The Setting up and Financing in Dental Private Sector: A Cross-Sectional Study ()
1. Introduction and Background
Setting up a private practice is the main choice for future dentists. According to a study conducted in 2018 among 228 graduates of the Faculty of Dentistry of Casablanca between 2000 and 2005, 82% of dentists practice in the private sector, while 16% practice in the public sector, only 1% of them work in the mutual insurance sector, and 1% have chosen to change completely the job [1].
Owning a dental office is an opportunity for dentists to manage their own business. But it can be a real challenge in terms of management and financing [2]. Indeed, in conjunction with the technical and medical requirements, dentists must also develop skills in communication, time management, problem solving, marketing and business management [3].
To master all these aspects, a management course is offered by the Faculty of Dentistry in Casablanca (FMDC), with lectures and tutorials at the end of the course, covering all the necessary topics [4] [5]. However, despite this training provided, dentists are always faced with a multitude of choices concerning their practice. Many challenges arise, such as finding suitable premises, acquiring the necessary materials and equipment, recruiting staff and setting consultation rates [6]-[11]. The lack of well-categorized and catalogued information and resources can be a real obstacle for young dentists in their plans to set up in private practice. The aim of this study is to evaluate the knowledge of students at the end of their medical studies concerning the setting up and financing of the dental practice.
2. Methodology
An exhaustive cross-sectional study was carried out using an anonymous questionnaire at the Faculty of Dentistry in Casablanca (FMDC).
The questionnaire consisted of 43 questions of which 27 questions were open and 16 questions were closed. The items in the questionnaire were established based on bibliographic research, laws published in the official gazette as well as information provided by the southern regional dental council [6] [7] [10]. Some items were borrowed from a similar study carried out in France [11], others were created to adapt the questionnaire to the context of dental practice in Morocco. Once the questions were written, their order of appearance was determined starting with the simplest questions towards questions that were more technical and/or required open-ended responses.
The questionnaire was validated by the southern regional council before being used. It contained 4 parts:
• General informations: This first part includes 7 questions allowing the identification of the population studied, the internships carried out and previous training on the subject studied.
• Setting up a dental office: This second part includes 15 questions on the choice as well as all the knowledge of the private practice (necessary documentation, types of contract, taxes and contributions, etc.). Among the 15 questions proposed, 14 questions have predetermined answers and one question has an open response.
• Financing the dental office and practice: This third part includes 7 questions with predetermined answers on the financing of the dental practice (Type of financing, financial management methods, insurance, etc.)
The Department of fixed Prosthodontics of our faculty approved the study protocol and consent was obtained from all the participants. A pre-survey was carried out before starting the study. Its objectives were to:
- familiarize investigators with data collection
-evaluate students’ understanding and acceptability of the questionnaire
- evaluate the average time required to complete the questionnaire
- prevent problems that could arise during the investigation itself
By carrying out the pre-survey, the last question concerning the need for training was reformulated.
The data entry and statistical analysis were done using the software (Statistical Package for the Social Sciences) SPSS version 2.0 at the Community Health Epidemiology and Bio-statics Laboratory at the FMDC.
3. Results
Among the 138 participants, 133 responded. This student population had an average age of 23.2 years (±0.8). 61.7% of participants were female students.
12% of students have voluntarily taken additional training courses on the liberal installation, 12% on the financing of the dental practice and the rest have never followed any complementary training in both sectors.
We found that 93% of students preferred to work in the private sector (Figure 1), but only 2.3% know the documents necessary for the registration to the National Order of Dentists (NOD), only 3% of students know the documents required for the installation in the dentist’s office and only 4.5% know the definition of a lease contract. For taxes, 80.4% of participants recognize their lack of knowledge regarding the taxes applicable to dentists. In addition, 96.2% do not know the types of taxes that concern them. Regarding the timing of the exemption for dentists, only 30.8% answered correctly. Likewise, the duration of exemption from the minimum contribution is largely unknown for 64.7% of participants (Table 1).
Figure 1. Sector of choice.
Table 1. Results of the setting up in the private dental practice.
Variable |
(%) |
Necessary condition to practice in the private sector: |
|
Correct answer |
63.2 |
Wrong answer |
33.1 |
No idea |
3.8 |
Documents required for registration in the register of dentists: |
|
Correct answer |
2.3 |
Wrong answer |
51.1 |
No idea |
46.6 |
Installation premises: |
|
Buy a office tray |
8.3 |
Buy an apartment and furnish it |
6 |
The premises is already purchased |
13.5 |
Rented a premises |
39.8 |
No idea |
32.3 |
Rental and purchase which is more important? |
|
Purchase |
31.6 |
Rental |
68.4 |
Document required when installing in a premise: |
|
Correct answer |
3 |
Wrong answer |
28.6 |
No idea |
68.4 |
Lease contract definition: |
|
Correct answer |
4.5 |
Wrong answer |
38.3 |
No idea |
57.1 |
Supporting evidence that the tenant is himself the owner: |
|
Correct answer |
31.6 |
Wrong answer |
15.8 |
No idea |
52.6 |
Knowledge of the taxes to which the dentist is subject: |
|
Yes |
19.5 |
No |
80.4 |
What are the taxes to which the dentist is subject: |
|
Correct answer |
3.8 |
Wrong answer |
35.3 |
No idea |
60.9 |
Dentist and exemption |
|
Correct answer |
30.8 |
Wrong answer |
9.8 |
No idea |
59.4 |
Duration of exemption from the minimum contribution: |
|
Correct answer |
12 |
Wrong answer |
23.3 |
No idea |
64.7 |
Duration of exemption from professional tax: |
|
Correct answer |
9 |
Wrong answer |
17.3 |
No idea |
73.7 |
For the financing, the results of our study show a diversity of financing choices among participants. 43% opted for financing from their own funds. 41% opt for the use of investment credits. Interestingly, 35% of participants have not yet made a clear decision on the type of financing, which may indicate a need for financial advice or more in-depth planning. The study reveals that 80% recognize the need for dentists to declare their income annually. Nevertheless, 88% were unaware of who is responsible for this declaration in a dental office. 75% are unable to define correctly the elements that must be included in the insurance. For the management of financial transactions, it is worrying to note that 39.9% of respondents do not have specific knowledge of financial operations and management. 75% are unable to define correctly the elements to be included in the insurance (Table 2, Table 3).
Table 2. Results of the dental practice financing choices.
Variable |
(%) |
Type of financing choosed: |
|
Clean bottom |
43.6 |
Investment credit |
41.1 |
Leasing Credit |
10.5 |
Housing credit |
6 |
No idea |
34.6 |
Method of purchasing equipment: |
|
Credit |
18.8 |
Cash |
3.8 |
Ease of payment |
63.9 |
No idea |
21.8 |
Table 3. Results of the dental practice financing parameters.
Variable |
(%) |
Obligation of the dentist to declare his annual income: |
|
Yes |
79.7 |
No |
9.8 |
No idea |
10.5 |
Responsibility for tax declaration: |
|
Correct answer |
12 |
Wrong answer |
62.4 |
No idea |
25.6 |
Financial operations management methods: |
|
Payment by check |
8.3 |
Payment by cash |
17.3 |
To open a single account |
9 |
To open two professional accounts |
46.6 |
No idea |
39.1 |
Insurance for office practice |
|
Yes |
94.7 |
No |
5.3 |
Elements to include in the insurance: |
|
Correct answer |
25.6 |
Wrong answer |
59.4 |
No idea |
15 |
A need for training on the setting up and the financing of the dental practice was reported by 88% of our population. The results are summarized in Table 4.
Table 4. Results of the need for training in installation and financing.
Need for training: |
(%) |
No |
9.8 |
Yes, in setting up |
90.2 |
Yes, in financing |
89.5 |
4. Discussion
The objective of our study was to evaluate the knowledge of students at the end of their medical studies concerning the setting up and financing of the dental practice. Different elements were treated:
Our results showed that 92.5% of students preferred to work in the private sector rather than the public sector. Similar results were found in the study by Pierre-Axel Domicile et al. [11], who found that 97% of participants plan to practice in private practice or were already in. A survey was carried out in Casablanca in 2018 by Badre et al., the team found that 82% of participants graduated between 2000 and 2005 worked in private practice [1]. Another similar study carried out by Guebbas et al. in 2022 found that 57.6% of general practitioners were in private practice [12]. These results highlight the predominance of private-sector employment.
To work in the private dental sector, prior preparation and mastery of the various conditions necessary for setting up and financing are required. According to Law 07-05 relating to the National Order of Dentists (NOD), which necessarily brings together all dentists practicing their profession privately in Morocco, no one can perform any act of the dental profession, if he is not registered on the NOD roll. Registration requires specific conditions and documents [13]. By collecting the answers to the questions, 63.2% of the students know the conditions necessary to practice in the private sector but only 2.3% know the documents required for registration. The lack of information found in our study was also noticed in the study conducted by Pierre Axel Domicile and al. The team used a scale of 0 to 10 to assess the state of knowledge on the setting-up on the private dental practice and found an average of 4.7/10 for all groups. By comparing the 3 groups, they found that once graduated, the participants had a score barely higher than that of the 6th year students, respectively 4.8/10 and 4.7/10 for graduates in 2017 and 2016 [11].
For the installation in the dentist’s office, only 3% of students know the documents required. 31.6% of students know the supporting documents needed to prove that the landlord or the landlady is also the owner. Only 4.5% know the definition of a lease contract (the lease contract defines an agreement by which the landlord undertakes to make real estate available to the tenant, in return for rent and for a fixed or indefinite and renewable period. The tenant, for his part, undertakes to pay the agreed rent and to use the property in accordance with the use provided for in the contract) [14]. It is crucial to determine whether the practitioner is the owner or tenant of the office, as he need must be neither in order to rent to a third person. Therefore, before committing to the rental, the practitioner must verify his status as owner or tenant and ensure that he has the right to sublet according to his rental. These rental contracts are not governed by specific legal rules but depend on the wishes of the people involved regarding duration and notice periods [14] [15]. In summary, our results indicate that participants have limited knowledge of the legal and documentary aspects associated with these decisions.
For taxes, the results highlight a significant lack of understanding for students regarding the taxes to which dentists are subject in our country. In our country, dentists are not spared from tax obligations. They must pay various taxes and duties regulated by the General Tax Code [16], namely income tax, the minimum contribution, professional tax and municipal services taxes. However, it should be noted that there are some differences regarding payment arrangements between practitioners practicing as natural persons and a professional civil partnership [17].
Financing a dental office in Morocco represents a challenge for the new dentists and an essential step with several possible options. The creation of a dental office generates significant expenses, including installation charges, the purchase or rental of the office, and their fitting out, expenses relating to the purchase of medical and dental equipment, as well as furniture. … The financial plan also includes current operating expenses, such as water and electricity costs, as well as insurance premiums and annual tax returns [18]-[20]. Investment costs must be taken into account, including the cost of renting or buying premises, and the cost of fitting out and acquiring the equipment needed to run the business. According to Florian Bolmont et al., to finance a project, the dentist must assess the amount necessary to start his activity. Investment expenses must be taken into account, it includes the rental or purchase of the local, the costs of fitting out of the office and the acquiring the materials and equipment necessary for the dental practice. These expenses can be financed by a personal contribution, by a bank loan or by leasing equipment. It is necessary to either provide a reserve of money (working capital), especially at the start of activity, which makes it possible to compensate for months where cash inflows are low (decrease in activity, deferred collection of fees, vacations, etc.) in order to pay due dates (bills, etc.); or negotiate an overdraft with the bank with reduced rates [21]. Annual income declaration of a dental practice usually depends on the country and its specific tax laws. In general, it is the dental office owner or dental professional who is responsible for declaring income and submitting it to the tax authorities by the due date. Some dental professionals choose to delegate this task to specialists to help them manage their tax obligations, but the final responsibility for declaring income remains with the dental professional [22]. The study reveals that 80% recognize the need for dentists to declare their income annually. Nevertheless, 88% were unaware of who is responsible for this declaration in a dental office. For financing the dental practice, the results of our study reveal that 79.7% recognize the necessity for dentists to declare their income annually. However, 88% do not know who is responsible for this declaration in a dental practice. According to the results of the study carried out by Taiss and al among 100 dentists, it appears that 82% of them request the assistance of an accounting firm to support them in the financial management of their practice, on the other hand, 32% of the dentists surveyed manage their practice finances using their personal skills, while 6% delegate this task to their secretaries, and 3% opt for the use of computer management software [23].
For the need for training in setting up and financing private practice, our results highlight a strong need for training among participating students which exceeds 88%. Regarding the types of training needed, the results show that 38.3% of students prefer lectures, 70.7% prefer workshops and 66.2% opt for guided teaching sessions. The diversity of preferences highlights the importance of providing a variety of pedagogical approaches to meet the varying needs of students. Similar results were found by the Pierre-Axel Domicile team in 2019 [11], 71.8% of participants expressed the wish to have more courses taught during 6th year seminars. These results indicate that, when students begin professional practice, they still feel unprepared for the administrative and financial obligations that fall to them.
5. Conclusions
The results of our survey showed that the participants are leaning towards a private practice, but they have not yet acquired all the knowledge they need to set up. The study highlighted a major need for further training in setting up and financing a practice, despite the efforts made by our faculty. To meet the training need we proposed:
To plan additional seminars and round tables covering the subject in the initial training of students
To integrate the setting up into continuing education cycles by organizing events within the faculty in collaboration with the dentists council and other partners involved.
Ethics Declarations
The authors declare no conflict of interest
Funding Sources
The authors received no specific funding for this work.
Data Availability
The data are available in the fixed prosthesis department of the Faculty of Dentistry of Casablanca. Morocco.
Acknowledgements
Authors would like to thank the Faculty of Dentistry of Casablanca for its support.