Consenting on essential oral health care benefit basket
Authors: Waitzberg Ruth , Durvy Beatrice , Schöner Lukas , Busse Reinhard 
Published: April 2024

Abstract

Introduction

Most countries worldwide cover oral health (OH) only partially within public systems compared to other health services. As a result, OH care can incur financial hardship for those in need and is the second main driver of catastrophic health spending in Europe. Efforts to improve OH coverage and integration into public health systems have gained momentum; however, the lack of consensus on defining ‘essential’ OH and how to set an essential OH benefits basket remains a challenge.

Objectives

This study aims to address these research gaps by conceptualizing what is deemed ‘essential’ in OH care in Europe and exploring criteria and perspectives to inform systematic and evidence-based prioritization mechanisms.

Methods

Study Design: This exploratory qualitative study employs focus group discussions (FGDs) to gather diverse perspectives on essential oral health (OH) services. Ethical approval was obtained from Newcastle University (Ref: 33388/2023).
Participants and Recruitment: Employing a maximum variation sampling strategy, participants were purposefully sampled. We recruited 33 experts in OH, law and health economics from Denmark, Estonia, France, Hungary, Netherlands, Portugal, and the UK, and the 182 members of the general population in Germany and Hungary.
Data Collection and Analysis: Data collection involved open-ended discussions and was conducted in English and French, utilizing a specially developed topic guide. Thematic and content analyses were conducted using ATLAS.ti 22, involving coding, theme development, and category structuring.

Findings

The definition of 'essential' in OH is a fluid and context-specific concept, varying with individual, cultural, socioeconomic, and temporal factors. ‘Essential’ in OH was also associated with Maslow's hierarchy of needs pyramid. A third dimension of ‘essential’ OH is 'good' OH, encompassing both survival functions and psychosocial needs, and recognized the strong link between oral health and general health. Participants highlighted broader factors beyond coverage of OH services, such as the impact of high sugar consumption on oral health. Participants stressed the importance of achieving various goals within the OH system, including equity in access, quality of care, responsiveness, and affordability, to enhance overall oral health outcomes.
When discussing the considerations to define OH coverage, participants recognized the diverse forms an OH benefits basket could take, including positive or negative lists of services, conditions, or population groups. Regarding the decision-making process, interdisciplinary involvement of stakeholders like patient representatives and oral health professionals was deemed crucial, emphasizing evidence-based decision-making. Various criteria for decision-making were mentioned, including contribution to OH, economic factors, people-centered care, societal values, and feasibility, aiming for effective and equitable access to care, while considering resource implications and administrative burdens
Most OH service groups were considered essential, particularly preventive measures, with individual preventive oral services being most frequently labeled 'essential' (n=49). Population-wide and self-care prevention measures followed as the second essential group of services (n=44). Emergency care was also frequently regarded as essential (n=40). Diagnostic oral services, advanced oral healthcare, and treatments for prevalent oral health issues were also considered essential, albeit to a lesser extent. When asked to prioritize population groups for coverage under limited resources, participants favored coverage for ‘everyone’ or coverage ‘based on need’. Children and adolescents were highly prioritized, followed by high-risk patients, older adults, and low-income populations. Notably, no population group was classified as non-essential across all focus group discussions. Cosmetic dental services were seldom seen as essential for specific population groups, except for a few instances linking them to low-income populations.

Conclusions

This work highlights the complexities of defining an OH benefits basket and proposes a four-step model to guide its formulation, emphasizing transparency, evidence-based decision-making, and stakeholder involvement. The study advocates for equitable coverage, particularly for vulnerable populations, reflecting a nuanced understanding of 'essential' OH services, with a consensus on prioritizing preventive measures and urgent care, especially for children.