|Year : 2019 | Volume
| Issue : 4 | Page : 266-268
Universal oral health coverage: An Indian perspective
Nandita Venkatesh, Venkitachalam Ramanarayanan
Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
|Date of Submission||03-Oct-2018|
|Date of Decision||29-Oct-2019|
|Date of Acceptance||18-Oct-2019|
|Date of Web Publication||12-Dec-2019|
Dr. Venkitachalam Ramanarayanan
Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi - 682 041, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Venkatesh N, Ramanarayanan V. Universal oral health coverage: An Indian perspective. J Indian Assoc Public Health Dent 2019;17:266-8
| Introduction|| |
The year 2018-19 brings a lot of hope with the improvement of health-care services across the globe and particularly in India. The World Health Organization's (WHO) Health Day's theme for this year is “Universal Health Coverage” (UHC) which put in simple terms is ensuring that everyone, everywhere, can access essential quality health services without facing financial hardship. This concept of UHC is based on the constitution of the WHO (1948) which considers health as a fundamental human right and on the Alma Ata declaration with the agenda of Health for All. Worldover, there has been a call for UHC to ensure not only health but also social and economic development.
Oral health is generally neglected both personally and politically and mostly viewed in isolation. For the very same reason, it does not tick most of the boxes that define UHC, namely, access, coverage, quality, and affordability. Hence, the concept of UHC must also encompass oral health as an important component with reinforcement and reorganization of oral health-care delivery systems.
| Universal Health Coverage is not a One-Size-Fits-All Approach|| |
It can be argued that “'universal health/oral health care” is not strictly universal. A one-size-fits-all approach cannot be tailored as the needs and resource availabilities for each country are different. Health in India is as unique and diverse as its landscape. Although the country has seen major improvements in vital health statistics over the years, the shift has been disproportionate within various sections of the country (read states, geography, and social class). High out-of-pocket expenditures have also pushed individuals and families into poverty. Hence, it would require a “trial and error” of various approaches to achieve the basic principles of UHC/oral health coverage.
| Who is Covered?|| |
UHC is for “everyone.” However, inequity in health care is a long-standing problem in India. The rural, tribal, and urban slums in India are traditionally underserved and demand special consideration. The recent Delhi Declaration 2018 reaffirms the principles and goals of Alma Ata declaration set 40 years ago. It calls for “Health for All Rural People” by the concerted efforts of all stakeholders and international community.
Oral health also faces similar issues, and its present status in India is dismal in terms of coverage. As in a majority of low- and middle-income countries (LMICs) across the world, dental treatments are available only in tertiary health-care centers and hence not always easy to avail. This has a profound impact especially on socioeconomically backward or geographically remote areas. Coverage increases with improved accessibility and availability. Therefore, bringing oral health care to the grassroots level of the health system in India seems the only promising solution. However, this demand has been long unheeded. Increasing the scope of health-care workers such as the Anganwadi/accredited social health activist workers/school health nurses to perform basic oral procedures (such as the highly successful basic package of oral care) could be a transitional measure.
| What is Covered?|| |
UHC is not only the bare minimum by the provision of “essential” services but also about ensuring that people receive better health services and financial protection as more resources become available. Yet in a country like India where bare minimum oral health services are unavailable to all, pole position should be accorded to providing primary oral health care to achieve universal coverage. The problem with insurance policies in India lies in the fact that they may not cover all the basic treatments which can again lead to out-of-pocket payments, thereby augmenting the financial burden on patients. A part of the reason is because there is no universally accepted definition of basic oral care and most of the common dental conditions such as dental caries and periodontal diseases do not meet the criteria for a condition to be considered insurable.
| How Can it Be Funded?|| |
UHC does not necessarily mean free coverage for all possible treatments, regardless of the cost. Oral diseases are the fourth most expensive disease to treat. In such a scenario, no country can afford or sustain providing free treatments. The current model of dentistry in India is predominantly driven and regulated by private sector. This system, quite expectedly, focuses primarily on the treatment of diseases rather than a more economical community-based preventive approach., Nevertheless, its contribution to oral health cannot be discounted. The challenge thus is to ensure that oral health is available to the people, without them having to face financial hardships. There is also very little regulation of the cost of treatment given by private oral health-care providers, despite concepts such as the table of allowances or usual, customary, and reasonable fee, leading to high expenditure rates. This necessitates a relook into the policies governing health-care provision by the private sector. The introduction of Clinical Establishments Act of 2010 to regulate the private sector is a long-awaited and welcome move. However, implementation is far less than adequate.
India could take a cue from countries such as Greece, Turkey, and Finland where dental care is provided through a mix of subsidized private practitioners and state-funded health services. Austria, Denmark, Germany, Poland, Spain, Sweden, and Mexico are providing basic dental care services through state-sponsored health insurance schemes funded through general taxation mechanisms.
Another comprehensive solution to make oral health affordable would be including dental/oral health coverage as a required component of health insurance. If the cost of private dental insurance also remains unaffordable to the lower socioeconomic strata, state-sponsored health insurances for oral health need to be mooted.
In recent years, the state and central governments have launched Public-Funded Health Insurance (PFHI) programs such as the central government's Rashtriya Swashtya Bima Yojana program (National Health Insurance Scheme). They cover a large percentage of the population and are another means to reduce out-of-pocket expenditure by involving both the public and private sectors. Unfortunately, PFHI schemes in India do not cover oral health needs adequately nor is enrollment or renewal mandatory, leading to reduced effectiveness of the scheme especially when it comes to oral health., The Rashtriya Bal Swasthya Karyakram is one of the programs which does cover oral health. The drawbacks with this though are that it only focuses on children below the age of 18 and among oral diseases and disabilities, focuses only on dental caries and cleft lip/cleft palate, thereby reducing its reach.
A universal coverage policy was brought into force by the Thai government in the past decade, which India could adopt as a model because it also takes into account oral health. This model which comes under the purview of the “National Health Security Office,” which controls the health-care funds, consists of three health insurance schemes, namely, the Civil Servant Medical Benefit Scheme, the Social Security Scheme, and the Universal Coverage Scheme which use different modes to cover health-care costs. Under these schemes, most of the common dental treatments such as extractions, oral prophylaxis, and prosthodontic and restorative care are covered. Another advantage with this model lies in preventive care. Adopting this model in India could prove to be successful as Thailand is probably more similar to India both culturally and socioeconomically.
Alternatively, in LMIC countries where health financing is in a crunch, systems such as public–private partnerships (PPPs) and corporate social responsibility can also help better the affordability of oral care.
At the time of writing this, Ayushman Bharat scheme has been announced. Touted to be the world's biggest health reform, this scheme definitely lays out India's map toward achieving UHC. The scheme aims to provide families in India with an annual insurance cover of INR 500,000 for covering secondary and tertiary care in empanelled public and private hospitals. However, the needs of the poor would be to get cost-free access to basic or primary health services. The financial viability of this scheme prima facie looks far from convincing. The silver lining, however, is that oral health does find a mention in the list of services/packages provided under this scheme. Yet, the lack of protection for outpatient services or expenditure for medicines would negatively impact oral health services, most frequently outpatient care.
| Whose Responsibility?|| |
In majority of the developed countries, UHC evolved as an outcome of political negotiations during and after the World War and Industrial Revolution. In India, however, there has been an absence of political thrust for this issue until recently. It is quite evident as India ranks among the lowest in the public spending for health. Oral health has often been neglected in national health plans and global health strategies., India lacks a robust policy to implement effective oral health programs which are accessible to all. The existing policies do not enjoy mainstream attention either. Communities and civil society organizations could play a major role as UHC also incorporates the whole population approaches such as public health campaigns.
| What are the Challenges?|| |
An imposing challenge this specialty confronts is the tendency among the general public to underestimate the role oral health plays in the general well-being of an individual. Thus, despite the large oral disease burden, oral problems at an early and preventable stage are not considered as felt needs by majority of the population. We must find a way to change public perceptions regarding oral health and disease so that it becomes an accepted component of general health. Integrating oral health with other health programs such as noncommunicable diseases could be the way forward.
As economics play a major role in ensuring UHC/oral health coverage, high out-of-pocket expenditure and low spending on public health in terms of gross domestic product is a major challenge. Deficiency of skilled human resources or the skewed distribution of dental health professionals in the country is also touted to be a major setback in our quest for universal oral health coverage.
Low utilization rates observed in health programs of the government is another challenge. Acharya et al. in their studies on the effect of national health insurance schemes, especially in the LMIC, found that enrollment rates, especially in the poor, were low. Hence, it is also important to generate awareness and educate the people on the importance of oral health for successful implementation of the various government schemes.
| The Way Forward|| |
According to Hawe et al., desirable outcomes can be achieved through “capacity building” to improve oral health which is defined as an approach to the development of sustainable skills, organizational structures, resources, and commitment to oral health improvement in health and other sectors to sustain and reproduce oral health gains. The following have been identified as key action areas for capacity building: (i) organizational change: formulation of policies and the management and regulation of these policies; (ii) workforce development: deals with dental public health education and producing a workforce which is capable of promoting oral disease prevention; (iii) resource allocation: lobbying to obtain resources such as financial, physical, and educational resources toward health promotion and prevention; and (iv) leadership: development of personal and interpersonal skills which enable personnel to promote health coverage.
Increase in the efficiency of the system may lead to an increased progress in achieving UHC. Reduction in the cost of treatment and materials, corruption, and increasing the efficiency of the health workers could in turn generate vast differences in the degree of oral health coverage achieved.
Use of information technology, namely, teledentistry, mCessation, mooting PPPs, and strengthening of national health programs by integrating oral health seems to be a promising solution.
With world leaders like Dr. Tedros Ghebreyesus, Dr. Margaret Chan, and Dr. Jim Yong Kim clamoring for UHC,, a unique opportunity currently exists to influence global health policy and ensure that oral health for “everyone, everywhere” is recognized as a key public health priority and is integrated into the emerging UHC policy agenda. Although miles away, the time is ideal for us to act.
The authors wish to thank Dr. Chandrashekar Janakiram (Oral Health Informatics Fellow, National Library of Medicine, National Institute of Health, Bethesda, USA) for his valuable inputs.
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