lo i A state-supported incentive program and distribution of dental manpower T. M. Roberson, DDS R. P. White, Jr., DDS, PhD, Chapel Hill, NC
To en c o u ra g e d en ta l h ea lth p ra ctitio n ers to p ra c tic e in a re a s o f low dentist/population ratios, an E d u ca tio n a l Loan P ro gra m h a s b e e n set up in North C arolina. T hrough p ra ctic in g in a re a s o f d e s ig n a te d sh o rta ge, g ra d u a tes ca n fu lfill th eir lo a n obligations.
J n the past quarter century, there have been m any different programs designed and im plem ented to en courage health professionals to prac tice in areas of the greatest need: the inner city and the rural com m unity. F in an cial in cen tiv es, special courses in health education institu tions, fed eral health initiatives, placem ent services, preceptorships, and in novative delivery system s have all show n som e success in addressing the problem of m ald istribution of health m anpow er.1 Congress is aware of the m ald is tribution of health m anpower. In de veloping the Health Professions Educational A ssistance A ct of 1976 (Public Law 94/484), provisions were inserted that w ill require the dental school to either increase its enroll m ent or provide training in rem ote sites for dental students as a con d i
tion for federal capitation paym ents to the school. Data show ing the extent of dental disease in the U nited States and the estim ated increase in the dem and for dental services during the next few years support the congressional ap p roach.2,3 Concern was expressed by members of Congress that th e current dental m anpow er w ill be un able to cope w ith the projected dem and; cu r rent data h ig hlig h t the problem s of geographic m ald istribution of dental m anpow er. Of the 3 ,1 2 8 cou nties in the U nited States, 282 (9%) have no dentists; 2,687 have dentist/popula tion ratios less than the national av erage of one dentist per 2 ,1 4 9 per sons; of these 2 ,6 8 7 cou nties, 689 have ratios less than one per 5 ,0 0 0 .2 The situation in North Carolina typifies the problem of m ald istribu tion of dental m anpower. Forty-three
of the 100 counties in North Carolina are designated as Federal Dental Shortage A reas.4 T h e overall d en tist/population ratio for North C arolina in 1975 w as 1/2,744 in com parison w ith the national ratio of 1/2,149. Eighty-seven cou nties in North Carolina have dentist/popula tion ratios less than the national ratio.5 M ore inform ation is needed to draw conclu sions from these figures. T he North Carolina Dental Society is sponsoring a study of the dental m anpow er needs of North Carolina. New approaches to providing dental m anpow er may be derived from th is study. T his paper describes the attem pts o f a state-supported in cen tiv e pro gram (the E ducational Loan Pro gram) to solve the problem of m ald is tribution of dental m anpow er in North Carolina. Program s accom plished at a state lev el can com p le m ent federal approaches, such as the N ational H ealth Service Corps (NHSC). A ll p o ssibilities for solving the m anpow er problem m ust be ex plored to find a satisfactory solution.
D e scrip tio n o f th e p r o g r a m The E ducational Loan Program , created by the North Carolina G en eral A ssem bly in 1 9 4 5 , was know n JADA, Vol. 97, October 1978 ■ 633
A RTICLES T o ta l d e n ta l lo o n r e c ip ie n t s (1953-1976)
219
originally as the M ed ical Student L oan Fun d. T h e program was de signed to m ake loans to m ed ical stu dents who agreed to p ractice m ed icin e after graduation in a rural area (a com m unity having a popula tion of few er than 2 ,5 0 0 ). T h e loan program was extended to students of dentistry, pharm acy, and nursing in 1947. S in ce that tim e, 15 other field s o f study in the h ealth professions have been added to the program . The purpose of the E ducational Loan Program is to encourage h ealth pro fession als to p ractice in sparsely populated rural com m unities in N orth C arolina in w h ich there is an urgent need. U n til recently , no pro visio n has existed for the under served urban com m unity. The Edu cational Loan Program accepts ap plication s from resid en ts of North C arolina who have b een accepted or are enrolled in sch oo ls of the desig nated health p rofessions. Students are not lim ited to institu tion s in North Carolina. T h e criteria for selectin g loan recip ien ts are interest, acad em ic cap ability, m otivation to p ractice in a designated area, and fi n ancial need. B efore 1965, the E ducational Loan Program required recip ien ts to both p ractice in areas w here there were few health professionals and repay the loan. Stu dents w ho served in these areas received a reduced rate of interest. In 1965, the program was altered, and a lo an -can cellation for m at was adopted. A recip ien t was then required to p ractice in an ap proved area for one fu ll calendar year for each acad em ic year, or part of an acad em ic year, in w h ich a loan was received. S in ce 1975, a dental stu dent receives $ 4 ,0 0 0 a year from the E ducational Loan Program and m ust agree to p ractice in a com m unity of few er than 1 0 ,0 0 0 people or in a des ignated local or state health facility. E ffective in 1977, the program ob li gation m ay also be satisfied by pri m ary care p ractice in any approved underserved area (urban areas w ith a population greater than 10,000). As a student, there is no obligation to the program. If a loan recip ien t does not fu lfill his p ractice requirem ents, he m ust repay the loan in fu ll w ith in634 ■ JADA, Vol. 97, October 1978
w ith d r«
133
g r a d u a t e d (rom d e n ta l
c u rre n tly in
s c h o o l w ith o b lig a t io n
sc h o o l o r d e fe r re d
c u r r e n tly in a 160
c o m p lia n c e p r a c tic e
h o v e c o m p le te d • th e ir o b lig a tio n r e p a id the lo a n b e fo r e co m p le tin g c o m p lia n c e p ra c tic e c o m p le te d a m p lio n c e p ra c tic e
»>16 c o m p le te d the c o m p le te d c o m p lia n c e p r o c tic e b e fo re J u ly , 1976
c o m p lia n c e p r a c tic e w ith in the la s t y e a r .
P articipation o f dental students in the Educational Loan Pro gram.
59 re m a in e d in o c o m p lia n c e a r e o a fte r
le ft the c o m p lia n c e a r e a a fte r fu lfillin g th e ir o b lig a t io n
fu lfillin g th e ir o b lig a t io n
terest within 90 days of the end of his deferred status, usually the date of graduation from dental school.
Results Data from 30 years of Educational Loan Program activity for dental par ticipants are presented in the Illustra tion. As shown, 2 1 9 dentists graduated with obligations. Of these 219, 59 currently are serving in a com pliance practice; the other 160 have com pleted the program obliga tion. Sixty-five of those who com pleted their program obligation did so by repaying in cash, seven repaid their loans after beginning a com pliance p ractice, and 88 com pleted their obligation by a com pliance practice. Thus, 55% (88 of 160) of those who com pleted their obliga tion did so by practicing in the iden tified areas. If the 59 dentists currently in a com pliance practice com plete their program obligations, then 67% (147 of 219) of the dentists who graduated from school with these obligations will have practiced in a sparsely populated area of North Carolina. Furtherm ore, 82% (59 of 72) of those who com pleted their practice before 1976 rem ained in the sparsely popu lated area. It is anticipated that a sim ilar percentage of the 16 who com pleted their com pliance practice
w ithin the past year w ill also rem ain in the sam e area. Therefore, 4 5 % (72 of 160) of those who have com pleted their loan obligation may rem ain in a sparsely populated area. O nly 14 of the 160 d entists w hose obligations have been satisfied re ceived loans after 1965 (w hen the program changed to a loan can cella tion form at w ith required com p lia n ce p ractice). O f th ese, 11 (79% ) entered a com p lian ce practice. Even though all dental loan re cip ients did not satisfy their obligation by p racticin g in sparsely populated areas in N orth Carolina, only 18 are know n to be practicin g in states other than North Carolina. Therefore, 92% (201 of 219) of the d entists who par ticip ated in th e program rem ained in North Carolina.
Discussion T he m ald istribu tion of dental m an pow er rem ains a problem in North Carolina. E ighty-seven of the 100 counties in N orth Carolina have den tist/population ratios less than the national ratio.2,5 However, the North Carolina E du cational Loan Program has proved to b e effective in provid ing dental m anpow er to rural areas. During th e 30-year history of the pro gram, 67 % o f th e dental loan recip ients have com plied w ith the pro gram requirem ent: to p ractice in
A RTICLES
areas of sparse population (J. Proctor, July 1977). Since the program was changed to a loan-cancellation for m at in 1 96 5, 79% of the dental loan recipients w ho received loans after that change and who have com pleted their program obligations have done so by practicing in a sparsely popula ted area. It is likely that an even great er percentage of those currently in school will fulfill their obligation through practice. The loan-forgiveness clause instituted in 1965 and the larger loan am ount provided in 1975 encourage com pliance with program goals. Student interest in the program rem ains high. A recent survey of den tal students from the University of North Carolina indicated that 60% of the respondents who did not have an Educational Loan would have partic ipated in the Educational Loan Pro gram , but w ere unable to do so be cause of lack of program funds. The high cost of dental education ($ 2 4 ,0 0 0 for four years) makes the approach attractive to m any stu dents. Increasing the level of the award from $ 4 ,0 0 0 to $ 6 ,0 0 0 a year would reduce the need for the dental student from North Carolina to seek additional loan support and make it more likely that the graduate would fulfill the obligations of the program . The Educational Loan Program has been m ade m ore effective by redefin ing areas with a shortage of health professionals to include inner-city areas where need exists. Other areas with a population of greater than 1 0 ,0 0 0 , where need can be shown, have been included as w ell.6 Federal guidelines relating to the designa tion of critical areas currently apply to m etropolitan as well as to rural areas.4 Subdivisions within urban populations as well as portions of several counties may now qualify as areas with shortages of dental m an pow er if adequate dental care is lack ing or available only at excessive dis tances. The results of the North Carolina Dental Society M anpower Study should provide additional in form ation that will suggest alterna tive approaches to areas in need. Consideration should be given to altering the population requirem ent
for loan com pliance of dental spe cialists. As specialty practices nor m ally require a larger population base, the elim ination of the popula tion requirem ent could make the program m ore attractive to those stu dents who will pursue dental spe cialties. Through this approach, a better distribution of dental spe cialists would be achieved in North Carolina. Proposed federal incentive or loan program s cannot be anticipated to reduce the need for the Educational Loan Program in North Carolina. The NHSC has only slightly m ore than 100 dentists employed throughout the United States. A pproxim ately 35 of these are in Region IV (the region to w hich North Carolina belongs) (Regional Dental Program Office, Public Health Service, A tlanta, July 1977). Opportunities for participa tion by dental students in the Na tional Health Services Corps Schol arship Program have been limited; from 1976 to 1 9 7 7 , 3,443 students in the health professions applied for these scholarships, and 585 of these applications w ere from dental stu dents. Fifty scholarships were aw arded to dental students nation ally.7 Dental student recipients make up only a small percentage of the 2 ,6 0 0 total scholarships awarded (approxim ately $ 1 0 ,0 0 0 per stu dent).1 The Health Professions Edu cational Assistance A ct of 1976 calls for m ore scholarships to be available in the NHSC Program , but the results of such an increase will not affect the m anpower pool for several years. In addition, appropriation levels for full funding of the NHSC Program are un likely. The federal attem pt through the NHSC Program will not solve the dental m aldistribution problems in North Carolina nor will it substitute for the successful North Carolina Educational Loan Program. The Area Health Education Center (AHEC) Program has great prom ise as a format to address the m aldistribu tion of health professionals. In spite of the early success of the program , it alone cannot be expected to solve the problem of m aldistribution of dental m anpow er.8 The AHEC Program was begun in North Carolina in 1972 to
decentralize m edical, dental, phar m acy, and public health education. In its educational effort, the program provides the student in the health professions w ith insight into how a com m unity solves its health care problems and how a com m unity at tem pts to avoid the cultural isolation that often results in the dentist and his family leaving the com m unity after only a brief period; it also pro vides an awareness of com m unity health care resources. A joint effort between AHEC and the North Carolina Educational Loan Program has been initiated to help retain health personnel in rural areas. With an introduction to a rural com m unity early in the dental student’s profes sional career (during the second year), the student will be better able to plan his educational program to ward a rural p ractice.8 His early asso ciation with the com m unity through AHEC m ay prevent the professional isolation that has discouraged health professionals in the past. A program that m atches interested students with com m unities seeking a dentist should be added to the list of approaches to solve the problem of m aldistribution of dental m anpower. Such a program has been successful in M innesota9,10 and is in devel opmental stages in North and South Dakota and in rural New England. A sim ilar m atching program is planned for North Carolina by the North Carolina Dental Society in coopera tion with the University of North Carolina Health Services Research Center. A cooperative approach of all of these program s m ay be the m ost ef fective m ethod to deal with m aldis tribution of dental manpower. Better com m unication and coordination m ust occu r between the Educational Loan Program and federal program s involved with addressing dental m anpow er distribution. Continued interaction of students in the health professions, especially those in volved in the Educational Loan Pro gram , with the AHEC Program should provide a continued high p ercentage of loan recipients who honor their practice com m itm ents. A student-com m unity m atching pro
Roberson-White : DENTAL MANPOWER DISTRIBUTION ■ 635
A R T IC L E S
gram should be developed that w ould coord inate and adm inister these efforts. T h e E ducational Loan Program data in d icate that a high percentage (82% ) of those who com p leted their com p lian ce practice re m ain in the area. T h is retention rate can be expected to con tin u e because of the student in terest in the pro gram, the increasing aw areness of the dental needs in the underserved areas, and the increasing cooperation among the different programs to coord inate their efforts in addressing these problem s.
Summary North Carolina has show n that it can m anage a program aim ed at solving its health m anpow er problem s. Ex p erien ce gained in m ore than 30 years can be used to m ake continual im provem ents in the program . F ed eral in itiativ es, such as the NHSC Program s, can add to N orth Caroli n a ’s effort, but show little prom ise as replacem ents for the North Carolina effort. A lthough we hope that lo cal funds cou ld be conserved, shift ing the funding to the federal level m ay not prove to be an effective so lu tion to the distribution of dental m anpow er. The Education Loan Program has been an effective approach aimed at im proving the distribution of dental m anpow er in North Carolina. More than half of the program participants
6 36 ■ JADA, Vol. 97, October 1978
(55% ) who have com pleted their ob ligation did so by practicing in an area of need. E vidence indicates that the rate of com p lian ce can be a n tici pated to increase as m ore of the loan recip ien ts who graduated after 1965 fu lfill their obligations. T h e data also in d icate that 8 2 % of the dentists who satisfied th eir loan obligation by p ractice before 1976 rem ained in the sparsely populated areas. The pro gram, in its 30-year history, has pro vided areas of sparse population in North C arolina with the equivalent of at least 500 years of dental services. P otentially, 147 com m unities with sparse populations m ay have derived needed dental care becau se of the program ; p ossibly 107 com m unities are affected perm anently.
1. Sax, E. Review of incentive programs promoting practice in underserved areas. Na tional Health Council, 1976.
2. T he report o f the Subcom m ittee on Health of the Senate Committee on Labor and Public Welfare for the Senate’s amendment of H R 5546 to ammend the Public Health Service A ct, 1976. 3. T he Carnegie Council on Policy Studies in Higher Education. Progress and problems in medical and dental education: federal support versus federal control. San Francisco, JosseyBass, Inc., 1976. 4. Federal Register, July 6, 1976, vol 41, no 130. 5. Dental manpower resources in North Carolina, ed 2. Chapel Hill, Health Services Re search Center, 1976. 6. Practice regulations as adopted by the North Carolina Medical Care Commission, Educational Loan Program, NC Department of Human Resources, Dec 17, 1976. 7. Health Resources News, vol 3, no 16, July 1976, DHEW. 8. Fields, C.M. Educators doubt doctors will stay in remote areas. Chron High Educ 13 Oct 25, 1976. 9. Tiede, J.W ., and Born, D.O. Professional opinions in the identification of dental man power shortage areas. JADA 91:139 July 1975. 10. Born, D.O. The dental information serv ice center: services and manpower studies. Northwest Dent 52:246 July-Aug 1973.
THE AUTHORS Dr. Roberson is associate professor of operative dentistry and director of stu dent affairs, and Dr. W hite is professor of oral surgery and dean of the Univer sity of North Carolina School of Den tistry, Chapel H ill, 27514. Address re quests for reprints to Dr. Roberson. ROBERSON
WHITE
To en c o u ra g e d en ta l h ea lth p ra ctitio n ers to p ra c tic e in a re a s o f low dentist/population ratios, an E d u ca tio n a l Loan P ro gra m h a s b e e n set up in North C arolina. T hrough p ra ctic in g in a re a s o f d e s ig n a te d sh o rta ge, g ra d u a tes ca n fu lfill th eir lo a n obligations.
J n the past quarter century, there have been m any different programs designed and im plem ented to en courage health professionals to prac tice in areas of the greatest need: the inner city and the rural com m unity. F in an cial in cen tiv es, special courses in health education institu tions, fed eral health initiatives, placem ent services, preceptorships, and in novative delivery system s have all show n som e success in addressing the problem of m ald istribution of health m anpow er.1 Congress is aware of the m ald is tribution of health m anpower. In de veloping the Health Professions Educational A ssistance A ct of 1976 (Public Law 94/484), provisions were inserted that w ill require the dental school to either increase its enroll m ent or provide training in rem ote sites for dental students as a con d i
tion for federal capitation paym ents to the school. Data show ing the extent of dental disease in the U nited States and the estim ated increase in the dem and for dental services during the next few years support the congressional ap p roach.2,3 Concern was expressed by members of Congress that th e current dental m anpow er w ill be un able to cope w ith the projected dem and; cu r rent data h ig hlig h t the problem s of geographic m ald istribution of dental m anpow er. Of the 3 ,1 2 8 cou nties in the U nited States, 282 (9%) have no dentists; 2,687 have dentist/popula tion ratios less than the national av erage of one dentist per 2 ,1 4 9 per sons; of these 2 ,6 8 7 cou nties, 689 have ratios less than one per 5 ,0 0 0 .2 The situation in North Carolina typifies the problem of m ald istribu tion of dental m anpower. Forty-three
of the 100 counties in North Carolina are designated as Federal Dental Shortage A reas.4 T h e overall d en tist/population ratio for North C arolina in 1975 w as 1/2,744 in com parison w ith the national ratio of 1/2,149. Eighty-seven cou nties in North Carolina have dentist/popula tion ratios less than the national ratio.5 M ore inform ation is needed to draw conclu sions from these figures. T he North Carolina Dental Society is sponsoring a study of the dental m anpow er needs of North Carolina. New approaches to providing dental m anpow er may be derived from th is study. T his paper describes the attem pts o f a state-supported in cen tiv e pro gram (the E ducational Loan Pro gram) to solve the problem of m ald is tribution of dental m anpow er in North Carolina. Program s accom plished at a state lev el can com p le m ent federal approaches, such as the N ational H ealth Service Corps (NHSC). A ll p o ssibilities for solving the m anpow er problem m ust be ex plored to find a satisfactory solution.
D e scrip tio n o f th e p r o g r a m The E ducational Loan Program , created by the North Carolina G en eral A ssem bly in 1 9 4 5 , was know n JADA, Vol. 97, October 1978 ■ 633
A RTICLES T o ta l d e n ta l lo o n r e c ip ie n t s (1953-1976)
219
originally as the M ed ical Student L oan Fun d. T h e program was de signed to m ake loans to m ed ical stu dents who agreed to p ractice m ed icin e after graduation in a rural area (a com m unity having a popula tion of few er than 2 ,5 0 0 ). T h e loan program was extended to students of dentistry, pharm acy, and nursing in 1947. S in ce that tim e, 15 other field s o f study in the h ealth professions have been added to the program . The purpose of the E ducational Loan Program is to encourage h ealth pro fession als to p ractice in sparsely populated rural com m unities in N orth C arolina in w h ich there is an urgent need. U n til recently , no pro visio n has existed for the under served urban com m unity. The Edu cational Loan Program accepts ap plication s from resid en ts of North C arolina who have b een accepted or are enrolled in sch oo ls of the desig nated health p rofessions. Students are not lim ited to institu tion s in North Carolina. T h e criteria for selectin g loan recip ien ts are interest, acad em ic cap ability, m otivation to p ractice in a designated area, and fi n ancial need. B efore 1965, the E ducational Loan Program required recip ien ts to both p ractice in areas w here there were few health professionals and repay the loan. Stu dents w ho served in these areas received a reduced rate of interest. In 1965, the program was altered, and a lo an -can cellation for m at was adopted. A recip ien t was then required to p ractice in an ap proved area for one fu ll calendar year for each acad em ic year, or part of an acad em ic year, in w h ich a loan was received. S in ce 1975, a dental stu dent receives $ 4 ,0 0 0 a year from the E ducational Loan Program and m ust agree to p ractice in a com m unity of few er than 1 0 ,0 0 0 people or in a des ignated local or state health facility. E ffective in 1977, the program ob li gation m ay also be satisfied by pri m ary care p ractice in any approved underserved area (urban areas w ith a population greater than 10,000). As a student, there is no obligation to the program. If a loan recip ien t does not fu lfill his p ractice requirem ents, he m ust repay the loan in fu ll w ith in634 ■ JADA, Vol. 97, October 1978
w ith d r«
133
g r a d u a t e d (rom d e n ta l
c u rre n tly in
s c h o o l w ith o b lig a t io n
sc h o o l o r d e fe r re d
c u r r e n tly in a 160
c o m p lia n c e p r a c tic e
h o v e c o m p le te d • th e ir o b lig a tio n r e p a id the lo a n b e fo r e co m p le tin g c o m p lia n c e p ra c tic e c o m p le te d a m p lio n c e p ra c tic e
»>16 c o m p le te d the c o m p le te d c o m p lia n c e p r o c tic e b e fo re J u ly , 1976
c o m p lia n c e p r a c tic e w ith in the la s t y e a r .
P articipation o f dental students in the Educational Loan Pro gram.
59 re m a in e d in o c o m p lia n c e a r e o a fte r
le ft the c o m p lia n c e a r e a a fte r fu lfillin g th e ir o b lig a t io n
fu lfillin g th e ir o b lig a t io n
terest within 90 days of the end of his deferred status, usually the date of graduation from dental school.
Results Data from 30 years of Educational Loan Program activity for dental par ticipants are presented in the Illustra tion. As shown, 2 1 9 dentists graduated with obligations. Of these 219, 59 currently are serving in a com pliance practice; the other 160 have com pleted the program obliga tion. Sixty-five of those who com pleted their program obligation did so by repaying in cash, seven repaid their loans after beginning a com pliance p ractice, and 88 com pleted their obligation by a com pliance practice. Thus, 55% (88 of 160) of those who com pleted their obliga tion did so by practicing in the iden tified areas. If the 59 dentists currently in a com pliance practice com plete their program obligations, then 67% (147 of 219) of the dentists who graduated from school with these obligations will have practiced in a sparsely populated area of North Carolina. Furtherm ore, 82% (59 of 72) of those who com pleted their practice before 1976 rem ained in the sparsely popu lated area. It is anticipated that a sim ilar percentage of the 16 who com pleted their com pliance practice
w ithin the past year w ill also rem ain in the sam e area. Therefore, 4 5 % (72 of 160) of those who have com pleted their loan obligation may rem ain in a sparsely populated area. O nly 14 of the 160 d entists w hose obligations have been satisfied re ceived loans after 1965 (w hen the program changed to a loan can cella tion form at w ith required com p lia n ce p ractice). O f th ese, 11 (79% ) entered a com p lian ce practice. Even though all dental loan re cip ients did not satisfy their obligation by p racticin g in sparsely populated areas in N orth Carolina, only 18 are know n to be practicin g in states other than North Carolina. Therefore, 92% (201 of 219) of the d entists who par ticip ated in th e program rem ained in North Carolina.
Discussion T he m ald istribu tion of dental m an pow er rem ains a problem in North Carolina. E ighty-seven of the 100 counties in N orth Carolina have den tist/population ratios less than the national ratio.2,5 However, the North Carolina E du cational Loan Program has proved to b e effective in provid ing dental m anpow er to rural areas. During th e 30-year history of the pro gram, 67 % o f th e dental loan recip ients have com plied w ith the pro gram requirem ent: to p ractice in
A RTICLES
areas of sparse population (J. Proctor, July 1977). Since the program was changed to a loan-cancellation for m at in 1 96 5, 79% of the dental loan recipients w ho received loans after that change and who have com pleted their program obligations have done so by practicing in a sparsely popula ted area. It is likely that an even great er percentage of those currently in school will fulfill their obligation through practice. The loan-forgiveness clause instituted in 1965 and the larger loan am ount provided in 1975 encourage com pliance with program goals. Student interest in the program rem ains high. A recent survey of den tal students from the University of North Carolina indicated that 60% of the respondents who did not have an Educational Loan would have partic ipated in the Educational Loan Pro gram , but w ere unable to do so be cause of lack of program funds. The high cost of dental education ($ 2 4 ,0 0 0 for four years) makes the approach attractive to m any stu dents. Increasing the level of the award from $ 4 ,0 0 0 to $ 6 ,0 0 0 a year would reduce the need for the dental student from North Carolina to seek additional loan support and make it more likely that the graduate would fulfill the obligations of the program . The Educational Loan Program has been m ade m ore effective by redefin ing areas with a shortage of health professionals to include inner-city areas where need exists. Other areas with a population of greater than 1 0 ,0 0 0 , where need can be shown, have been included as w ell.6 Federal guidelines relating to the designa tion of critical areas currently apply to m etropolitan as well as to rural areas.4 Subdivisions within urban populations as well as portions of several counties may now qualify as areas with shortages of dental m an pow er if adequate dental care is lack ing or available only at excessive dis tances. The results of the North Carolina Dental Society M anpower Study should provide additional in form ation that will suggest alterna tive approaches to areas in need. Consideration should be given to altering the population requirem ent
for loan com pliance of dental spe cialists. As specialty practices nor m ally require a larger population base, the elim ination of the popula tion requirem ent could make the program m ore attractive to those stu dents who will pursue dental spe cialties. Through this approach, a better distribution of dental spe cialists would be achieved in North Carolina. Proposed federal incentive or loan program s cannot be anticipated to reduce the need for the Educational Loan Program in North Carolina. The NHSC has only slightly m ore than 100 dentists employed throughout the United States. A pproxim ately 35 of these are in Region IV (the region to w hich North Carolina belongs) (Regional Dental Program Office, Public Health Service, A tlanta, July 1977). Opportunities for participa tion by dental students in the Na tional Health Services Corps Schol arship Program have been limited; from 1976 to 1 9 7 7 , 3,443 students in the health professions applied for these scholarships, and 585 of these applications w ere from dental stu dents. Fifty scholarships were aw arded to dental students nation ally.7 Dental student recipients make up only a small percentage of the 2 ,6 0 0 total scholarships awarded (approxim ately $ 1 0 ,0 0 0 per stu dent).1 The Health Professions Edu cational Assistance A ct of 1976 calls for m ore scholarships to be available in the NHSC Program , but the results of such an increase will not affect the m anpower pool for several years. In addition, appropriation levels for full funding of the NHSC Program are un likely. The federal attem pt through the NHSC Program will not solve the dental m aldistribution problems in North Carolina nor will it substitute for the successful North Carolina Educational Loan Program. The Area Health Education Center (AHEC) Program has great prom ise as a format to address the m aldistribu tion of health professionals. In spite of the early success of the program , it alone cannot be expected to solve the problem of m aldistribution of dental m anpow er.8 The AHEC Program was begun in North Carolina in 1972 to
decentralize m edical, dental, phar m acy, and public health education. In its educational effort, the program provides the student in the health professions w ith insight into how a com m unity solves its health care problems and how a com m unity at tem pts to avoid the cultural isolation that often results in the dentist and his family leaving the com m unity after only a brief period; it also pro vides an awareness of com m unity health care resources. A joint effort between AHEC and the North Carolina Educational Loan Program has been initiated to help retain health personnel in rural areas. With an introduction to a rural com m unity early in the dental student’s profes sional career (during the second year), the student will be better able to plan his educational program to ward a rural p ractice.8 His early asso ciation with the com m unity through AHEC m ay prevent the professional isolation that has discouraged health professionals in the past. A program that m atches interested students with com m unities seeking a dentist should be added to the list of approaches to solve the problem of m aldistribution of dental m anpower. Such a program has been successful in M innesota9,10 and is in devel opmental stages in North and South Dakota and in rural New England. A sim ilar m atching program is planned for North Carolina by the North Carolina Dental Society in coopera tion with the University of North Carolina Health Services Research Center. A cooperative approach of all of these program s m ay be the m ost ef fective m ethod to deal with m aldis tribution of dental manpower. Better com m unication and coordination m ust occu r between the Educational Loan Program and federal program s involved with addressing dental m anpow er distribution. Continued interaction of students in the health professions, especially those in volved in the Educational Loan Pro gram , with the AHEC Program should provide a continued high p ercentage of loan recipients who honor their practice com m itm ents. A student-com m unity m atching pro
Roberson-White : DENTAL MANPOWER DISTRIBUTION ■ 635
A R T IC L E S
gram should be developed that w ould coord inate and adm inister these efforts. T h e E ducational Loan Program data in d icate that a high percentage (82% ) of those who com p leted their com p lian ce practice re m ain in the area. T h is retention rate can be expected to con tin u e because of the student in terest in the pro gram, the increasing aw areness of the dental needs in the underserved areas, and the increasing cooperation among the different programs to coord inate their efforts in addressing these problem s.
Summary North Carolina has show n that it can m anage a program aim ed at solving its health m anpow er problem s. Ex p erien ce gained in m ore than 30 years can be used to m ake continual im provem ents in the program . F ed eral in itiativ es, such as the NHSC Program s, can add to N orth Caroli n a ’s effort, but show little prom ise as replacem ents for the North Carolina effort. A lthough we hope that lo cal funds cou ld be conserved, shift ing the funding to the federal level m ay not prove to be an effective so lu tion to the distribution of dental m anpow er. The Education Loan Program has been an effective approach aimed at im proving the distribution of dental m anpow er in North Carolina. More than half of the program participants
6 36 ■ JADA, Vol. 97, October 1978
(55% ) who have com pleted their ob ligation did so by practicing in an area of need. E vidence indicates that the rate of com p lian ce can be a n tici pated to increase as m ore of the loan recip ien ts who graduated after 1965 fu lfill their obligations. T h e data also in d icate that 8 2 % of the dentists who satisfied th eir loan obligation by p ractice before 1976 rem ained in the sparsely populated areas. The pro gram, in its 30-year history, has pro vided areas of sparse population in North C arolina with the equivalent of at least 500 years of dental services. P otentially, 147 com m unities with sparse populations m ay have derived needed dental care becau se of the program ; p ossibly 107 com m unities are affected perm anently.
1. Sax, E. Review of incentive programs promoting practice in underserved areas. Na tional Health Council, 1976.
2. T he report o f the Subcom m ittee on Health of the Senate Committee on Labor and Public Welfare for the Senate’s amendment of H R 5546 to ammend the Public Health Service A ct, 1976. 3. T he Carnegie Council on Policy Studies in Higher Education. Progress and problems in medical and dental education: federal support versus federal control. San Francisco, JosseyBass, Inc., 1976. 4. Federal Register, July 6, 1976, vol 41, no 130. 5. Dental manpower resources in North Carolina, ed 2. Chapel Hill, Health Services Re search Center, 1976. 6. Practice regulations as adopted by the North Carolina Medical Care Commission, Educational Loan Program, NC Department of Human Resources, Dec 17, 1976. 7. Health Resources News, vol 3, no 16, July 1976, DHEW. 8. Fields, C.M. Educators doubt doctors will stay in remote areas. Chron High Educ 13 Oct 25, 1976. 9. Tiede, J.W ., and Born, D.O. Professional opinions in the identification of dental man power shortage areas. JADA 91:139 July 1975. 10. Born, D.O. The dental information serv ice center: services and manpower studies. Northwest Dent 52:246 July-Aug 1973.
THE AUTHORS Dr. Roberson is associate professor of operative dentistry and director of stu dent affairs, and Dr. W hite is professor of oral surgery and dean of the Univer sity of North Carolina School of Den tistry, Chapel H ill, 27514. Address re quests for reprints to Dr. Roberson. ROBERSON
WHITE
