Essay: Essay on inequalities in the accessibility of dental health services in Australia

TOPIC: Inequalities in the accessibility of dental health services in Australia
ISSUE: Lack of universal access to dental services, inadequate public dental services and extremely high costs of dental treatments in private sector have resulted in increased inequalities in the dental services in Australia.
Does the issue cover a contested problem that may be resolved through public policy?
There is enough evidence which indicates that oral diseases significantly affect the quality of life but dental health care is not given equal importance just as general health care by the upper levels of bureaucrats and policy-makers which leads to an impaired policy reaction (Spencer, 2004). According to Australian Healthcare & Hospitals Association (AHHA, 2011), the inequalities in access to dental health services have remarkably elevated in the last three decades in Australia and the government policies are primarily responsible for increasing these inequalities (AHHA, 2011). ‘There is concern about lack of transparency, equity and timeliness in access to public dental services across Australia’ (AHHA, 2011).
Some facts
Unlike Medicare, there is no universal access to dental services in Australia which are mainly provided by the private sector. There is a marked difference in the treatments received by public and private patients. Private patients receive (72.9% compared with 43.7%) more preventive treatments than the public patients (Chrisopoulos et al., 2011). According to a report released by Australian institute of health and welfare (AIHW) (2011), the average waiting time for public dental treatments is more than twenty months with over 500,000 people on waiting list. This further leads to inequities as people belonging to lower income groups are not able to avail the expensive private dental services. Limited and substantial misdistribution of dental workforce in private and public sector, the geography and funding in the public sector are some other factors which contribute to these inequalities.
Evidence of successful and failing policies so far.
In 1997, the commonwealth stopped funding for the public dental services because of reduced waiting times and increased financial pressures, however, the waiting lists had actually increased by 20% within a year (Hass & Anderson, 2005). The Howard-led Coalition government in 2004, for the first time, took an initiative of breaking the norms and establishing the Chronic Disease Dental Scheme (CDDS), under universal Medicare for the patients with chronic conditions which was unluckily, ended in 2012 by the Gillard Government as a response to fiscal pressures and issues of providing the services (Lam et al., 2013). The government also retaliated to these issues by stating that the responsibility of public dental services lied with the State and territories just as for other public health services and that the access to private dental services had been facilitated by giving 30% rebate on Private health insurance (PHI) for dental treatments. However, it was quite likely that PHI is usually taken up by the wealthier group. A National Advisory Council was established in 2011 and a new dental reform package was declared by the government in August 2012, replacing two existing programs namely, Chronic Disease Dental Scheme and Medicare Teen Dental program (Gussy et al., AHHA, 2013).
Evidence that suggests that it is a contested problem
Scholarly sources
In relation to policy, the results of a study by Hopkins et al. (2013), suggest that although the government has been successful to a large extent by increasing the PHI coverage, yet to some extent it might have come at the cost of socio-economic inequality as people with PHI can avail more affordable care and better access. The findings of one of the latest age-period-cohort analysis by Chrisopoulos et al. (2013), state that apart from rise in the costs of dental treatments, various age and income specific policies are also responsible for causing inequality in access to dental care. The result is better oral health for the wealthier people as they can afford more advanced and costly dental treatments. On the other hand, waiting lists for public dental services had increased by 20% per annum. Kelly (2014), states selection criteria on the basis of social determinants is a new approach for the sorting process in dental care and is comparatively non-tested in the literature. This validation study suggested that the reported individual need for dental treatment and the status of oral health along with the indicators of social disadvantage can be used as an indirect measure for relative priority of access to routine dental care (Kelly, 2014).
The disadvantaged population
Australians experiencing the worst oral health due to all these factors are those on lower incomes, Indigenous people, population living in regional areas, aged and homeless people. A systemic review by Costa et al., (2012), confirmed that higher incidence of dental caries in adults is directly related to socioeconomic indicators for instance education, employment and income. In 2010, 27.4% of overall population (8.7% for children aged 2-4 to 37.0% for adults aged 25-44) did not visit or delayed visiting a dentist due to cost (Chrisopoulos et al., 2012). 43% of Indigenous children were found to have poor oral health by Child Health Checks (CHCs) (AIHW & DoHA 2009). The scale of inequality in the rates of dental caries in rural Indigenous children as compared to their urban counterparts has not changed rather may have increased which indicates an immediate and crucial need for research on the determinants of these inequalities (Christian & Blinkhorn, 2012). Majority of dental workforce work in urban settings and remote/rural population (37%) face accessibility issues as compared urban population (AIHW, 2012).
Media coverage
In an interview to the ABC News, Australia Consumers Health Forum chairman, Stephen Murby, describes current figures of dental care waiting lists as ‘horrifying’ with over six hundred and fifty thousand people waiting for periods over 2 years. For this reason consumer’s health forum is launching a campaign for reforming the dental care system. He talks about the appalling state of public dentistry in Australia and that it is a disgrace for this nation to have some of the most marginalised people in this third world with less access to dental care. Menzies policy centre has found that more than 2 billion dollars are lost a year in lost productivity due to lack of public dental care (http://youtu.be/2jTUv1zCjsE). Guy Rundle, Crikey (independent media) writer (2013), states that it is unacceptable for dentistry to be so unaffordable in Australia. He highlights the pattern of failed policies in Australia and also about the disparity between rural and urban services (http://fb.me/24dpqZYYj). Richard Di Natale, an Australian Greens Senator for Victoria, states in Drum Opinion, that Greens supported the Labor Government on a condition that the urgent issue of dental care should be placed firmly on the national agenda. The first result of this agreement is the formation of a new National Advisory Council on Dental Health (http://www.abc.net.au/unleashed/3208234.html)
Two policy options that would resolve the issue
Distributive and regulatory approaches seem to be relevant in resolving the issue.
Ripley and Franklin (1982) suggest that distributive policies, which is allocating funds to different groups, are relatively easy to implement (As in Buse et al., 2005). In order to ensure sustainability of public dental care at national level, the dental health needs of a substantial population which is not subsidized in any form through public dental health system, needs to be addressed first. ADA (Australian dental association) argues that Australians with low income suffer inequality due to lack of coordination between the state and federal government as to who is responsible for public dental services payments (Gallego, 2007). Policy paper on oral health by AHHA, (2011) also emphasize on adequate and continuing funding with equitable distribution per capita through the states and territories. In addition to this, the co-payments should also be adjusted on a more consistent levels such as to the jurisdictions having more Indigenous population and more complex needs (AIHW, 2011). The eligibility criteria for accessing the public dental services should be more research and evidenced based so that that maximum disadvantaged population can be covered. Research has assessed the discriminant and predictive validity of relative social disadvantage for priority access to public dental care (Kelly, 2004).
Secondly, there is an urgent need of dental workforce reform in Australia. Government interventions that enforce rules and standards are called regulatory approaches and they are moderately difficult (Buse, 2005). These regulatory approaches can be used for a better use and distribution of the dental workforce. According to a review of Australian Government Health Workforce Programs, the geographical distributions show that 81.0% of dentist, 87.4% dental hygienist, 62.2% dental therapist, 74.7% oral health therapist and 67.5% of dental prosthetics work in urban settings and 37% of rural and remote population has accessibility problems in comparison to 27% urban (AIHW, 2012). The sector distribution shows that a huge number of dental workforce is working in the private sector (84.2% of dentists, 92.7% of dental hygienists, around 62% of oral health therapists and 90.5% of dental prosthetists).
Stephen Murby, the chairman of Consumers Health Forum of Australia, states in an interview that it is not just an economic issue and that the role of oral health professionals other than dentists, like dental hygienists, oral therapists etc. should be extended across the public and private dental services. More places should be provided for young graduates to enter into public dentistry. There is a lot of scope for creating a more flexible workforce environment through national registration of all the dental professionals which would also compel the government to use public and individual funds more efficiently (AIHW, 2012). The creation of dental internship in rural regions is a good scheme in this regard (Rundle, 2013). PHAA (Public Health Association of Australia) submission to the Inquiry into Adult Dental Services in Australia suggests that it is necessary to map the distribution of current workforce to identify gaps and areas of needs (PHHA, 2013).
Policy actors that would be in favour of each option
The identification of the policy actors who seek to place the problem on policy agenda and who demand for policy response is very essential for policy analysis (Barraclough & Gardner, 2008). The policy actors who would support these policy options include the dental health care providers, academic research institutions, policy think tanks, and mass media. Barraclough & Gardner (2008), state that usually, the political parties and interest groups also play role in placing the problem on the policy agenda and that is true in this case too, as for some political parties like Greens and interest groups like Consumer Health forum of Australia, consider Dental health reform as one of the most important policy agenda.
Providers of public dental services have always supported the policies that aim to revitalise the public dental system because the existing under-resourced public dental system is able to meet only a fraction of demand for dental services which results in months long or in some cases many year long waiting lists. The regulatory policy options would ease off some burden from public dental system by more efficient distribution of dental workforce. AHHA is an independent peak body representing the providers in the acute, community, primary and aged sectors. It is a national voice for universally accessible quality dental care in Australia and has made several submissions including policy papers in this regard.
Academic researchers have produced enough evidence of the deteriorating oral health status in Australia. Evidence based studies and evaluation reports conducted by the academic researchers and institutions serve as a vital tool to develop a positive and receptive policy environment. A policy paper, widely supported by providers of public dental system, was submitted by John Spencer, professor of social and preventive dentistry at the University of Adelaide, through the Australian health policy institute in 2004, summarizing the evidence of oral health status in Australia and proposing policies to improve it (Hass &Anderson, 2005). An age-period-cohort analysis by Chrisopoulos et al. (2013) and evidence of selection criteria on the basis of socioeconomic status by Kelly, (2014) are a few more examples. Most of these studies provide evidence which support the distributive and regulatory approaches. Mass media is capable of bringing a problem to the attention of wider public and hence, creating an expectation that Government would act upon it. Some media groups have exclusively used the story to illustrate the problems of disadvantaged population with access to dental group as described before through some media expressions.
Three possible policy actors that would be opposed to each option
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 (AIHW, 2012). Dentists argue that private practice offers higher clinical satisfaction and that the variety of treatments available to private patients is not offered in public dentistry. There is mal-distribution of dental workforce in Australia where supply exceeds demand in private sector and there is considerable undersupply in the public sector and in rural and remote regions (PHAA, 2013). Therefore, regulatory policy proposals aiming to revitalise the public dental system for example bonding dentists for three to five years of rural work with punitive clauses, would be less likely welcomed by the private dental workforce.
Different political parties form different coalitions which have different views and this always lead to conflict in politics. It is evident from the history of different successful and failing dental policies since last 30 years. In 2012, Gillard government ended the CDDS which was started by the Howard Government in 2004, in response to fiscal pressures and inability to deliver services. They argued that the responsibility of public dental services lied with the State and territories just as for other public health services and that they have facilitated access to private services by giving 30% rebate on PHI. Therefore, this complex funding system is often an area of dispute and distributive policies are prone to be opposed by some coalitions.
The commonwealth can exercise significant influence through its monetary provisions in states and territories, regulation of private health insurance, direct funding to health organizations and prioritization and formulation of national programs (J Hall, 1999). The distributive and regulatory policies can affect the private health insurance companies in many ways and therefore, can attract many opposing policy actors from there. National Health and Hospitals Reform Commission, 2009, recommended the creation of Denticare scheme under which Australians have an option to take membership of a dental health plan with a private insurer or to use public dental services. The chief executive of a private insurance company, NIB, had strongly opposed this scheme by describing it as inefficient and had opposed the nationalisation of dental health services (Gallego & Gisselle, 2009). The Australian Dental Association also described Denticare as extremely impractical and ineffective.
A possible process that would lead to the adoption of a policy that aims to resolve the issue.
Spencer (2004), stresses that oral health and diseases are not given an equal importance like other burden of diseases and this results in poor policy response. Very less work has been done on evaluation studies as in what works well, where and why. This authenticates that the academic researchers should collaborate and come up with more evidence based studies and evaluation reports for enabling the policy makers to understand the crisis and take appropriate decisions. Extensive media campaigns can also play a significant role in illustrating problems encountered by people belonging to all disadvantaged groups in access to dental care. Together these efforts would strengthen the issue to be placed on policy agenda, therefore, building a more positive, receptive policy environment at all levels of government (State, Territory and Commonwealth) for taking strategic decisions about access to publicly-funded dental care: who should be eligible, how often should they be able to access services, and what services.
Three policy theories that can explain this policy process
The policy sub system or Advocacy coalition approach by Sabtier & Jenkins- Smith
According to the policy sub system or advocacy approach, policy change is seen as a continuous process that takes place within policy sub-systems (for example, public health system) bounded by relatively stable limits and shaped by major external events (Buse et al., 2012). Within the policy sub system there are , large number of actors, all sorts of limitations, power, network and resources that can be mobilised and organised into advocacy coalitions for resolving issues and hence, playing the policy game. An advocacy coalition is a group with distinct set of norms, beliefs and resources and defined by their ideas not by the exercise of self-interested power (Buse et al., 2012). They are in conflict with one another and interact over a considerable period of time. Sabatier does not include public in any policy sub-system on the grounds that the ordinary people do not have time or inclination to be direct participants. So the actors include those who play a part in the generation, dissemination and evaluation of policy ideas (Buse et al., 2012). These include politicians, civil servants, members of civil society organization, journalists etc.
During the policy process, the contesting and the dominating types of coalitions might try to pull in more actors respectively on the basis of argument, power, rewards, and better alternatives. Both coalition groups construct policy environment and place their arguments in their own way which are called policy ontologies (PO). PO of dominating coalition might be different from that of contesting coalition but in between incrementally decisions will be made by the Government and institutions will be changed. Policy outputs and impacts are the result. Following this there is feedback as people see what happens. It is not an entirely stable system for example, through elections new government with different PO may come into rule and coalition may change. This theory states that if a coalition manages to dominate the discourse well with enough partners it will be able to win the game. Example, Tobacco control in Victoria (VIchealth). It explains and manages to predict what happens if you want to make policy. This theory remains one of the most ambitious policy frameworks which tries to provide an overview of the entire policy process (Paul, M., 2013).
Kingdon’s multiple streams theory
Kingdon approach focuses on the role of policy entrepreneurs inside and outside government who take advantage of agenda- setting opportunities known as policy windows- to move items onto the government’s formal agenda (Buse et al., 2005). Kingdon’s work developed from case studies of US federal policymaking. Kingdon draws on Cohen et al’s ‘garbage can’ model of policymaking in organisations. Cohen et al suggest that the problem identification, solution production, and choice are ‘relatively independent streams’. The garbage can is where a mix of problems, solutions and choices are dumped. He developed a multiple stream theory according to which there are three streams namely the problem stream, politics stream and policies stream. He states that these streams always exist and are kind of autonomous and that policies are only taken seriously by governments when the three streams run together.
In each of the stream there are visible and invisible participants. Visible participants are those who have a legitimate role for example, in the problem stream the legitimate framers are the academics and I politics stream the politicians are the visible partners. In politics the academics have a little say so they are the invisible participants. Kingdon state that there is a good opportunity for new policy development if a window of opportunity is created to bridge these streams and in Kingdon’s world policy entrepreneurs are the ones who continuously push at the connection between problems, politics and policies. Kingdon describes policy ideas in a ‘policy primeval soup’, evolving as they are proposed by one actor then reconsidered and modified by a large number of participants (who may have to be ‘softened up’ to new ideas). To deal with this disconnect between lurching attention and slow policy development, they develop widely accepted solutions in anticipation of future problems, then find the right time to exploit or encourage attention to a relevant problem (Paul, M., 2013).
It is a little more complex so a hybrid theory (policy network theory was connected with Kingdons multiple network theory) was developed called IMPoLS (Interactive mapping of policy streams). It states that there are Central actors and Peripheral actors. Policy entrepreneurs can move the actors and change the policy network. One of the idea of policy network theory is that the shape of the network predicts the outcome. One who is in centre will have more influence on the outcome than those who are on periphery as they will be able to manipulate and help the policy entrepreneurs to gain momentum they want to establish.
Mazmanian & Sabatier: Theory about implementation.
Mazmanian & Sabatier developed a top down approach and devised a list of categories necessary and sufficient for effective policy implementation. There are categories of dependable variables in implementation process namely, tractability of the problem, ability of the statute agency or organization to structure implementation and non-statutory variables affecting implementation. Tractability of the problem is: how well you know the problem, how complex is the problem, and how much change is required in the policy that you propose.
Ability of the statute agency or organization to structure implementation: how well can you do it, do you have clear and consistent objectives you want to accomplish, is there adequate casual theory (valid theory as to how particular actions would lead to the desired outcomes), an implementation process for example, is there money (appropriate sanctions and incentives), do you integrate implementation within and between the implementing institutions, do you have enough people to do that, do you need to recruit people and committed skilful implementing officials. Non statutory variables affecting implementation is the support in society for implementation of program. Part of this is socioeconomic conditions, what are the attitudes and resources of those who are supposed to work together and is there any support from leadership,
This theory has been tested many times but is very complex. Most public policies found to have fuzzy, potentially inconsistent objectives. However, analysis along these lines show that lots of implementation issues can be explained by applying this theory to policy change. It can distinguish empirically between failed and successful implementation processes and thereby provide useful guidance to policy makers (Buse et al., 2012).
Choose one of these theories and describe how the actors you mentioned above would play a role in the policy process according to this theory
I think the issue of inequalities in the accessibility of dental health services in Australia can be addressed by using the Advocacy coalition approach by Sabtier & Jenkins- Smith. Policies related to access to dental care has always been affected by the varying policy ontologies of different governments. New Governments create new coalitions which impact system wide parameters and also effect the limitations and resources of the actors. There are three factors that affecting the formulation of policy in relation to access of dental care. Firstly, there has been less than appropriate emphasis on evaluation of what works well and why and where required for access to dental care. Secondly, oral health care receives less attention from bureaucracy and policymakers as compared to the burden of other diseases which leads to a poor policy response (Spencer, 2004). Thirdly, social disadvantage is not used as screening criteria for priority access to public general dental care (Kelly, 2014)
The policy subsystem in this case is the public dental health system comprising of several actors like the providers of dental health care, associations, academic researchers, media groups, journalists etc. These actors are aware of the policy issues which are deemed to require attention and can be mobilized to form advocacy coalitions at local, state and national level. Their policy ontologies are aligned and therefore, they can collaborate together to present their arguments. Existing evidence suggests that there is an urgent need for more research on the determinants of oral health inequalities. The academic researchers should therefore, collaborate with the providers and media groups to come up with more evidence based studies and evaluation reports for deriving the attention of policy makers. Extensive Media campaigns can also play a significant role in illustrating problems encountered by people belonging to all disadvantaged groups in access to dental care. The idea is to drive as many as actors (at local, state and national level) possible in their coalition by, well framed evidence based arguments and viable solutions so that they can dominate the discourse with enough partners and win the game.