Financing, Coverage and the Structural Gaps in Universal Oral Health Provision for Older Adults: A Cross-Country Review.

Abstract

Objectives: To evaluate health system readiness for UHC for oral health in ageing populations, using a cross-country analysis of eight countries (Japan, India, Colombia, Rwanda, the UK, Nigeria, Australia, Canada). The analysis encompasses health system organisation, financing and service delivery; dental workforce volume and distribution; oral health policies and provisions for older adults; and age-based differences in oral disease burden.

Methods: A narrative review was conducted across eight countries, purposively selected to represent diverse health system financing and governance arrangements using three established health system frameworks, by Böhm et al., Mackintosh et al. and Karan et al. Data were sourced from the WHO Global Oral Health Status Report and supplementary country-specific sources, and findings were organised thematically across four domains. Age-based differences in oral disease burden were quantified using disability-adjusted life years (DALYs) rates per 100 000 population, comparing adults aged ≥ 65 years with those aged < 65 years over the period 2001-2021, with both absolute and relative differences calculated.

Results: Considerable variation in readiness towards achieving UHC for oral health in ageing populations was observed. High-income countries nominally included essential dental services under UHC but often with shallow coverage, significant co-payments and limited rehabilitative services, leading to substantial out-of-pocket spending (notably Australia and Canada). Lower-income countries provided minimal public financing for oral health, leaving most dental care to private out of pocket expenditure (as observed in India and Nigeria). Dental workforce shortages and maldistribution were pronounced in low-resource settings (Rwanda and Nigeria recorded dentist-to-population ratios of approximately 1:57000 and 1:35000 respectively). Few countries had specific policies or programmes targeting oral healthcare for older adults (Japan and the UK). In most countries, adults ≥ 65 years had a higher oral disease burden than younger adults, especially in contexts with lower overall disease levels and greater longevity.

Conclusions: Health systems are largely underprepared to deliver adequate coverage for oral health services for ageing populations. Strengthening financial protection, broadening coverage of preventive and restorative dental services, enhancing workforce capacity and embedding oral health in general health and ageing policies are critical to achieving equitable oral health outcomes for older adults.