Special Feature

Oral health inequalities: A major public health challenge for Asia-Pacific

David Williams1 & Manu R Mathur2

doi:10.1038/nindia.2017.21 Published online 16 March 2017

Policy Recommendations

• Oral disease prevention must be included in the broader non communicable diseases (NCD) framework.

• Targets and indicators must be within the global sustaina­ble development agenda.

• Achieving Universal Health Coverage (UHC) will progress on oral health outcomes, inequalities and socio-economic impact.

• Links with other development sectors such as poverty re­duction, agriculture and food, education, climate change and gender must be recognised. 

David Williams & Manu R Mathur
Oral diseases are the most prevalent non-communicable diseases (NCDs), affecting almost 4 billion people worldwide1. They share social determinants and risk factors2 with the other NCDs and ex­hibit a similar social gradient in prevalence, resulting in global inequalities in oral health3. Oral diseases create a major economic burden, through loss of productivity1, so can be both a cause and consequence of relative poverty. Most dental diseases are preventable, and early dental treatment is cost-ef­fective.

While many high-income countries have enjoyed considerable improve­ments in oral health in recent years, the same does not hold true for the Low and Middle Income Countries (LMICs) especially those from the Asia Pacific region. Oral health inequalities within and between countries of the region are wide and reflect unequal exposure to common risk factors, inequitable access to healthcare, as well as widening disparities in socioeconomic status.

The link between oral and general health and its impact on an individual’s quality of life, provides a strong conceptual basis for the integration of oral healthcare into general healthcare improvement approaches.

Oral health & sustainable development goals in Asia-Pacific

Since the 2000 adoption of the Millennium Development Goals (MDGs), the Asia-Pacific region has witnessed multiple transitions such as rapid urbaniza­tion, changing demographic profiles (from a predominantly young to ageing populations), changing dietary patterns (towards a high-sugar western diet), increasingly sedentary lifestyles, environmental degradation, cultural chang­es and uneven economic growth. The compound effect of these, overlaid by uneven economic development, an under-resourced health system and inad­equate multi-sectoral action on social determinants, are reflected in the oral health profile of the region.

Recognizing the need for a more sustainable, equitable and inclusive ap­proach to development and health, the MDGs were replaced by Sustainable Development Goals (SDGs) in 2015 and these provide a framework for actions across multiple sectors for human development with the most sustainable use of resources. The emergence of NCDs, including oral diseases, as the major cause of morbidity and mortality was highlighted as a major challenge for sus­tainable development and included as a stand-alone target in the lone health SDG.

The quest for UHC in Asia-Pacific

The SDGs also recognise Universal Health Coverage (UHC) as the foundation to achieve health and well being at all ages. This is ‘a state of health system performance, when all people receive the health services they need without suffering financial hardship’4. It is expected to provide equitable access to affordable, accountable, appropriate health services of assured quality to all people, including promotive, preventive, curative, palliative and rehabilitative services.

Many LMICs have made progress in achieving UHC in the past 15-20 years, but most only cover basic dental services. The inclusion of more pre­ventive, promotive and rehabilitative oral healthcare coverage is still rare es­pecially in the Asia-Pacific region. Some countries, including the Philippines, Sri Lanka and Thailand have begun to include comprehensive oral health with­in their UHC model5 and to decompose the source of inequality in utilization. Further, to identify the determinants that effect to out-of-pocket payments for oral healthcare. Methods: Using the data of 32748, Thai adults aged 15 years and over from nationally representative Health and Welfare Survey and Socio-Economic Survey in 2006. This study employs concentration index (CI, demonstrating what can be achieved. It is now for others to follow their ex­ample.

The way forward

UHC, delivered through an adequately-resourced and well-governed health system with a strong prevention component, is the most likely approach to address oral health challenges. UHC will also have positive externalities for development, gender empowerment and social solidarity. Within the health sector, primary healthcare should be ranked as of the highest importance, because of its ability to provide maximum health benefits to all sections of society and ensure sustainable oral healthcare expenditure levels.

Inclusion of oral health into the broader NCD and UHC framework will in turn prove beneficial for all Asia-Pacific countries, as the focus on health pro­motion, prevention, multi-sectoral action and addressing social determinants (which are more defined for oral health) will help identify support pathways for other NCDs. The attainment of UHC will only be possible when oral dis­ease prevention and control is prioritized. Achieving UHC, will in turn provide a robust launching pad to foster progress on oral health outcomes, inequalities and socio-economic impact.

Oral health in all policies

It is becoming recognised that, like general health, the critical determinants of oral health lie outside the health sector. Oral health is also influenced by policies and programmes in other development domains, such as poverty re­duction, agriculture and food, education, climate change and gender6, 7, 8. It is essential that the post-2015 development agenda and resulting policies rec­ognise these linkages. When designing policies to achieve future development goals, the impact of oral health across multiple sectors should be taken into account. Responding to the challenges of global health transition and recog­nising the close links with other development sectors, oral health must be positioned centrally in the framework of sustainable development. The post-2015 development agenda must also promote synergies and partnerships that align actions for better oral health.

[Nature India Special Issue: Oral Health Inequalities and Health Systems in Asia-Pacific]

1Professor of Global Oral Health, Bart’s and The London School of Medicine and Dentistry, London United Kingdom (d.m.williams@qmul.ac.uk); 2Research Scientist & Assistant Professor, Public Health Foundation of India, Gurgaon, India (manu.mathur@phfi.org).

References

1. Federation Dentaire Internationale. The challenge of oral disease – A call for glob­al action. The Oral Health Atlas. 2nd Edition. Geneva: FDI, World Dental Federation (2015)

2. Petersen, P. E. The World Oral Health Report 2003: Continuous improvement of oral health in the 21st century - the approach of the WHO Global Oral Health Programme. Geneva (2003)

3. Sabbah, W. et al. Social gradients in oral and general health. J. Dent. Res. 86, 992–996 (2007)

4. WHO. The world health report: health systems financing: the path to universal cov­erage. Geneva (2010)

5. Somkotra, T. &  Detsomboonrat, P. Is there equity in oral healthcare utilization: Expe­rience after achieving Universal Coverage. Community Dent. Oral Epidemiol 37, 85–96 (2009)

6. Sheiham, A. et al. Billions with oral disease: A global health crisis -- a call to action. J. Am. Dent. Assoc. 146, 861–864 (2015)

7. Mathur, M. R. et al. Universal Health Coverage: A unique policy opportunity for oral health: Editorial. J. D. R. Clin. Res. Suppl.94, 3S–5S (2015)

8. Mossey, P. A. & Petersen, P. E. Budapest Declaration: IADR-GOHIRA(R). J. Dent. Res. 93, 120S–121S (2014)