A health systems and policy analysis to inform universal child oral health coverage and Irish oral health reform
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Date
2025
Authors
McAuliffe, Úna
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University College Cork
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Abstract
Background
Oral diseases are among the most prevalent of all non-communicable diseases, with dental caries in children representing a significant public health concern. Access to preventive oral healthcare improves oral health outcomes, yet oral healthcare is often excluded from general health systems and policies. Globally calls are emerging for oral health system and policy reform under the universal health coverage agenda (UHC). However, research on oral health systems and policies remains limited. In Ireland, oral health coverage for the entire population, including children, is restricted, and oral health system reform has historically been minimal. ‘Smile agus Sláinte’ Ireland’s national oral health policy published in 2019, represents the first policy update in over 25 years. A robust evidence base to inform oral health policy implementation and potential system reform is therefore needed.
Aim
The overall aim of this PhD is to carry out a health systems and policy analysis that informs the delivery of oral health reform for children through the implementation of Ireland’s national oral health policy, Smile agus Sláinte, in line with the global policy aim of universal oral health coverage.
Objectives
This thesis had three objectives:
1. To generate an in-depth understanding of the key factors that impeded or promoted the development and implementation of oral health policy in Ireland during the period 1994 to 2021.
2. To provide a detailed description and mapping of publicly funded oral health coverage for children across six European each representative of a different oral health system model, and to report on that coverage in line with the World Health Organisation Coverage Cube.
3. To describe and compare two key oral health ‘indicators’ of child universal oral health coverage, (i) oral disease, specifically dental caries prevalence at age 12 years and (ii) oral health workforce, across the same European countries.
Methods
Three studies were conducted to address the thesis aim and objectives.
Study One involved a detailed oral health policy analysis adopting a case study approach with triangulation, including documentary analysis and semi-structured interviews with elite participants. Data analysis was guided by the Multiple Streams Framework.
Study Two employed an inter-country comparative analysis to describe and map publicly funded oral health coverage for children across six European countries representative of oral health system models (Denmark, Germany, Hungary, Ireland, Scotland and Spain). A multiple case study approach was adopted, combining documentary analysis with in-depth interviews with local experts. The WHO Universal Health Coverage Cube guided data collection and analysis.
Study Three involved a narrative literature review of peer-reviewed and grey literature to assess the two key indicators across the six countries. Data were verified by two local experts per country (n=12).
Results
A strong and persistent finding from this research was the low political priority afforded to oral health in Ireland. This was illustrated by the exclusion of oral health from broader health polices and by repeated non-implementation of evidence, including a national oral health policy. It also contributed to an absence of oral health advocates in positions of influence within the health system, leading to poor visibility for oral health particularly when competing for scarce resources during times of fiscal constraint. This perpetuated a system hallmarked by unequal access to publicly funded oral healthcare for large sectors of the population, including children.
Findings from Study Two identified two clear models of oral health coverage for children across the countries analysed: systems adopting ‘universal’ approaches whereby all children were eligible for almost all care without cost (Denmark, Germany, Scotland, and Hungary) and systems adopting ‘targeted’ approaches, restricting coverage by age and/or geography (Ireland and Spain).
The private sector was found to play a dominant role in ‘targeted’ systems, and, in Hungary owing to difficulties accessing its ‘universal’ system. Most universal systems were characterised by good access to care, prioritisation of prevention utilising a broad oral health workforce, and evidence of effective reform underpinned by political commitment, stakeholder collaboration, and high-quality data.
Study Three expanded upon these findings by examining oral health workforce and dental caries indicators. It revealed significant methodological inconsistencies across the countries studied, underscoring the broader challenges of making meaningful international comparisons between oral healthcare systems. Ireland was found to have the lowest overall ratio of oral health professionals, including dentists and dental hygienists, among the countries studied, highlighting a structural barrier to system reform.
Conclusion
Oral healthcare for children in Europe is ‘at a tipping point’ in 2025 with targeted systems seeking expanded coverage and universal systems remaining ‘alert’ to maintain the coverage they have. In Ireland, progress on implementing ‘Smile agus Sláinte’ has been limited. However, global momentum toward universal oral health coverage, along with Ireland’s broader political commitment to universalism, presents an opportunity for meaningful reform. Advancing UHC for oral health, both globally and nationally, will require a renewed emphasis on prevention, a commitment to addressing inequalities and strategic advocacy underlined by reliable, high-quality data.
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Keywords
Universal health coverage , Oral health , Childhood dental caries , Oral health policy , Health service accessibility , Healthcare reform
Citation
McAuliffe, Ú. M. 2025. A health systems and policy analysis to inform universal child oral health coverage and Irish oral health reform. PhD Thesis, University College Cork.