This Sunday, 12 December 2021, we will be celebrating Universal Health Coverage (UHC) Day under the theme “Leave No One’s Health Behind: Invest in health systems for all”. Noncommunicable diseases (NCDs), including oral diseases, play an important role in this discussion.

NCDs are the most common cause of death and disability worldwide, causing 74% of all deaths globally. They often exist together in the form of co-morbidities, which are conditions occurring at the same time in the same person, because they share the same risk factors, or because some diseases predispose individuals to developing others. The term ‘noncommunicable diseases’ often refers to the five conditions on which the NCD response has focused until recently: cancer, cardiovascular diseases (CVD), chronic respiratory disease, diabetes, and mental and neurological disorders. But it also includes many other conditions of public health concern, such as oral diseases, which are highly prevalent and closely linked with the most prioritized NCDs.

Investing in health systems for all: adding an oral health lens to UHC

Oral diseases are in fact the most prevalent condition worldwide; however, oral health is often not considered (nor covered) as an integral element of health systems. Why is this, when there are strong synergies to reduce overall health system costs through joint prevention efforts, early and cost-effective oral health interventions, and referrals for other NCDs? On a positive note, the recent resolution on oral health approved by the World Health Assembly in May 2021 (WHA74.5) urges Member States “to strengthen the provision of oral health services delivery as part of the essential health services package that deliver universal health coverage”.

Ahead of UHC Day, we would like to reflect on the meaning of universal, health, and coverage, providing an oral health lens to the concept of UHC.

‘Universal’…equal access to health services for all people

As highlighted across FDI’s Vision 2030: Delivering Optimal Oral Health for All, oral diseases disproportionately impact people from low- and middle-income countries (LMICs) and marginalized groups with limited access to health promotion, oral healthcare, and other NCD services. This exacerbates existing social and health inequalities, given that oral diseases lead to preventable long-term pain and result in a significant number of lost work and school days. 520 million children suffer from cavities of primary teeth, and if tooth decay is not treated early, these cavities can lead to painful abscesses or even sepsis. In countries like Australia, Israel, New Zealand, and the USA, one of the most common reasons for hospitalization of children is tooth extraction due to dental cavities.

To address the social determinants of health, essential health services including oral health services must be accessible universally, ensuring equity in access to those services. One mechanism for this is the implementation of population-wide interventions that promote health and tackle risk factors shared by oral diseases and other NCDs, such as sugars. Public health interventions to reduce sugar intake can include taxation of sugary drinks, implementation of clear front-of-package labelling of processed food and drinks, regulation of all forms of marketing and advertising of food and beverages high in sugar to children, improvement of the food environment in public institutions, and increasing awareness and access to clean water.

‘Health’…much more than reducing deaths from disease

Another aspect of UHC to consider is, what do we mean by ‘health’? Why exclude oral health services from UHC benefit packages when oral health is an essential element of general health? For instance, periodontal (gum) disease is the seventh most prevalent disease worldwide; affects the alveolar bone, leading to tooth loss; and often manifests as a common complication of diabetes. It can also affect blood glucose control, thereby increasing the risk of diabetes. Moreover, when we talk about health, we are also referring to quality of life. UHC efforts should not only focus on halting and reducing mortality rates, but needs to ensure people’s right to life, health, and well-being.

FDI and the NCD Alliance recently published WHY and HOW to integrate oral health into the NCD and UHC responses, a briefing note for policymakers that includes five key messages outlining calls to actions for each message. (1) It makes the case for oral health to be considered a key indicator of general health, well-being, and quality of life; (2) it calls for joint prevention efforts given shared risk factors; (3) it recognizes poor oral health as a risk factor for NCDs beyond oral diseases; (4) it raises awareness about the positive impact that good oral health can have for NCD treatment outcomes; and (5) it addresses the need to engage people living with oral diseases, communities, and health professionals to succeed with integration efforts.

‘Coverage’…affordable access to all elements of healthcare

Under coverage, we must mention that UHC has three core elements: ensuring quality, equitable access, and financial protection for a wide range of health services (i.e., health promotion, prevention, treatment, and rehabilitation). These three elements must be met in order to achieve real coverage. In the European Union, oral diseases were the third highest driver of health expenditure in 2015 among NCDs, after diabetes and CVD. However, less than one-third of oral healthcare expenditure is covered by government or compulsory insurances across EU countries (2018 figures).

This demonstrates the limited financial protection available for oral health services and the exposure to high out-of-pocket expenses for low-income families. For many LMICs, availability and coverage of oral health services is often very low or non-existent, exposing households to a higher risk of catastrophic health expenditure if they receive dental treatment, or even entirely precluding access to oral health services.

This year for UHC Day, we’d like to stand behind the words of Stephen, a health advocate based in Kenya with lived experience of severe tooth decay, who suffered years of pain, affecting his diet, productivity, and sleep, because treatment was inaccessible and expensive: “I believe oral health services need to be more accessible to the millions of people who currently have no availability, to safeguard their quality of life.”

Authors

Enzo Bondioni works to ensure that best practices in oral health science, education, preventive care and treatment are shared broadly, helping improve the oral and general health of people globally. He has been Executive Director of FDI World Dental Federation (FDI) since 2015. His previous roles have included being Chief Operating Officer at the International Osteoporosis Foundation and the World Heart Federation.

Nina Renshaw joined the NCD Alliance in July 2018 and is responsible for leading, developing, implementing and managing NCDA’s global policy and advocacy work. Nina has over twelve years of international policy and advocacy experience in diverse fields including environment, transport, industrial policy, taxation and health. Prior to joining the NCD Alliance she was based in Brussels, as Secretary-General of the European Public Health Alliance (EPHA).