Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

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 It has been observed that Indigenous Australians face deprivation to a range of services including primary health care, due to various factors such as cultural barrier, environmental factors and racism. As a result, there was increase in the rate of obesity, overweight, chronic diseases and mortality rate. However, Australian governments have introduced programs that increase the availability of services to rural and remote areas but still Indigenous Australian’s health needs urgent consideration. Therefore, it should be prioritized by the Australian government to provide all the primary health care services to indigenous Australians without any discrimination.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

 

 

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Medical dominance in Australia Within Australia, medicine has traditionally dominated every facet of health care delivery (Germov, 2002; Willis, 1989). The professional status that medicine holds in Australia has been gained by means of its historical and political advantages (Germov, 2002; Willis, 1989). Willis’s (1989) seminal work on medical dominance provides an extensive review of medical relationships and the power that medicine yields. Historically, in Australia, medicine gained its position of political and economic power through its relationship ARTICLE IN PRESS 1064 A. Kenny, S. Duckett / Social Science & Medicine 58 (2004) 1059–1073 with the state (Willis, 1989). 
97). The constraints being imposed by McDonaldization is not only apparent in private medical clinics but also is evident in the rise of managerialismin the public health care system( Clarke, Gerwitz, & McLaughlin, 2000; Clarke & Newman, 1997; Exworthy & Halford, 1999; Germov, 2002; Rhodes, 1991). Deprofessionalization refers to public skepticism to medical authority prompted by such things as medical fraud and negligence (Daniel, 1998; Gabe et al., 1994; Rosenthal, Mulcahy, & LLoyd-Bostock, 1999). It is claimed that medicine is also being deprofessionalized by the public’s increased knowledge and demand for participatory health care (Gabe et al., 1994; Germov, 2002) and by increasing public interest in alternative and complementary therapies (Easthope, 2002; Eisenberg et al., 1998; Ernst & White, 2000; MacLennan, Wilson, & Taylor, 1996; Zolman & Vickers, 1999). Proleterianization refers to ‘a process (rather than an end state) whereby medicine loses control over the context and content of medical care because of the bureaucratisation and corporatisation of health care
If we could grade the social conditions of society from excellent to poor we would find that population oral health status followed precisely the same gradient. Where social conditions are excellent, oral health status tends also to be excellent. Where social conditions are poor, oral health likewise is poor. This is so because the oral health of populations is socially determined. 'Social determinants of oral health: conditions linked to socioeconomic inequalities in oral health in the Australian population' illustrates the social distribution of oral health status in the Australian adult population. It draws links between material, psychosocial and behavioural factors with oral health status. Among adults in the labour force it highlights links between socially produced work conditions and oral health status. It looks back in time to social and psychosocial conditions of childhood and links those experiences with contemporaneous outcomes in adulthood. This thought-provoking publication leaves one wondering to what extent society should help people cope with the social conditions of their lives and to what extent those social conditions themselves should be addressed to improve oral health.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

For over 30 years, the WHO has been advocating an integrated approach in chronic disease prevention. The concept of the common risk factor approach (CRFA) highlighted shared risk factors for chronic conditions including oral diseases has provided the basis for closer integration of oral and general health promotion activities. Although considerable progress has been undoubtedly made in combating the isolation and compartmentalization of oral health, this paper will argue that future action on tackling oral health inequalities requires a reorientation of oral health policy away from a fixation on changing oral health behaviours to instead action on the common social determinants of oral health inequalities. The narrow and restricted interpretation of the CRFA is a serious threat to developing effective action to address oral health inequalities. Based upon the WHO conceptual framework on the social determinants of health inequalities, an overview will be presented of a range of actions that could be implemented to tackle the social gradients in oral health outcomes.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

The next Australian Government will confront major challenges in the funding and delivery of health care. Australia’s health care system ranks well internationally, as reflected in our continuing high average life expectancy and low rate of infant mortality.1 These advances are now under threat as our health system is stretched by an ageing population, the growing burden of chronic illness, and the increasingly outmoded organisation of our health services. Inequalities in health between our most and least advantaged citizens persist, and are the sentinels that remind us that there is no room for complacency, or for inertia in reforming our health care system.

Healthy eating advice therefore aims to promote good health by encouraging all sections of society to make diet choices which are healthier, both nutritionally and in terms of calories consumed versus calories expended.9 Furthermore, healthy eating advice forms the basis for many health improvement interventions proposed by government, government organisations, local authorities, health promotion charities and even supermarket chains  Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Evidence suggests that the public are bored by healthy eating advice and confused by nutritional labelling on food items.13 This may explain why many of the agencies involved with promoting accessible healthy eating advice use colourful and/or cartoon style logos to create interest.4 Examples were included on my poster to highlight the variety and wealth of information available.

In terms of oral health, healthy diet is paramount for prevention of oral diseases such as caries, acid erosion and oral cancers.14 The relationship between diet and oral diseases is dependent on what is consumed and the quantities and frequency of consumption.8Evidence confirms that lower socio-economic groups are consuming a poorer quality diet, but are further subject to poor dental health for a variety of other reasons, such as pollution, smoking, education, access, ethnicity and cost. They are also less likely to be accessing dental services on a regular basis.15 Figure 2 from the poster provides evidence of caries experience in relation to social class in children  Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

The poster provides a brief evaluation of some of the healthy eating research and advice available in relation to oral health, much of which is problematic. For example, there is a wealth of research available relating to the issue of healthy eating in the UK. Using the Google search engine returns almost 1.5 million hits for ‘healthy eating’. However, adding ‘for oral health’ to the search string reduces the number of hits to under 72,000. Moreover, oral health does not always appear to be explicit in the accessible non-dental research available. Furthermore, the term ‘healthy eating’ does not explicitly include drinks, a major source of dietary sugars responsible for both caries and acid erosion.14,17

In addition, there is confusion within areas of health promotion over what is healthy for the body but of risk to oral health and vice versa. For example, dried fruit is considered a low-fat snack, ideal for tackling obesity, but it presents a high caries risk. Conversely, cheese reduces acidity levels in the mouth, contributing to remineralisation and therefore oral health, but it has a high fat content so is not considered good for general health.9This conflict and the implied lower status of oral health are apparent in the government's Change 4 Life campaign. The website recommends cariogenic snacks such as dried fruit and fizzy drinks made with fruit juice and lemonade. Furthermore, none of the advice, health toolkits or ‘Links and Resources’ take account of, or have links with oral health.4Moreover, the Change4Life website is in conflict with the government's Scientific Advisory Committee on Nutrition (SACN) and the FSA. The FSA Manual of nutritionestablishes the links between sugar intake and dental caries.18 However, the information within the FSA website is also contradictory, recommending dried fruit for snacking on the one hand,19 but stating that dried fruit is high in sugar and presents a caries risk on the other  Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Tobacco

Significantly, chewing tobacco is not addressed in healthy eating advice, in spite of evidence that it is used as a dietary treat.9 Betel Nut Quid, Paan or Gutkha are chewing tobaccos which can be combined with vegetable matter and flavoured with spices, citrus fruits and even chocolate. These products are often used by whole families as a snack or to refresh the mouth after a meal, since chewing tobacco is socially acceptable within the Indian culture. As a result, pre-teenage children are presenting with pre-cancerous lesions.22 However, chewing tobacco is referred to only in terms of smoking cessation advice.9 This would suggest that children at risk of developing oral cancers may be missed because they are not representative of traditional tobacco users.

Incorporating trained and knowledgeable DCPs into all aspects of health promotion would ensure that dental risk elements Kentbecome subsumed.

Each of these examples appears to be indicative of the apparently low status of oral health considerations in the area of healthy eating advice. The evaluation highlights the omissions and inconsistencies that surround healthy eating advice to address oral health inequalities. The poster suggests that there are many and varied ways in which DCPs can be involved in addressing these issues.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

The first suggestion is that DCPs must employ an evidence-based approach using reliable guidance.23 Many of the poster recommendations are based on activity in practice, for example, incorporating evidence from the Delivering better oral health toolkit into all dealings with patients in general, community or hospital practice.9 Similarly, training DCPs as formal oral health educators, providing a level of expertise and communication skills to encourage health eating behaviour change in patients.24 Dietary supplements of fluoride, while not considered an effective measure for the majority, may be appropriate for some ‘at-risk’ groups, such as those with pre-disposing medical conditions or other special needs and could be further promoted.14

However, oral health shares common risk factors with other diseases and as such should be recognised as part of the wider public health agenda.3 Therefore, incorporating trained and knowledgeable DCPs into all aspects of health promotion would ensure that dental risk elements become subsumed. Consequently, further suggestions for DCPs involve the wider community and ‘Communities of Practice’ (CoP), where CoP are defined as, ‘Groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly’ Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Maggie (back row, far right) with fellow students studying for the BSc in Primary Dental Care at the University of Kent

Whitehead similarly suggests that interventions should be interconnected across sectors and adopt far wider approaches, to include communities, environment and policy.6 Outreach programmes promoting healthy eating advice for prevention of oral diseases are necessary for capturing those not accessing primary dental care services.15 Furthermore, the oral health agenda would benefit from improved links between Public Health (PH) and Dental Public Health (DPH) practitioners and widespread adoption of a CRFA.3 The poster reinforces the idea of the CRFA by incorporating Sheiham and Watt's visual representation Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

In a time of health system transformation, greater attention is now being paid to access, utilization, and quality of health care and its effects on population health [1]. Similarly, research and case studies highlighting the importance of poverty, the physical environment, and educational attainment among others on health outcomes provide a better understanding of the complex social and structural determinants of health [1]. The landmark 2008 report of the World Health Organization’s (WHO) Commission on Social Determinants of Health [2]and the “The Marmot report” for the UK in 2010 [3] clearly showed evidence for a social gradient in health, which is closely related to the social and economic factors that determine the conditions of daily life. The place in the social hierarchy that individuals and groups occupy, in addition to the environment, then determines exposure to health-enhancing or health-damaging conditions in daily life (e.g., where people are born, grow, live, work, and age) [4••].Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Impacts of social determinants of health (SDH) can be accumulated during a lifetime, alter health trajectories across the life course, and be transferred across generations [5]. Despite acknowledgement that there are multiple sectors that contribute to the SDH, many actions to address these factors have traditionally been generated from the health systems only, excluding the education, economic, and environmental sectors among others. Multisector approaches to reducing the SDH impact [6•] are much needed and dentistry is not an exception.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

The term “social determinants” is relevant to communicable and noncommunicable diseases (NCDs) alike. Oral diseases share the same determinants and risk factors as the main NCDs comprising heart disease, cancer, chronic obstructive pulmonary disease, diabetes, dementia, and stroke. We know many oral diseases is associated with socioeconomic status, which links to family income, educational attainment, employment status, housing, physical health, and mental health. Children and young people in poorer areas have worse general and oral health than those in the more affluent neighborhoods [7]. Current understanding of these associations have prompted the development of a new approach for oral health promotion, which recognizes that the behaviors accounting for the most important NCDs contribute to oral diseases as well. The “Common Risk Factor Approach” (CRFA) is directed to reducing risk factors common to a number of NCDs, [8, 9••] and addresses the SDH from an integrated and comprehensive health care approach. This review presents the most recent studies and evidence on the social determinants of oral health.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Health Disparities and Oral Health

There are significant disparities in oral health worldwide. Oral health disparities are most commonly reported for caries, chronic periodontitis, and cancers of the head and neck, as well as for receipt of preventive dental visits, sealants, tooth loss, and quality of life [10, 11]. Moreover, the increase in dental caries and periodontal disease, particularly among the elderly and children, indicate that the causes of those diseases are not being controlled [11]. Hence, there is an urgent need for oral health policy to emphasize translational research and reinforce public health approaches to tackling the ‘causes of the causes’ addressing common risk factors [8, 9••]. Several definitions of health disparities exist, but they all have a profound connection with the SDH [12], as these health differentials are closely linked with social, economic, and/or environmental disadvantage, and, in some countries, to race, ethnicity and education [4••, 13]. Furthermore, the self-perceived social standing has come up as a significant determinant of health disparities in more recent analyses conducted with data from Australian adults [14].Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Taking into consideration the constellation of proximal and distal determinants of oral health, it has been suggested that population level approaches may be superior to high-risk group identification and targeting, though combinations of both strategies can be most valuable [15, 16]. Actions and efforts addressing “upstream” causes are critical from ethical, human rights, and social justice perspectives. They also confer equitable health promotion benefits in substantial population groups [17] and not only in high-risk groups. The former strategy has failed to reduce the oral disease burden gap between disadvantaged and more affluent groups of the population [15].

Policy and systems change is essential for reducing health disparities and creating communities of opportunity that support good health. Local policy work that is rooted in community partnerships and cross-sector collaborations is a key part of achieving this mission [18]. There is a fundamental need to integrate initiatives to improve oral health with more general interventions to support good physical and mental health. Primary care is the first point of contact with the health service and is the setting in which most general and oral healthcare is provided. Oral health teams have the largely unexploited potential to be important advocates, enablers, and mediators for oral and general health and for the reduction of disparities because the risk factors for oral and general health are the same [7]. Legislative, regulatory, and fiscal policies can be implemented to promote and maintain oral health through creating caring local environments especially in settings such as preschools so that positive and supportive early life experiences are fostered.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Dental Caries

Costa and colleagues [19] recently carried out a systematic review of the relationship between socioeconomic indicators and dental caries and found that, across 41 studies, education, income, occupation, and the Gini coefficient (measure of income or wealth inequality) were associated with higher rates of caries. Along these lines, Bernabé and Hobdell [20] analyzed data from 48 countries and found that, among affluent countries, income inequality may be a stronger determinant of childhood dental caries than is absolute income. In the United States, racial and ethnic disparities are prevalent for a variety of oral health indicators across various age groups, especially for untreated dental caries among children and adolescents. Data from the National Health Nutrition and Examination Survey, 2009-2010 showed that among children aged 3–5 and 6–9 years, untreated caries is significantly higher for those living at or below the federal poverty level compared with those living above the poverty threshold [10]. Early childhood caries continues to be a social, political, behavioral, and medical problem that can be controlled only through understanding the vigorous changes that are taking place in society, particularly those related to the environment such as neighborhood, family structure, nurturing of children, and socioeconomic status [21].Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Periodontal Diseases

Periodontal diseases are highly prevalent, particularly amongst socially disadvantaged populations, impact on quality of life and are costly to treat. Populations generally at risk are characterized by inequity related to factors such as low income, less years of education, and black or mixed color ethnicity [22]. Moreover, these disadvantages might exist among all age groups. The prevalence of adverse periodontal conditions among adolescents has been associated with the color/race, type, and location of school, [23], while a cross sectional study found significant differences in adults’ oral health between welfare state regimes [24]. A study among adults 18-64 years old reported that SDH such as social security and health insurance, low literacy levels, dental care utilization, and other behavioral aspects such as high tobacco consumption were major risk factors for periodontal and other oral diseases among groups with similar socioeconomic status [25]. Furthermore, a longitudinal study among a similar age group reported that level of education, income, and marital status were associated with periodontitis and tooth loss [26]. A distinct social aspect is religiosity. Religiosity has been described as a protective factor against periodontal diseases through extrinsic factors, by higher social support, and intrinsic factors, by higher spirituality pathways [27].Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

 

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Clinical treatments and chair side preventive approaches alone will never adequately address health differentials related to periodontal diseases. Indeed, in many parts of the developing world, clinical care and chair side prevention are both unaffordable and inappropriate for the control of periodontal diseases. A recent review suggested that selling and dispensing such resources as toothbrushes and nicotine replacement therapies at cost price to patients can prevent periodontal diseases among socially disadvantaged groups [28].

A paradigm shift away from the individualized treatment approach to a population public health model is needed to promote periodontal health and, in particular, to address social inequalities in periodontal status. Public health measures need to focus on the underlying determinants of periodontal diseases. Poor hygiene, tobacco use, psychosocial factors, and related systemic diseases are the main risk factors for periodontal diseases. Public health interventions need to tackle these factors but also must recognize and act upon the distal underlying influences that determine and pattern these identified risks globally [28, 29]. Finally, recognition also needs to be placed on the interlinking and common risk factors shared by periodontal diseases and other chronic conditions

Current national goals of public health policy include tackling health inequalities and social determinants of health (SDH). These follow the reports of the WHO Commission on Social Determinants of Health(CSDH) and the Rio Conference on the subject. SDH are the structural determinants and conditions of daily life responsible for a major part of health inequalities between and within countries, consisting of i) social and physical environment, individual behaviors and genetics; and ii) the health care system. The determinants of health and health inequalities, the 'causes of the causes', are socioeconomically patterned.

As the determinants of oral diseases, e.g. unhealthy diet such as excessive intake of sugars, tobacco usage and excessive alcohol consumption, are common to other noncommunicable diseases (NCDs), oral healthcare professionals should be involved in policy making for prevention and control of the determinants of NCDs.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Health inequalities and the increase in oral diseases

There are significant inequalities in oral health worldwide. Moreover, the increase in dental caries and periodontal disease as people get older indicates that the causes of those diseases are not being controlled. Thus there is an urgent need for oral health policy to emphasize translational research and reinforce public health approaches to tackling the ‘causes of the causes’ addressing common risk factors.

The time is now right for developing a new model for oral health promotion, which recognizes that the behaviours accounting for the most important NCDs such as diabetes, cardiovascular disease, certain forms of cancer and respiratory diseases critically contribute to oral diseases as well. This Common Risk Factor Approach (CRFA) is directed to reducing risk factors common to a number of NCDs

  1. Emphasizing the significance of psychosocial determinants of oral health-related behavioor and care-seeking behaviour in whole populations, especially the underprivileged.
  2. Engaging with key partners, in particular WHO and the International Association for Dental Research (IADR), to develop an integrated approach to reduce oral health inequalities globally.
  3. Highlighting oral health inequalities in public debates and the principle of proportionate universality for improvement of health of the underprivileged.
  4. Advocating for the inclusion of oral health with other sectors in all policies, in line with the Adelaide Statement of Health in All Policies. Oral healthcare professionals should engage with leaders and policy-makers of government and NGOs, locally, nationally, regionally and globally.
  5. Adopting the broader Common Risk Approach and building links across general health disciplines, including child health and primary care, to learn from others’ experiences, cross-fertilize ideas and approaches, develop lateral support, maximize lobbying capacity and address common issues, for improving health conditions in general and reducing health inequalities.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper
  6. Calling on FDI National Dental Associations (NDAs) to translate what is known about prevention into practice and to encourage further translational research.
  7. Oral healthcare professionals should be advocates for oral and general health as recommended in FDI’s Vision 2020.
  8. The main priority for oral health interventions should be on collaborative enabling policies and research that address the main determinants of oral diseases, including unhealthy diet like excessive intake of sugars, tobacco usage, excess alcohol consumption, poor hygiene, stress and socio-economic disparities.
  9. Training specialists in dental public health should include competencies in social determinants of health, comprehensive health planning and behavioral change.

Health disparities are differences in health outcomes between socially disadvantaged and advantaged groups. This essay provides a brief review of the voluminous literature on health disparities, with a focus on several major threads including populations of interest, incidence and prevalence of morbidity and mortality, determinants of health, health literacy and health information seeking, media influences on health disparities, and efforts to reduce disparities. Populations of interest tend to be defined primarily by socioeconomic status (income/education), race, ethnicity, and sex or gender; however, differences in sexual orientation, immigrant status, geography, and physical and mental disability are also of concern. Determinants of health can be categorized along a number of dimensions, but common designations consider behavioral, social, and environmental factors that lead to health disparities, as well as differences in access to health care and health services. Of central interest to communication researchers, differences in health literacy and health information seeking are revealed between advantaged and disadvantaged groups. Media influences involve the effects of access or exposure to different kinds of health information on the health behavior and health outcomes of different groups, as well as the effects of health disparity media coverage on public support for initiatives to reduce health disparities. Efforts to reduce health disparities are extensive and involve government and foundation efforts and research-driven interventions.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Taking a broader view, this essay briefly discusses trends in scholarship on health disparities, noting the precipitous increase in academic journal article publications on the topic, including the publication of journals specifically focused on publishing health disparities scholarship. Future directions for research are suggested, and recommendations for interventions to improve health disparities offered by the Principal Investigators of the 10 Centers for Population Health and Health Disparities are presented. Finally, an annotated list of primary sources (books, special issues of journals, reports) and a list of sources for further reading are offered to provide a starting point for beginning scholars to orient themselves to research in health disparities.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Socio-economic inequalities in oral health remain a major challenge for health policy and public health (Marmot and Bell, 2011; Williams, 2011). In particular, the general demographic transition and its impact on oral health (Harford, 2009) have attached special importance to tackling inequalities among elderly generations (Tsakos, 2011). Although the existence of such inequalities has been well-documented for many years (Watt and Sheiham, 1999; Locker, 2000; Gilbert et al., 2003; Sanders et al., 2006; Watt, 2007; Holst, 2008; Tsakos et al., 2009), we still do not comprehensively understand how such inequalities can best be reduced. Strategies for tackling oral health inequalities are increasingly being discussed within the context of a ‘common-risk factor’ approach (Sheiham and Watt, 2000; Sanders et al., 2005), which aims at addressing the joint causes of multiple common diseases, oral health impairment being just one of them (Marshman and Robinson, 2009). Policy areas generally relevant to oral health promotion are use of fluoride, food and health policies to reduce sugar consumption, community approaches to improve body hygiene (including oral cleaning), smoking cessation, policies on reducing accidents, and ensuring access to appropriate preventive care (Sheiham, 1995). In relation to the latter, dental attendance patterns have been proposed as one specific pathway contributing to oral health inequalities (Newton and Bower, 2005). Despite some concern about limited effectiveness of health care interventions (Gulliford, 2009), regular dental attendance has been shown to be associated with better oral health and to be more common among individuals at the upper end of the socio-economic scale (Donaldson et al., 2008).Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

For health-care decision-makers, it is essential to know whether socio-economic disparities in dental attendance among late-middle-aged and elderly generations are readily responsive to contemporaneous institutional arrangements, or whether such disparities rather reflect a continuation of health behaviors acquired in early life. On the one hand, it has been suggested that accessibility features of health care systems, such as health insurance coverage, may be relevant determinants of simultaneous inequalities in health care use (van Doorslaer et al., 2004). On the other hand, the lifecycle approach provides a suitable conceptual framework for explaining a potential perseverance of socially determined dental attendance behaviors throughout the life-course. In particular, it has been proposed that, in the sense of an accumulation of risk model (Kuh and Ben-Shlomo, 2004), children growing up in a social environment in which regular dental attendance is the norm are more likely to adhere closely to a pattern of routine dental visiting in adulthood than peers growing up in settings in which an example is set of problem-oriented dental visiting (Nicolau et al., 2007). Therefore, if socio-economic disparities in adults’ dental attendance primarily reflect a continuation of earlier acquired health behaviors, such inequalities may be relatively unresponsive to contemporaneous health policy interventions.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

A recent paper (Listl, 2011) has documented income-related inequalities in dental service utilization for several elderly generations in Europe. While inequalities were evident for all countries examined, these could not be explained by contemporaneous differences in health care systems. Moreover, the results of another recent study based on the same study population (Listl et al., 2011) are indicative of a potentially large impact of childhood socio-economic status on dental care use in early life. The purpose of the present paper is, therefore, to extend previous work on inequalities in dental service utilization among elderly Europeans by tracking the corresponding socio-economic disparities back into childhood and forward into the further life-course.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

The present study is based on data from waves 1 to 3 of the Survey of Health, Ageing, and Retirement in Europe (SHARE). SHARE represents the first European dataset with detailed cross-national information about health, socio-economic conditions, and family backgrounds of the elderly population. The initial wave of SHARE included 11 countries and was conducted in 2004, followed by wave 2 in 2006-2007, which incorporated three additional countries. Wave 3 (referred to as SHARELIFE) was designed to collect detailed retrospective life-histories during 2008-2009. SHARE data are collected on the basis of computer-assisted personal interviews and self-completed paper & pencil questionnaires. Study participants are representative of the European population aged 50 and over in Scandinavia (Denmark and Sweden), Central Europe (Austria, France, Germany, Switzerland, Belgium, and the Netherlands), and the Mediterranean (Spain, Italy, and Greece), as well as two transition countries (the Czech Republic and Poland). Eligible as study participants are all household members aged 50 yrs and over. A detailed description of the SHARE and SHARELIFE methodology is available in the literature (Börsch-Supan et al., 2008; Schröder, 2008) and on the SHARE Web site (www.share-project.org).Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

SHARELIFE provides retrospective information about regular dental attendance throughout the life-course of 26,525 persons from 13 European countries. Based on the questions (see Appendix for details), a series of variables was constructed for depicting whether respondents had or had not regularly visited a dentist throughout their life history. These are:

  • regular dental attendance between life-years 0 and 15 (childhood);

  • regular dental attendance between life-years 16 and 25;

  • regular dental attendance between life-years 26 and 40;

  • regular dental attendance between life-years 41 and 55;

  • regular dental attendance between life-years 56 and 65;

  • regular dental attendance between life-years 66 and 75;

  • regular dental attendance from life-year 76 onward.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Two frequently applied socio-economic measures are income and education. While SHARE contains information about respondents’ current income at the time of interview, i.e., at age 50+, the information in SHARELIFE about the income situation in earlier life-years is relatively limited. However, SHARE provides detailed information about respondents’ education. Importantly, educational attainment has been shown to have a strong impact on income level (Ashenfelter and Krueger, 1994). In accordance with human capital theory, education provides the skills and knowledge needed in the workplace. The more human capital an individual obtains, the more valuable (s)he is in the labor market, which then results in higher earnings (Mincer, 1958; Schultz, 1961).

In SHARE, respondents were asked about their highest educational attainment upon their first participation in the survey, i.e., either in wave 1 or in wave 2. Thereby, educational attainment was measured according to the International Standard Classification of Education [ISCED] (UNESCO, 1997; see Appendix for the definition of ISCED levels). Using educational attainment as a socio-economic measure is particularly appealing within a lifecycle framework. Its informative content already applies to the age at which education is usually completed, i.e., late adolescence and early adulthood. Moreover, it holds effective throughout the subsequent life-course, particularly due to its strong associations with income (see above). However, ‘educational attainment accomplished’ does not directly apply to socio-economic conditions in childhood and early adolescence.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

There is almost universal agreement that the health care system must focus on prevention and better management of chronic illness.2,3 This will require targeting populations with the greatest need, especially Indigenous communities, establishing better links between primary, acute and rehabilitative services, and developing innovative ways of delivering health care to rural and remote communities. There is little flexibility to do this in a system hamstrung by a focus on fee-for-service and isolated episodes of acute care, growing out-of-pocket costs for patients, and workforce shortages.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Here, we present a number of pressing challenges that will require national leadership. We do not propose solutions here, but we are committed to being part of the search for effective responses to these challenges after the upcoming federal election.

While our list of health challenges confronting an incoming federal government may not be definitive, we believe these challenges must be addressed if Australians are to maintain or improve on present levels of health and wellbeing, have the health services they need when they need them, and be able to participate fully in the workforce and the community.

Changing demography and disease patterns

Our ageing population challenges the ability of health services to maintain health and wellbeing, manage serious and continuing illness, and provide support for the frail and disabled.

The average Australian can expect to live 73 years of healthy life. Actual life expectancy is some 10 years longer, but this longevity is often accompanied by increasing disability from chronic illness.4 Actions taken earlier in life can prevent or mitigate chronic illness, yet preventable chronic illnesses, such as diabetes (Box 1),5 pose a significant and growing burden of mortality, morbidity and health care costs.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

The ageing of the population is not a major contributing factor to rising health costs. The federal Treasury’s intergenerational report for the financial year 2002–03 concluded that “ageing of the population will have only a small effect on spending”.6However, the chronic diseases associated with ageing pose both medical and managerial challenges. Chronic diseases also dominate the long list of health problems experienced by our Indigenous communities.

Preventive initiatives do not reach out effectively to those most at risk, and services for the chronically ill are concentrated in the acute care sector, with suboptimal links to general practice and community care. Coordinating services in the cause of better primary, secondary and tertiary prevention, and better care for patients with serious and continuing illness, some of whom may require support for decades, is hindered by the separate and competing contributions made by the federal and state governments and the private sector to the funding and supply of health services.

The costs of new technology

Much of the rise in health care costs can be attributed to advances in medical technology (Box 2).7 Diagnostic and therapeutic advances, such as new radiological scanners, biological therapeutics, minimally invasive surgical procedures and prostheses, frequently come at a considerable cost. Listing these for subsidy through Medicare or the Pharmaceutical Benefits Scheme (PBS) greatly increases their availability and use, and therefore the cost to the community. Failing to subsidise them inevitably raises questions about why new medical advances are not available to all Australians, and generates political pressure.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

The willingness of doctors and other health professionals to work extended hours has diminished as the health workforce ages, as the proportion of women in the health workforce increases, and as individuals seek to balance work and family life.11 Work, social and educational aspirations of health professionals and their families influence decisions about where to live and practise, and their criteria may not easily be met outside metropolitan areas.

These and other factors have led to problems in the supply and distribution of the health workforce (Box 3).11,12 There are serious shortages of general practitioners, dentists, nurses and some key allied health workers. Shortages are more significant in outer metropolitan, rural and remote regions, especially in Indigenous communities, and in particular areas of care, such as mental health, aged care, and disability care. Overseas-trained doctors now make up 25% of the medical workforce compared with 19% a decade ago.13

’ Conference developed the National Health Workforce Strategic Framework in 2004 to address these issues, but its implementation has faltered because of lack of national leadership and lack of integration across health and education bureaucracies, governments, and public and private training sectors.14

Quality and safety

Medical errors in Australia cost over $1 billion — possibly $2 billion — annually.15 The Quality in Australian Health Care Study found that about half of these errors were potentially preventable.16

Australia has not come to terms with medical error, neither recording its occurrence nor adapting systems from other high-risk industries, such as nuclear power and aviation, to reduce it. Rigid, fault-seeking, blame-allocating cultures are tolerated, even enshrined, in professional hierarchies. There is a new agency for quality and safety, built on a succession of preceding committees and councils, but its effectiveness has yet to be demonstrated (Box 4).17

Australia’s previous Chief Medical Officer* on the Herculean task of improving health care quality and safety17

We do not know whether a decade of quality and safety activity has produced improvements; there are insufficient data at state or national level, in the public or private sector, or for in-hospital or out-of-hospital care.18

The public–private mix in health care funding

Access to health services is becoming less equitable. Patients’ out-of-pocket costs have grown 50% in the past decade19 and now, for some, present a sizeable barrier to needed care.20

Australia has always had a health system that relies on public and private financing and service delivery. This has been presented as a matter of choice. However, the private health insurance surcharge can be seen as unfair by those who live in rural areas where access to private health facilities is limited (Box 5).21

Some areas of surgery are now performed predominantly in the private sector, and the 57% of Australians without private health insurance must wait, often for months, for elective surgery in the public system. This creates an equity challenge where access to care is based on ability to pay rather than need. Specialist surgical training remains concentrated in the public sector, where the caseload is diminishing.

The private health insurance sector is heavily regulated. Premiums for private health insurance are the same for the active and the indolent, the prudent and the profligate. Should this be so? Health funds respond by shifting their bad risks back to the public sector — for example, they do not pay for home renal dialysis and limit payments to specific dialysis centres.

The reinsurance scheme, which evens out the risk to insurance companies irrespective of performance, obliterates incentives for funds to seek out and develop imaginative solutions to chronic disease management and prevention. Innovations linking health services to health service financing are forced to the margins, and flourish in the health management programs of the Department of Veterans’ Affairs. An example is the program to improve hospital discharge planning and prevent hospital readmissions, which is expected to deliver savings of $46.1 million in hospital costs over the next 4 years.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

Addressing modernity’s paradox

Since the beginning of the last century, there has been a dramatic decrease in the mortality rates of babies and children. But after decades of progress, children’s health is under fresh threat from an array of modern conditions that impair their life expectancy and quality of life.

 

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In what is described as “modernity’s paradox”,22 many Australian children are now not as healthy as were children of earlier generations. The responsible afflictions include: low birthweight; rising rates of obesity and diabetes; childhood asthma and other allergies; a range of developmental disorders; autism; and mental health problems including depression, anxiety and behavioural disturbance. There is an increase in learning disabilities, aggressive behaviour and violence. Children living in rural and remote areas and from the lowest socioeconomic groups are particularly at risk.23

Such problems are likely to become more prevalent as these children, impaired through no fault of their own, become adults and parents (Box 6).23

Rapid expansion of the urban Australian population is creating challenges in planning for healthy and sustainable communities.

Increasing urbanisation — especially when there has been little attention paid to the preservation of pedestrian amenities, public safety, access to cheap, fresh food, social cohesiveness and the potential for pollution — is associated with higher rates of obesity, asthma and depression (Box 7).24

This urban challenge, akin to those that initiated the public health movement in the industrial revolution, extends beyond health to jurisdictions of town planning, architecture, commerce and industry. Threats to the global environment and international concerns about the transmission of infectious diseases are perceived with growing clarity in Australia, but the impact of urban design has yet to be appreciated adequately.

Health inequality and concerns with equity

Despite the great improvements in average life expectancy achieved in recent decades, health gains have not been equally shared across the Australian population. Women do better than men; well educated city dwellers in leafy neighbourhoods do better than people living in the bush or less affluent suburbs, the less well educated and the unemployed (Box 8).25 Indigenous Australians live, on average, almost 20 years less than other Australians.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

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).Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper
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.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper
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).Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper
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.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper
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.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

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).Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper

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).Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper
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 Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper
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.Inequalities in the Accessibility of Dental Health Services in Australia Essay Paper