these match the population census files in the same format, as required for geo-mapping and analysis of geographical data. This cross-sectional study was conducted over a duration of twelve weeks between September and November 2020. Figure 1 gives the location map of the study area, with reference to India.

Universal healthcare facilities are one of the pillars of the healthcare planning process. Access to healthcare is different from the geographic accessibility, in that, the former encompasses both: 1.

spatial components (availability and accessibility) and

Hence, in our study we tried to measure geographic accessibility by locating the availability of dental practitioners in the coastal districts of Karnataka using GIS. A geographic information system (GIS) is a computerized system, that is created to analyse and display geographically referenced information as a layered map 6. According to Padminee K et al., Karnataka has the largest number of Dental practitioners for any state in India (34,768). ¹⁵ For our work, geo-coordinates of the public and private oral health centres were collected and this data was used for GIS analysis using the open-source software, QGIS 3.14.

In the present study the average D:P was 1:12836. This is in accordance with the national D:P of 1:10,271. ¹⁶ World Health Organization (WHO) recommendations state the ideal dentist to population ratio should be 1:7500. ¹⁷ The above data is in sync with that of other developing countries. In India there are more than 300 dental colleges with 24,000 dental graduates adding to the pool every year. This ratio is similar to the studies conducted by Periera I et al. and Hosny G et al. in Srilanka and Egypt, respectively, ^{17 , 18} but more than that of the study conducted by Omogunloye OG et al. ¹⁹ but much lesser than the ratio reported in studies conducted in Australia and the United States (US). ^{20 , 21}

There is a severe misallocation of dentists in terms of urban and rural distribution. A high proportion of dental professionals are concentrated in the urban agglomerations. Only a small Indian population of 15 – 20% have access to dental health services through national schemes. The average per capita public health funding for a year in India is a meagre 2.6$. ¹⁵

According to the current study, a meagre 25% of the dental practitioners were practicing in the rural areas, serving 37.2% of coastal population, making D:P in the rural areas to 1: 39,401. This is very similar to the national estimates of rural D:P of 1:30,000. ¹⁶ This contrasts with an urban D:P of 1:6859. These values are very similar to the national urban D:P of 1:4,000. ¹⁶ This distribution pattern is common to many countries. Brazil and Taiwan (as developing nations) report an average D:P of 1:735 and 1:1603, respectively, but show uneven distribution between urban and rural areas. ^{22 , 23} The solution for this uneven distribution lies in bringing all dentists under the umbrella of primary health-care system. In India, providing dental care starts at the level of community health centers. Employment of dental manpower at the primary health center level can help reduce this burden. The dental practitioner to population ratio has markedly improved from 1:301,000 in the 1960s to 1:9992 in the present times and yet, the state-wise distribution of dentists is disproportionate. ²⁴

Public health centers are providing affordable oral care services, but the services are very limited. This in turn, compels the people to consult private health care facilities, resulting in excessive expenditures. This situation is the same as in other developing countries like Nepal, Taiwan and Brazil. ^{22 – 24} In Nepal the current ratio is 1:16000 according to a population report by Central Bureau of Statistics. Only 8% of dentists work in public sector, and these values are even lower in comparison to countries like Denmark and South Africa. Though the ratio has improved to 1:24000 in 2010 from 1:120000 in 2000, it is much lesser when compared to countries like Singapore and United Kingdom. ²⁵ These countries provide holistic dental care via the National Health Service and have a strong network of public health centres for all its citizens. ²⁶

Since the 1990s, there has been a boom in the number of dental schools, most of which are private. At present, 86% of all Indian dental schools are private colleges. We observed dissimilarity in the distribution of dental schools across the region. Four dental schools, all private, are located in a single taluk, with one district devoid of any dental schools. Privatization increases the divide between rich and poor, boosting the facilities richest while driving the poor to further penury. ²⁶ This should not be acceptable to a civilized society. This wave of privatization has side-lined access to universal oral health services and has alienated the underprivileged. ²⁷

The results of our study confirm the hypothesis that dentists are concentrated to areas with high population density, easy geographic access and a higher wealth distribution. This disparity in distribution of oral healthcare amongst the districts of Coastal Karnataka is similar to that of other countries, with dental services being more easily found in the large cities and along the coastal areas. ^{6 , 23}

Our study has some limitations. Comprehensive data on the dental clinics were not available. Many countries around the world have an annually updated database of dentists in both private and public and sectors. The Indian database is substantially inadequate in this regard. For this study we collected all the data on private dental clinics via the registered dentists under Indian Dental Association. We also hand searched for any private clinics via Google search engine. The latest population data available to us was that of the National Census 2011, whereas, the dental clinics data is updated to 2019 and hence, there are possibilities of overestimation of clinics/D:P ratio. Also, the study cannot envisage the differences that may occur in the dental services utilization among urban and rural populations.

From our study, we came to the conclusion that oral health services were concentrated in areas with higher annual income per-capita, increased urbanization and population density. The same were unevenly spread across coastal districts. Rural population in four taluks have only one dentist for over a lakh population. Most of the rural areas have only public centres to cater to their oral health. Private clinics are unevenly distributed. Also, we could identify the poorly served areas in the three districts. Shockingly, the share of funds allocated for public healthcare provision is only 1% of the total GDP. Moreover, India lacks a separate and specific allocation for dental health. In the last financial India spent only 6% of its total GDP towards healthcare. ²⁸

We anticipate that above problems can be solved with appropriate governmental support by the establishment of public health centers in inaccessible areas. Meticulous planning of survey data comprising of geographical distribution parameters and economic status of the surrounding population can give an accurate representation of the ease of accessibility of treatment.