The analysis of the results of the interviews resulted in the identification of 7 main themes and 20 sub-themes as described in Table 1. The main themes identified were challenges in policy making, implementing, educational, stewardship, prevention, insurance, and resource allocating.
As shown in Table 1, policy making challenges included four sub-themes: lack of policymakers, weakness in evidence-based policy making, differences in target groups, and conflicts of interest. The participants stated that lack of relevant policy makers in the field of oral health has caused weaknesses and problems in improving oral health. In this regard, a participant stated:
“After the Islamic Revolution, a number of physicians received specialization. In addition to specialization and becoming a surgeon, internist, ophthalmologist, they became familiar with the management requirements of the modern world and health policy making and health economics, and advanced in the field of medicine, management and dentistry, who went on to pursue a career in dentistry, pursuing specialization, residency and business in the dental market with no attention to management and policy making in the field of dentistry, this is our major challenge: no manager and policy maker in the field of oral health” (P1).
In this regard, another interviewee stated:
“We educate social dentists here who are managing health care, policymaking with prevention, new ways of social grouping, and many topics that are related to the health system, and then coming into the field when practicing just education or finally a responsibility with no maneuver and who will go after is not a specialist, just a clinician, when dealing with a patient has no vision of community and health. A prosthodontist is not aware of problems of the community and those with low social status, not know what they need in terms of oral health, cannot properly plan and execute prevention and health” (P2).
Another sub-theme of policy making was the lack of attention to evidence in oral health policy making. In this regard, one of the interviewees stated:
“When we ignore the evidence that proven prophylactic packages can improve oral health today, but we, for example, put free restoration packages, assuming everyone does this, it won’t improve oral health. It becomes endo, then it breaks down, the root removed, we have this problem as long as there is no therapeutic approach and policy makers don’t take a preventive approach” (P3).
In this regard, another interviewee said:
“I believe in the Ministry of Health plans, Oral Health is ignored, because the Ministry of Health goes the wrong way as people go. Because the policies of the Ministry of Health do not follow evidence-based policy making, the policies of the Ministry of Health are passive i.e. act when there is money, discontent or collapse, but there is no public demand for oral health. There is no need to change it. The Ministry of Health either because of resource constraints or because of a lack of understanding of complete benefit packages, lack of attention to dental health or lack of public demand did not seriously dealt with” (P6).
Other major themes in this study were educational challenges in the field of oral health which led to the identification of the sub-themes of “lack of appropriate educational curriculum”, here is the statement of a participant:
“Inefficiency of educational rules”, “educational structure”, and “training of intermediate forces (oral health care providers)" (P7).
Furthermore, another interviewee said:
“Dental curriculum is problematic, not being community oriented. This is a debate in our dental education. Let’s see, in developed countries we have that number and the country may have had a successful dental education but this was not tailored to the needs of the community. The distribution of sources is not just” (P11).
Or in another place, the other interviewee said:
“Educational curriculum is not based on community needs. The curriculum should be changed and demographic conditions such as population aging should take a preventative approach and pay attention to the burden of non-communicable diseases by relying on common risk factors” (P1).
One of the sub-themes was the inefficiency of educational rules. In this regard, one of the interviewees stated:
“For years, the Ministry of Health accepted some people with lower dental facilities and ranks in dentistry who, after graduating, provided dental services in disadvantaged areas, but due to lack of proper education, this was not the case. We are faced with a shortage of dentists in deprived and underprivileged areas. On the other hand, dentists studying abroad have returned to the country due to a lack of specific legal mechanisms and have been educated in domestic colleges so that for example in Shiraz there are 800 surplus dentists according to international standards” (P12).
Regarding the structure and infrastructure of oral health education, the interviewees stated:
“At one point parliamentarians pushed and built a college in every city. A huge budget that should be spent on preventative dental health was for the dental colleges, which now stands forever to educate students with no administrator dares to close these colleges every year devours huge budgets and the dentist’s job is broken” (P1).
Another interviewee stated:
“There are a lot of oral health budgets now spent for colleges that are not needed much. I think the number of colleges and students is much higher than needed, I remember, for example, a few years ago, a field work on oral health focused on increasing colleges and students was monitored by the World Health Organization and it was found that increasing the number of dentists and dental colleges did not have an effect on oral health state as the need assessment for dental care is different and not like medicine. For example, we cannot say that per 1000 persons we have a doctor, dental field is better, than the increase in general and special dentistry, multiple forces can be trained with limited responsibility and complete supervision that do not go beyond the scope of duties” (P2).
One of the sub-themes in the educational challenges was training oral health care forces as in this regard one of the participants stated:
“It was very interesting at the beginning of the revolution when the health system went along with the training of health workers, dental hygienists, and we spent a lot for this health work, we said go to deprived areas, the entrance was made to convert health workers to dentists and then the training program of health workers stopped. This would indicate that the system should train health workers on an ongoing basis that they would turn to the dentists. We have intermediate forces. This is very important because dental services are expensive so if there is no intermediate force for oral hygiene to work on prevention, life style and tooth brushing we would have no advance in this field, and just being a dentist does not help, in other words no relationship was found between the development of dental colleges and oral and dental indices. We made available in the golden age of the health network system. But it was not continued because of the conflict of interest, which means that the dental colleges considered it as a rival and hindered” (P4).
The interviewees emphasized the topic of educating oral health practitioners and believed that training these forces could improve and develop the oral health state. In this regard, another participant stated:
“In order to promote oral health, we need to have intermediate forces, such as a dental technician’s hygienist not like the present case. Dental technicians at some universities are now trained but due to lack of proper supervision they go to dentistry and sometimes they do specialized work while they have to do preventive and educational work, and despite having a commitment to serve in deprived areas, but that has not actually happened. The intermediate forces can be very effective for example in many developed countries due to high costs of training dentists intermediate forces are trained and tasks of preventing, educating and surface restorations are done that are very effective that will be faded if there is no proper monitoring” (P7).
The executive challenges were one of the main themes that led to the identification of sub-themes in the field of “service delivery”, “health interventions” and “monitoring and evaluation”:
In this regard, one of the interviewees stated:
“In the provision of dental services, no relationship is found between the private and public sectors, such as public and special problems in this field. Dentistry as a luxury field of study has its own costly services, difficulty and easy access is not yet fully established, network structure was available for this monitoring and now, and there seems to be a wandering of the structure of the sources and etc.” (P4).
Or elsewhere, an interviewee said:
“In service delivery, there should be a leveling service, referral system.If the referral system is implemented, the service delivery will be improved as well, which of course requires intermediate forces to provide basic services and, if necessary, referring the patient to the dentist will save money and provide him with timely services” (P3).
Monitoring and evaluation as another sub-theme stated in this regard:
“Monitoring and evaluation are very important, especially in national plans, and if the plans are not implemented effectively, I think due to lack of proper monitoring after implementation some of the prevention plans that have been implemented so far have failed. For example, we send our students for training in schools reporting that, for example, a 200-student school would have fluoride therapy one day, which would practically not yield a good result, indicating improper monitoring” (P4).
And / or in this regard another interviewee added:
“Much attention should be paid to the evaluation and monitoring of oral health plans, and the point to be made in this regard is the need for a supervisor and evaluator to be separated, unfortunately not the case now” (P9).
The design of health interventions was another sub-theme and the emphasis of the interviewees was on the need for serious attention to preventive interventions. For example, an interviewee stated:
“In terms of interventions, there has been an experience in Thailand, Thailand in terms of health system is among good countries. They have been increasing tools and dentists for many years but no change in dental health has worsened the case, investing in two areas of insurance based on training and providing simple tools such as toothbrushes, extensively at school level, wherever people work as a team and after a few years this changed indicators. It seems that it is the best things to do because the simple tool for a lot of people costs a lot, it is not included in the cost of purchasing and if such interventions are done certainly we obtain better results” (P3).
The insurance challenges were the other themes of the study that included the sub-themes of “target group coverage”, “basic insurance package reform” and “attention to cost effectiveness of services”. In this regard, the participants stated:
“In many European countries, children are insured since birth, examined every three or six months until the age of 18, and children and their parents are trained to do preventive activities such as fluoride therapy is compulsory just like vaccination even if a person does not refer. This prevents the burden of treatment. Nowhere else in the world dental insurance coverage is free because expensive services and high costs cannot be insured. This is possible when we undertake preventive work and provide coverage to persons under 12 years of age or surface repair. Restoration of teeth was implemented for 6 teeth but due to lack of proper supervision all refer for the restoration of teeth even if it is not required dentists do because receive per case and leads to the demand induction” (P6).
Other important challenge in this field that has been addressed in this study is the challenges of stewardship. Some participants stated:
“The stewardship should coordinate all the three departments of education, health and treatment. It is suggested to manage an office by the Minister to run all the three departments and coordinate accordingly. In the health sector in the twelfth government, an enormous and unprecedented amount of funding was provided to the oral health, over 300 billion, no one evaluated what the cost of effectiveness is. So, stewardship is poor in this sector. This is a major problem for treatment and HR and private centers were not distributed fairly. Once monitoring can be better controlled that any force works where you that is the problem of trusteeship that is better if it is considered as a unit” (P2).
Or another interviewee stated:
“No one is the responsible of stewardship. The universities have different practices, in fact, because the principal executives do not hire those who have both knowledge and expertise so we have these problems. That is to say, we need a single stewardship to control all fields of treatment and education” (P4).
And another interviewee noted:
“The task of the College is finally to train the human resources. The stewardship should return to the Ministry of Health. Health stewardship should be return to treatment, treatment has no dominance or interest for health. If treatment stewardship returned to health, health has no ability to manage the private sector and maybe its best is to separate the health and treatment and coordinate. So I believe that if health department is established, these two offices should be one to increase monitoring, and then experts in the field of prevention and experts in the field of treatment should work separately” (P5).
The challenges related to prevention were another topic that interviewees stated in this regard:
“In the field of health and prevention, the attraction of the treatment sector caused increasing the willingness to treatment and wealth. And the health care sector is not considered. The therapists are influential and take jobs for policy making. For example, the highest level of oral health policy making a prosthodontist, who cures a condition of a patient that has lost all of teeth and should provide with teeth. Definitely a person with this concept,or for years the principal for oral health policy making in the country was an endodontist,while, policy makers in the developed countries are specialized in oral health, social oral health. Many years ago, the government funded 6 or 7 persons in the field of social dentistry in the hope of returning later to and each manage the country oral health policies. All of them returned and became professors at universities, and all do is publish papers. In the Oral Health Policy finally, there should be somebody to point out these problems. Some are illiterate and some are not” (P1).
Or another interviewee mentioned elsewhere:
“The statistics presented are inaccurate. The layout looks appealing, but when we get into the treatment cycle, the amount of support we receive for dentistry is not enough and so expensive that one goes into the treatment cycle inevitably. The treatment package with a therapeutic approach is not very effective and should be a prevention approach and monitoring the method” (P4).