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Access to dental care in Australia

Country: 
Australia
Partner Institute: 
Centre for Health, Economics Research and Evaluation (CHERE), University of Technology, Sydney
Survey no: 
(5)2005
Author(s): 
Marion Haas and Rob Anderson
Health Policy Issues: 
Funding / Pooling, Benefit Basket, Access
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no no yes no

Abstract

Between 1960 and 1990, the oral health of Australians improved. In 1997 the Australian government ended funding for public dental programs. State governments continued limited programs for the most disadvantaged. Subsidies for private dental care and Medicare rebates for dental services for people with a chronic condition have been introduced. There is evidence that decreased access to dental services for disadvantaged groups has resulted in the decline of oral standards in Australia.

Purpose of health policy or idea

One of the objectives of the Australian health care system is to ensure that individuals have access to care on the basis of need rather than ability to pay. However, this objective has never been fully met in relation to dental services. Most dental services are provided by private practitioners operating as small businesses. Private health insurance covers a proportion of costs but consumers have always faced relatively high out-of-pocket costs for dental services. As evidence merges that there is a socioeconomic divide in oral health, a number of policies have been suggested to address the inequalities that currently exist.

A separate system of primary dental care for children and adolescents is funded by state goovernments and delivered by salaried school-based dental therapists. Originally free at the point of delivery, some now have co-payments.

State-funded dental care is provided to adults through community or hospital-based dental clinics. Access to these services is restricted to the elderly, disabled, single parents with health care cards and the unemployed.

In 1997, the Australian government withdrew funding of $A100 milion per year for dental health programs. Some states have made up the shortfall but others, including the largest, NSW, have not. On the other hand, government subsidies for private health insurance covering the provision of private dental services have increased to $A430 million per year.

The outcome has been increased inequity in access to care. People from wealthier groups have better oral health and make use of more complex and expensive services whilst waiting lists for public dental care have grown by 20% per year.

Approximately 85% of the dental workforce in Australia are employed in private practice where they can earn between 2-5 times more than dentists employed in the public system. Dentists also claim that clinical satisfaction is higher in private practice as public dentistry cannot offer the range of treatment available to private patients.

Main points

Main objectives

One of the objectives of the Australian health care system is to ensure that individuals have access to care on the basis of need rather than ability to pay. However, this objective has never been fully met in relation to dental services. Most dental services are provided by private practitioners operating as small businesses. Private health insurance covers a proportion of costs but consumers have always faced relatively high out-of-pocket costs for dental services. As evidence emerges that there is a socioeconomic divide in oral health, a number of policies have been suggested to address the inequalities that currently exist.

Type of incentives

In 1997, the Australian government withdrew funding of $A100 milion per year for dental health programs. Some states have made up the shortfall but others, including the largest, NSW, have not. On the other hand, government subsidies for private health insurance have increased to the tune of $A430 million per year.

Approximately 85% of the dental workforce in Australia are employed in private practice where they can earn between 2-5 times more than dentists employed in the public system. Dentists also claim that clinical satisfaction is higher in private practice as public dentistry cannot offer the range of treatment available to private patients.

Groups affected

public dental patients, school students, dentists

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Characteristics of this policy

Degree of Innovation traditional traditional innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low low very high
Transferability strongly system-dependent system-neutral system-neutral

As previously mentioned, there is nothing new about the proposals in terms of the structure of the proposed services. Public dental services have previously and in some cases, still do operate in schools, in community or hospital clinics and through health promotion and education strategies.

This system is supported by the general public and politicians - the argument is over whose responsibility it is to provide the funds for it. As some services are still operational in all States, increasing its scale and scope would have a marginal impact on the structure of the system.

Unless the problems are highlighted in the media, the public visibility of the dental service is low - however, in the past 3 months, its visibility in NSW has risen sue to increased attention in the print media.

The policies are not system dependent. Many public dental services use similar structures and strategies to fulfill their objectives.

Political and economic background

The Commonwealth Dental Health Program was not renewed in 1997 because waiting times for public dental services had been reduced and therefore, faced with increased fiscal pressures, the government considered that it was no longer necessary. However, within a year, waiting lists had grown by 20%.

In the years between 1998 and 2004, evidence emerged that although the oral health of the Australian population as a whole was good, amongst diadvantaged groups, its decline was immediate and, in some cases, dramatic.

With the 2004 election looming, the Australian government reacted to information that the oral health of Australians had declined since access to public dental care was reduced in the mid 1990s. However, the reaction was limited to increased funding for a small group of people with chronic conditions as the government claimed that

1) the States and Territories were responsible for the provision of public dental care (as they are for the provision of other public health care services) and

2) the 30% rebate on private health insurance had ensured increased access to private dental services.

Private dental services make up the bulk of dental services provided in Australia although it should be noted that private health insurance is more likely to be taken up by the wealthy.

The ensuing debate over the standard of oral health amongst Australians and the differential access to dental care based on socioeconomic status has raised the profile of oral health research as well as public dental services.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no no yes no

Origins of health policy idea

Researchers and clinicians working in public and social and preventive dentistry have produced evidence that the decrease in funding for public dental services has created a divide between rich and poor. A number of suggested policies have been canvassed:

  • extend the coverage of water flouridation
  • engage in health promotion activities
  • revitalise the school dental health services
  • reform public dental health services
  • earmark funds for public dental services and set minimum standards and expenditure levels.
  • establish advisory committees on dentistry in general and on the dental workforce in particular.

The ideas are not new to Australia and have been driven by academics and public health clinicians, aided to some extent by the media.

Initiators of idea/main actors

  • Providers: Providers of dental health care have been supportive of the propsed policies aimed at revitalising public dental services
  • Scientific Community: Academic researchers have produced evidence of the worsening levels of oral health in Australia
  • Media: Some media groups have used the story to illustrate individual's problems with access to dental care

Approach of idea

The approach of the idea is described as:
renewed: The policies are essentially about revitalising and renewing current services which have become de-funded.

Stakeholder positions

A policy paper has been produced by the Australian Health Policy Institute (author John Spencer, professor of social and preventive dentistry at the University of Adelaide) which summarised the evidence available about standards of oral health in Australia and proposed new policies to improve it. This has been supported by providers working in public dental services.

The reaction from the Australian Government has been to reiterate that the provision of public health services (including public dental services) is the responsibility of the States and that there has been an increase in funding for such services in the past 5 years. In addition, access to (private) dental services has been supported by the government subsidy for private health insurance.

Actors and positions

Description of actors and their positions
Providers
Providers of public dental servicesvery supportivevery supportive strongly opposed
Scientific Community
Scientific communityvery supportivevery supportive strongly opposed
Media
Mediavery supportivesupportive strongly opposed

Influences in policy making and legislation

n/a

Actors and influence

Description of actors and their influence

Providers
Providers of public dental servicesvery strongweak none
Scientific Community
Scientific communityvery strongneutral none
Media
Mediavery strongneutral none
Providers of public dental servicesScientific communityMedia

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

n/a

Monitoring and evaluation

n/a

Results of evaluation

n/a

Expected outcome

If the proposed policies were implemented, because they represent a return to previous policies which were known to be successful in improving oral health and increasing access to dental services for disadvantaged groups, there is good reason to suppose that they would be successful.

The effect that the proposed policies would have on the dental workforce is less clear. Whilst there does not appear to be a current shortage of dentists or dental support staff, such as dental therapists and hygenists, the only school of dentistry in NSW has halved the number of places available for students in the past 20 years, due to funding cuts. In addition, the salary differential makes work in public dental services far less attractive than work in the private sector. Currently, there are vacancies for dentists in public clinics in all parts of NSW.

Whilst implementing the changes would require additional resources to those currently available, the most important question is what would be sacrificed to provide the resources needed for a service which would reduce inequity of both access and health.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low high very high

Because the public dental services are available to a small proportion of the population, changes to policies concerning them will not have a major impact on the overall quality of health sevices provided. However, they will have an impact on the quality of dental services provided.

Reductions in availability of services have increased inequity of access and oral health amongst Australians. Therefore, improvements in access will reduce the inequity.

The implementation of the proposed policies are likely to provide value for money. For a modest investment, improvements would occur not just in clinical outcomes such as reduced pain, fewer extractions and lower levels of denture use, but in more general measures of oral health such as the ability to eat, speak and socialise without embarassment or discomfort.

References

Sources of Information

Spencer, John. Narrowing the inequality gap in oral health and dental care in Australia. Australian Health Policy Institute, University of Sydney. Commissioned Paper Series 2004.

Pearlman, Jonathon, Ryle, Gerrard. Dental crisis exposes great divide. February 15, 2005 http://smh.com.au/news/Health Accessed 16/2/05

Pearlmen, Jonathon. Community groups take up fight. February 16, 2005. http://smh.com.au/news/Health Accessed 16/2/05

States fail their dental patients despite record funding. Press release. July 16, 2003 http://www.health.gov.au/internet/wcms Accessed 4/4/05

Medicare items for dental care for people with chronic conditions and complex care needs. http://www.health.gov.au/Medicare Accessed 4/4/05

Birch, Stephen, Anderson Rob. Financing and delivering oral health care: what can we learn from other countries.  Journal of Canadian Dental Association 2005;71(4):243

Author/s and/or contributors to this survey

Marion Haas and Rob Anderson

Suggested citation for this online article

Marion Haas and Rob Anderson. "Access to dental care in Australia". Health Policy Monitor, April 2005. Available at http://www.hpm.org/survey/au/a5/3