Master of universal care

Photography: Eamon Gallagher

Associate professor Sajeev Koshy OAM has a vision: needs-based universal dental care. He tells Susanna Nelson what it would take to make his vision reality

Dentally speaking, associate professor Sajeev Koshy can claim to have seen it all. There aren’t many medical professionals with his breadth of experience, which extends from the Indian public health system, to Hong Kong—where he worked with Vietnamese refugees—and on to Mexico, Guatemala, Kenya and New Zealand, before finally landing in regional Victoria.

Along the way, the head of endodontics at Melbourne’s Royal Dental Hospital has honed his specialty, becoming one of the first dentists to earn an MBA, picking up a number of awards for his work and establishing himself as a leader in quality health care provision in his home state of Victoria. In addition to his work at the Royal Dental Hospital, he currently leads the dental teams at Plenty Valley Community Health and Boort District Health as director of Dental Services.

In 2016, he was awarded an OAM for services to dentistry in Victoria.

But Dr Koshy is not driven by wanderlust or by a quest to win plaudits, but by a healthy attitude towards self-improvement and continuing education, and by an unwavering belief in the importance of universality of access to quality dental care.

He started out as a student leader and activist back in Kerala State in India, fighting for social change—a heritage he credits with shaping his approach to his work and career. “One of my pet projects has always been low-cost care—the rights of the poor to access quality health care,” he says. “Kerala has always had a strong social justice movement. The state has its own distinct heritage and boasts very high standards of health care—along with exemplary literacy, because the two go side by side—which are comparable to those in the West.”

Dr Koshy believes there is a wealth of ideas to be shared between the different dental systems he has encountered, including some lessons for dentistry from the example of his home state. He says one of the first things he noticed when he and his wife moved the family to Dunedin in New Zealand to further their professional training, along with the cold weather, was a surprising difference in wait times for certain procedures.

“Public health care is still affordable to those who live below the poverty line in Kerala,” he says. “People do not have to wait for elective surgery— cataracts for example—whereas there are extremely long waiting lists for these sorts of procedures in Australia and New Zealand.”

How is this possible? According to Dr Koshy, what Kerala lacks in physical infrastructure, at least in the public setting, it makes up for in workforce capacity and skill, and a needs-based approach to care. “Facilities are lacking—Kerala can’t afford the capital works we enjoy in the West because of funding and population density,” says Dr Koshy. “It is one of the smallest states in India, with a population of 30 million. Wards are overcrowded in public hospitals. And yet, if you look at the incidence of mishaps within that population, it is very low.

“We brought in the National Partnership and the Child Dental Benefits Scheme, but these programs are not sustainable in the long term. We need a long-term vision that incorporates a cost-benefit approach in our models of care.”

“What I learned from my experience in Dunedin was the emphasis on quality, particularly in the standard of care. I also honed my skills in relation to benchmarking against the standard of care. This prompted me to do a Master of Business Administration (MBA) at Otago University. I did the MBA and then I signed up for my specialisation in endodontics.”

A range of business behaviours that are often alien to dental and other medical practitioners were unlocked to Dr Koshy when he chose to study business. He developed skills in organisational behaviour, finance, strategy and benchmarking. It allowed him to make further links between economics and dental medicine at an administrative level.

“In the work I have undertaken in my career, you really need to have that bird’s eye perspective on organisations and this really helped me understand them. That said, I wanted to keep dentistry as my core competency. I wanted the MBA to supplement my clinical skills, not the other way around.”

This is where the endodontic specialty came into it. “There were very few endodontists in New Zealand at the time I did my specialty. I think there were something like 12 practitioners in the whole of the country,” Dr Koshy says. “The specialty fascinated me because it was clinically very challenging and it offered me a chance to perform to the best of my ability as a dentist.

“Endodontics involves a lot of pain management so it’s a very fine area. You need the skills and the patience to really diagnose properly and then manage the case based on individual requirements, ” he says.

“Some dentists really enjoy doing this as part of their general practice. At the same time, the specialist endodontic programs in Australia and New Zealand—in particular, Melbourne, Otago, Perth and Adelaide—are highly regarded and have produced some of the best specialist endodontists in the country.”

Dr Koshy believes his profession is well supported to provide high quality care by the Australian and New Zealand Academy of Endodontists (ANZAE) and that assistance for general practitioners from the Australian Society of Endodontology, which offers membership and delivers proximal development courses, can help to increase understanding of the specialty. “It’s a great partnership,” he says. “There are basic and advanced upskilling courses across the country that can really improve your confidence in this area.”

Global travel has given Dr Koshy a unique perspective on population-wide dental challenges. He has worked with remote indigenous communities not only in Australia, but around the world, along with groups supported by the United Nations High Commissioner for Refugees (UNHCR), including Vietnamese refugees in Hong Kong.

“We are currently only seeing about a quarter of the eligible population. What about the rest of them? They are slipping through the cracks. When you combine this with the consumption of sugary foods, we are still failing underprivileged communities. These are the challenges for dentists.”

This multicultural experience has given him in insight into the diverse health care issues that affect different cultures and communities, and how best to treat them. The challenges are immense: “I was working with the Quechi, an indigenous group in Guatamala shortly after Hurricane Mitch,” recalls Dr Koshy. “At the time the country was also destabilised by guerrilla warfare. I had to travel for many hours on unsealed roads to the rainforest to reach these communities.”

Shockingly, Dr Koshy found that fresh running water was more expensive to access than sugar-dense soft drinks. “That was a real cultural shock to me. I’ve seen the same thing with multinationals dumping sugary foods in poor developing countries—in Kenya and Mexico. Whatever we do we cannot keep up.”

Dr Koshy has observed a huge variance in the standards of care across cultures. “The cost of materials and commercial viability vary widely between different countries,” he says. “If you compare the cost of the same dental chair in six different countries, you’ll find a different price in each country. Complex factors such as population density, health funding and government priorities all play a part.”

These insights were particularly useful when Dr Koshy arrived in Australia in 2004 and observed the disparity between urban and regional dental health. “I discovered that at Bairnsdale regional hospital there was a waiting list of 57 months. So I moved over to Bairnsdale with the objective of setting it right,” he says.

During his time at Bairnsdale Regional Health Service, which covers a vast area from the border of NSW to Gippsland in Eastern Victoria, he won over the confidence of his colleagues and started to implement change management to address access to services.

In his two and half years at Bairnsdale, he pared back the 57-month waiting list to less than seven months, achieving something of lasting benefit to this regional community. For their efforts, Dr Koshy and his colleagues in the Bairnsdale team were awarded ‘best health care team’ in the 2007 Victorian Health Care awards, by the-then Health Minister, Daniel Andrews, now Premier of Victoria. “I had a great team working with me,” says Dr Koshy. “That was my first journey with transforming dental health care in Australia.”

Dr Koshy holds out hope for universal dental health care in Australia, but he recognises there’s a long way to go. “We brought in the National Partnership and the Child Dental Benefits Scheme, but these programs are not sustainable in the long term,” he says. “We need a long-term vision that incorporates a cost-benefit preventative approach in our models of care.

“My dream is that we should bring in universal dental care based on need. It can happen incrementally, starting with certain population groups, until you have a statistical reduction.

“We are currently only seeing about a quarter of the eligible population. What about the rest of them? They are slipping through the cracks. When you combine this with the consumption of sugary foods, we are still failing underprivileged communities. These are the challenges for dentists.”

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