Introduction by Croakey: Innovation in primary healthcare, cultural safety, the unmet needs of aged care residents, and the imperative for national leadership in oral healthcare reform are topics up for discussion at a #CroakeyLIVE webinar today, from 5pm AEST, Tackling Oral Healthcare Inequities.
Register here to join the discussion, to be moderated by Croakey Health Media director Alison Verhoeven. We will hear from:
- Renee Blackman, Chief Executive Officer for the Aboriginal and Torres Strait Islander Community Health Service (ATSICHS) Brisbane
- Abe Ropitini, Executive Director, Population Health, VACCHO
- Leonie Short, a member of Aged Care Reform Now and a longstanding advocate for oral health equity.
- Clare Lin, Director Policy, Dental Health Services Victoria
- Tan Nguyen, spokesperson for the National Oral Health Alliance, co-convenor of the Public Health Association of Australia’s Oral Health Special Interest Group, and Casual Research Fellow, Deakin Health Economics.
The webinar is part of our #Medicare40Years project and also marks Global Public Health Week. We acknowledge and thank the webinar sponsors: Public Health Association of Australia, Oral Health Special Interest Group; Deakin Health Economics; and the Violet Vines Marshman Centre for Rural Health Research.
Below, Tan Nguyen and Darren Qiang, a public health graduate, explore potential solutions for improving population oral health in Australia, drawn from international experience.
Tan Nguyen and Darren Qiang write:
In the latest year for which statistics are available (2022-2023), about 30 percent of Australians who needed to see a dental professional did not do so or delayed seeking care, according to Australian Bureau of Statistics data.
Cost was the primary reason, and was more often reported as a barrier by people living in areas of socioeconomic disadvantage. Australia ranks in the top five countries for the highest dental expenditure per capita, surprisingly slightly more than the United States.
Dental expenditure in Australia is inequitable when comparing government and non-government contributions. Just under 21 percent of dental expenditure is from government funding sources, and the rest is borne by individuals and private health insurance (co-funded by federal government subsidies and individuals).
Dental services are the second most costly health expense to consumers, consisting of 20 percent of the annual individual health expenditure per capita.
Factors contributing to the costs of oral healthcare include the composition of the dental and health workforce, funding models, inadequate efforts to integrate oral health in primary care, and the limited investment in prevention at population, community and individual levels.
The compounding effects of inadequate funding, equipment, and facilities are also major barriers within our public dental system. Consequently, patients face long waiting periods, which can ultimately delay treatment and exacerbate oral health problems.
Furthermore, national oral health surveillance data is outdated, with the latest population oral health data being more than 10-years-old for children and five years for adults, making it difficult to assess and address oral health inequities.
Australia’s current approach towards targeted funding of dental programs aims to address cost barriers to oral healthcare. Oral diseases follow the social gradient – the prevalence and severity of oral diseases increases with higher levels of socioeconomic disadvantage.
However, international experiences tell us that universal health coverage that includes oral health generally has better oral health outcomes – but with caveats.
Funding models in other countries
Of 31 countries reviewed in Europe, Germany has the highest dental expenditure per capita. This is not surprising given Germany’s healthcare system covers comprehensive dental coverage for preventive dental services, most treatment services and cost-sharing arrangements for selected dental services. It also ranks first in government public dental expenditure.
In addition, the inequity gap for dental services is minimal in Germany, among other countries that offer comprehensive dental coverage including Austria, Czechia, Croatia, and Luxembourg. However, Malta, Finland, Slovenia and Netherlands have performed relatively better in this domain, some with limited statutory coverage and partial coverage for oral healthcare.
However, 14 percent of Germans reported having unmet dental needs, with financial costs as a barrier to seeking dental care. This proportion drops to 11 percent in the United Kingdom, although there are increasing concerns about oral healthcare inequities and access to NHS dentistry, largely related to the NHS dental contract (capitation payments).
As policy-decision makers grapple with the United Kingdom’s ‘NHS crisis’, it raises the question, how should healthcare be funded?
Australian government funded dental programs are funded on a ‘fee-for-service’ basis. Ease of implementation makes this attractive to policy-makers and the dental profession, but capitation payments are more likely to enable a focus on prevention.
There is interest to introduce blended funding models for Victorian public oral healthcare. This is linked with implementing value-based healthcare. In NSW, several initiatives on value-based healthcare are being expanded in primary care.
Towards medical-dental integration
Unsurprisingly, oral healthcare is mostly provided by dentists.
Despite Germany’s significant government funding for oral healthcare, it has not diversified its oral health workforce and has a dentist-dental hygienist workforce ratio of 200:1. Whilst narrowing this workforce ratio can achieve cost-efficiencies, oral healthcare should also be delivered in non-traditional dental settings.
The United States has made considerable progress in this area through medical-dental integration. A range of different initiatives have supported the co-location of medical and dental services. In addition, there has been a rapid expansion of non-dental primary care providers delivering preventive dental services to young children.
This strategy is in line with World Health Organization’s (WHO) advocacy that oral healthcare should be integrated into the context of primary care and universal health coverage. Not only will this improve equity in oral healthcare, but also has co-benefits as poor oral health are also associated with a range of contributing health and risk factors such as excess sugar intake, cardiovascular disease, diabetes, tobacco, alcohol consumption, and worse general health and wellbeing.
Fluorides play a critical role in preventing and treating dental caries (tooth decay). The WHO has listed both fluoride varnish (2023) and silver diamine fluorides (2021) on the Essential Medicines List, including for children. Various state/territory drug and poison regulations still create unnecessary barriers to access these products, in particular for relevant registered health practitioners in primary care.
Additionally, dental practitioners have relevant potential scope to provide non-dental primary care such as health screening for hypertension, diabetes and osteoporosis.
Dental practitioners have also been involved in the COVID-19 response to provide vaccinations. In the United States, some jurisdictions reimburse dental practitioners to deliver COVID-19 and HPV vaccines.
Proportionate universalism and prevention
There is no doubt that Australian governments need to significantly increase investment in publicly funded oral healthcare.
The Select Committee on Access and Provision on Dental Services recommends a staged approach to universal access to essential oral healthcare.
But national clinical leadership for oral health is critical for it to be prioritised at a national level, and would be enhanced by establishing an Office of Dental and Oral Health in the Department of Health and Aged Care.
Many dental services currently funded by the Australian Government are potentially driving unnecessary oral healthcare. For example, there is no evidence that six-monthly dental check-ups and scale and polish improve oral health outcomes.
Any government-funded dental service should be critically reviewed using health technology assessment processes to determine their cost-effectiveness.
Ongoing research and evaluation are needed to develop a better understanding of barriers and enablers to successful oral health services and systems alignment with other health services.
Cost-effective preventive dental services such as fluoride varnish and silver diamine fluoride should be accessible to all Australians. This is particularly advantageous for consumers who are receiving regular healthcare by nurse practitioners and midwives, who can be trained to apply these fluorides. The proposed Health Legislation Amendment (Removal of Requirement for a Collaborative Arrangement) Bill is a step forward.
Establishing a core set of preventive-focused dental services for essential oral healthcare would be important to ensure all Australian have universal access.
Other considerations include how to ensure different service delivery models can reach under-served populations, so that clinically necessary dental treatment is timely and affordable for those with higher oral health needs and oral disease burden.
Author details
Tan Nguyen is an oral health therapist and health economist. He is the co-convenor for the Oral Health Special Interest Group, Public Health Association of Australia, and Casual Research Fellow from Deakin Health Economics.
Darren Qiang is a graduate with Master of Public Health and Bachelor of Biomedicine from the University of Melbourne.
The perspectives are those solely of the authors.
Previous articles in this series
- A short history of the oral healthcare workforce – and please join our upcoming webinar
- Please join us in tackling oral healthcare inequities – and here’s a guide to policy challenges and opportunities.
Also see Croakey’s archives on oral health
Croakey Health Media is seeking sponsors for further #CroakeyLIVE webinars as part of our #Medicare40Years project.
