Kenya has already run this experiment once, and it worked. When Universal Health Coverage became a national priority, the country did not wait for a fresh generation of doctors to graduate before it moved.
It looked at the clinical officers and nurses already trained, already licensed, already living in the communities that needed them, and it asked them to carry more of the load. The results built the primary healthcare system Kenya now leans on.
It is time to ask why oral health, which touches nearly every Kenyan household and yet remains one of the most neglected corners of the health sector, has not been given the same trust.
A nation starved of smiles: The scale of the deficit
The numbers are not subtle. The dentist-to-population ratio in Kenya currently stands at 0.27 per 10,000 people, a figure the Ministry of Health itself concedes falls well below the level the World Health Organisation recommends, and only 13 per cent of health facilities nationwide offer any oral health services at all, with the gap most severe in rural and primary care settings.
Regionally, the picture is bleaker still. The WHO African region carries the lowest dentist density on the planet, at roughly one dentist for every 30,000 people, and although the continent's oral health workforce grew by nearly 300 per cent between 2013 and 2022, the region still needs an additional 160,000 oral health professionals simply to reach a modest universal health coverage service index of 70 out of 100 points.
In Kenya specifically, researchers have counted roughly 1,300 registered dentists serving a population of about 55 million, and geospatial analysis of the dental workforce found that while Nairobi enjoys a dentist-to-population ratio of about 1 to 9,018, counties such as Wajir have no dental facility at all.
Community Oral Health Officers already make up about 15 per cent of the country's registered oral health workforce, the second largest cadre after dentists themselves, and they are disproportionately the ones reaching the areas dentists rarely go.
What Universal Health Coverage already taught us
Kenya's UHC rollout was never a story about doctors alone. At the point President Uhuru Kenyatta declared UHC one of the government's Big Four priorities, the country had roughly as many clinical officers as doctors in the public sector, a workforce that was more rapidly trainable, more evenly distributed, and more willing to serve in far-flung facilities.
The government leaned into that reality rather than away from it, posting additional clinical officers to understaffed facilities as part of the UHC pilot of 2018 and 2019.
This was not improvisation. It was the product of a deliberate national Task Sharing Policy launched in 2017 and running to 2030, which legitimised the shifting of clinical tasks between cadres by redefining scopes of practice to match what was already happening on the ground and what the evidence supported.
Nurses were authorised to prescribe, to run primary care consultations, and to manage patients that had once been the exclusive preserve of doctors.
The evidence for this approach is not anecdotal. A study of nurse-led management of non-communicable diseases in Kibera, run jointly by Médecins Sans Frontières and the Ministry of Health, found that nurses could adhere to clinical protocols for hypertension, diabetes, asthma and epilepsy with encouraging consistency, freeing overburdened clinical officers to handle more complex cases while patients still received safe, protocol-driven care close to home. The programme was expanded rather than reversed because it worked.
Kenya has since gone further still, training Family Health Clinical Officers through a higher diploma specifically designed to strengthen primary healthcare delivery, on the reasoning that a shorter, targeted, competency-based training pathway can produce a workforce that is cheaper to train, faster to deploy and more likely to remain in the communities it serves than a doctor trained for years in an urban teaching hospital.
The same lesson, told in enamel and dentine
Oral health is not a peripheral concern dressed up as a crisis. The Ministry of Health has reported that 98.1 per cent of Kenyan adults are affected by some form of gum disease and that 46.3 per cent of five-year-olds already have tooth decay, conditions with documented links to cardiovascular disease and diabetes when left untreated.
Yet the professionals trained specifically to manage this burden at community level, the Community Oral Health Officers who complete a dedicated diploma programme and are registered and licensed by the Kenya Medical Practitioners and Dentists Council under Cap 253, remain confined by convention rather than by evidence to a narrower role than the crisis demands.
If Kenya trusted clinical officers to manage stable non communicable diseases, deliver babies and run entire rural health centres largely unsupervised, and trusted nurses to prescribe and manage chronic conditions once reserved for physicians, then the same government and the same regulator have every reason grounded in evidence rather than sentiment to expand what a properly trained and licensed COHO may do for a population that cannot get a dental appointment within twenty kilometres of home.
Beyond 8.4.4: Let competence, not credential alone, govern the right to practice
There is a deeper argument here, and it is one Kenya's health sector cannot keep avoiding. We remain, in our professional culture, prisoners of a grading system built for a different purpose.
The old 8.4.4 mindset taught generations of Kenyans that a certificate's length and a title's prestige are the measure of a person's worth to society.
But healthcare regulation exists to answer one question only, and it is not how many years someone spent in a lecture hall.
It is whether that person has been trained, examined and licensed by a competent regulator to perform a specific task safely.
A Community Oral Health Officer who has completed a recognised diploma, sat and passed the Council's licensing examination and holds a current practising licence has, by definition, been certified by the very body Parliament entrusted with protecting the public.
Where that officer operates strictly within the scope the Council itself has approved, the officer is not endangering anyone. The officer is doing exactly what the law and the regulator say a person with that training may safely do.
Skill and licensure, not the number of letters after one's name, are what should determine who is fit to treat a patient's mouth, just as skill and licensure already determine which clinical officer may run a maternity ward at two in the morning in a county hospital with no doctor for a hundred kilometres in any direction.
The danger in a word: Why calling a licensed COHO a quack is not a costless insult
Kenya does have a genuine quackery problem, and it deserves to be named honestly. Unlicensed operators working out of kiosks, salons and backrooms, performing extractions and root canals with no training and no registration, have caused real harm, including a recent death following a reportedly botched extraction at an unlicensed clinic that drew national attention.
That is quackery in the true sense, and it should be prosecuted with the full force of the Health Act and the Medical Practitioners and Dentists Act.
But there is a world of legal and moral difference between an unlicensed impostor and a Council registered, practising licence holding Community Oral Health Officer performing a procedure the Council itself has gazetted within that officer's scope of practice.
Collapsing the two into a single insult, quack, is not robust professional advocacy. It is a factual assertion dressed as opinion, and it happens to be an inaccurate one where it is levelled at a licensed practitioner acting within a lawfully approved scope.
Kenyan courts have consistently held that words which allege incompetence or malfeasance in a person's professional responsibilities are capable of being defamatory.
The High Court at Meru put the principle plainly, adopting Black's Law Dictionary's definition of slander as including false statements alleging malfeasance or incompetence in reference to the person's professional responsibilities, and going on to affirm, citing Gatley on Libel and Slander, that a defamatory imputation is any statement that injures a person's reputation in his office, trade or profession, judged by the standard of right thinking members of society generally, see Zamzam Hussein Aligele v Joseph Lekuton [2020] KEHC 8773 (KLR) at paragraphs 22 and 23.
The same judgment reaffirms, citing Musikari Kombo v Royal Media Services Limited [2018] eKLR and Miguna Miguna v Standard Group Limited & 4 others [2017] eKLR at paragraphs 27 and 28, that a claimant need only show a defamatory statement was published and that it referred to them.
Kenyan courts have awarded damages running into millions of shillings where a professional's competence was falsely impugned in public, and there is no principled reason a licensed COHO, or the institution that trains and deploys them, would be treated differently from an advocate or a journalist whose competence was similarly maligned.
None of this forecloses honest debate about scope of practice. The Kenya Dental Association is entitled to argue, as it has done, that any expansion of what COHOs may do should proceed through open, consultative rulemaking rather than administrative notice.
That is a legitimate procedural and policy argument, and it deserves a hearing on its own terms. What is not legitimate, and what carries real legal exposure, is skipping that argument altogether in favour of branding an entire licensed cadre with a word the law reserves for the criminal and the unqualified.
The path forward: Train more, post more, trust the regulator
The lesson of Kenya's UHC decade is not complicated. Where the country trained mid-level cadres properly, licensed them rigorously and then trusted them to work at the edge of their competence, health outcomes improved, and access widened, most visibly for the rural and peri-urban Kenyans who had been waiting longest. Oral health deserves the same formula, applied deliberately rather than left to drift.
Kenya should expand enrolment in the Diploma in Community Oral Health at the Kenya Medical Training College and its peer institutions, so that the pipeline of licensed COHOs grows in step with the population it must serve rather than lagging decades behind it.
County governments should be required, not merely encouraged, to post COHOs to level two and three facilities in underserved wards, mirroring the deliberate deployment strategy that made the clinical officer-led UHC pilots work.
The Kenya Medical Practitioners and Dentists Council should be allowed to complete a properly gazetted, evidence-based scope of practice for COHOs, arrived at through the stakeholder consultation the law contemplates, so that the boundaries of practice rest on training and competence rather than on turf.
And the public conversation must change its vocabulary. A country that cannot fill its dentist gap for another generation cannot afford to sneer at the professionals standing in that gap today.
It is about the skill and the licence a person holds, not the letters after their name, and that is precisely where modern health systems the world over are heading.
Kenya trained its way out of a doctor shortage once, through clinical officers and nurses who were given the trust their licences already promised.
It can, and should, do the same for the millions of Kenyans still waiting for a working set of teeth.
Mokua is an advocate of the High Court of Kenya and Partner at MNW & Advocates LLP; [email protected]
