Special Feature

doi:10.1038/nindia.2017.20 Published online 16 March 2017

Oral health inequalities and health systems in Asia-Pacific: A call for action

[Nature India Special Issue: Oral Health Inequalities and Health Systems in Asia-Pacific]

Marco A Peres1, David S Brennan2, Madhan Balasubramanian3

Marco Peres, David Brennan & Madhan Balasubramanian

Asia-Pacific is home to about half the world’s population. It is a diverse region comprising 38 countries, including the World Health Organ­ization’s Western Pacific and South-East Asian regions. Six coun­tries (Australia, Brunei, Japan, New Zealand, South Korea and Singapore) are high-income; two are low-income (Nepal and North Korea), and rest are clas­sified as middle-income. China, India, Malaysia, Thailand, Indonesia, and the Philippines are among the fastest growing economies in the world. Health is an intrinsic factor in economic development in the region1, and central towards achieving global Sustainable Development Goals2, 3.

Oral health describes the health of the mouth and adjacent structures. Tooth decay,  gum disease and tooth loss rank among the most common con­ditions in the world4. They cause pain, infection, difficulty in eating, and can have a negative impact on quality of life and social functioning. Oral diseases are also linked with other systemic conditions, such as cardiovascular diseas­es5,6. The cost of treating oral diseases account for a large proportion of overall expenditure on health. For example, direct treatment costs of oral diseases were estimated at US$298 billion a year globally, an average of 4.7% of the global health expenditure7.  Even though oral diseases are largely preventable, oral healthcare is a neglected area and given low priority in most systems8.

Oral health inequalities and health systems

In simple terms, oral health inequalities refer to the uneven distribution of oral health or oral health resources amongst the population. Oral diseases dis­proportionately affect the poor and socially disadvantaged, who are have great­er exposure to risk factors and have inadequate access to necessary health services. Denied or delayed access to dental care is influenced by factors such as the availability of practitioners and cost of dental services. Inequalities in oral health are seen both within and across several countries in the Asia-Pa­cific region. The global dental research community has consistently argued that these inequalities are both unfair and unjust and demand the immediate attention or policy-makers9.

A health system comprises all organizations, people and actions whose aim is to promote, restore or maintain health10. Strengthening these systems is fundamental to address oral health inequalities and this include efforts to influence determinants of health as well as more direct health-improving ac­tivities. The six building blocks of health systems include: workforce, service delivery, information; medical/dental products; technologies; financing; and leadership and governance10.

The oral health workforce in the region is primarily made of dentists. Mid-level providers (such as nurses, hygienists and assistants), who could provide a range of preventive services and be more readily available in areas of need, have been neglected in many countries. An appropriate mix of den­tal personnel, together with improved teamwork and collaboration with other health professionals is necessary to address oral health inequalities. Further, dental service and health financing models may require revamping to be more effective at reaching the under-served. In general, health systems research has been minimal, and there is a lack of information and quality evidence from developing countries in the region. Strengthening leadership and governance is necessary to address many health systems challenges in the region.

Purpose of the special issue

This special issue is an effort to address key challenges facing oral health inequalities and health systems in the Asia-Pacific region. We have brought together a group of experts who strengthen the call for action in the region. All the authors are senior academic or policy personnel who have made a sig­nificant contribution to oral health research regionally and globally.

In the first section, we bring together four commentaries that focus on pertinent issues across several countries in the Asia-Pacific region. David Wil­liams and Manu Mathur make a case for including oral disease prevention and control in the broader non-communicable disease framework. Ankur Singh presents an interesting case of social determinants of oral health inequalities while Jun Aida discusses broad challenges facing oral health inequalities in the region. Madhan Balasubramanian, Jennifer Gallagher, Stephanie Short and David Brennan, focus on dentist migration and workforce inequalities in the region.

The second section features country-specific commentaries focussing on seven countries: Australia (by Marco A. Peres & Liana Luzzi), Brunei (by Karen G. Peres, Malissa SY A. Sikun, Paulina KY Lim and Kaye Roberts-Thomson), China (by Edward C. M. Lo), India (Balaji S. Muthiah, Vijay P. Mathur, O. P. Kharbanda & Kunaal Dhingra), New Zealand (by W. Murray Thomson), Papua New Guinea (by Leonard A. Crocombe, Mahmood Siddiqi & Gilbert Kamae) and Vietnam (by Loc Giang Do & Diep Hong Ha). While these are not a com­plete representation, they represent a cross-section – geographically, cultural­ly and economically – to reflect the region’s diversity.

Significance and future implications

There is an urgent demand for collaboration among researchers, policymak­ers, public health practitioners, clinical teams and public, to improve oral health in the Asia-Pacific region. Based on the London Charter for Oral Health Inequalities9, we stress the importance of advocacy on oral health inequalities in the region. We widen the agenda to strengthen essential aspects of health systems in the region, such as dental workforce, service delivery, organisation of care, health financing, governance and leadership.

This call for action aligns with the objectives of research groups, such as the International Association for Dental Research and Global Oral Health In­equalities Research Network and professional groups such as the FDI World Dental Federation.  We also believe that the dental community needs to work more closely with the World Health Organization, so as to develop tangible solutions to address oral health inequalities and health systems strengthening in the region.

We hope that this issue will be informative for policy-makers, and useful for the dental industry, dental schools, health professionals and the general public throughout the Asia-Pacific region.


1Professor of Population Oral Health and Director of the Australian Research Centre for Population Oral Health (ARCPOH), Adelaide Dental School, University of Adelaide, Australia (marco.peres@adelaide.edu.au);  2Professor, ARCPOH, Adelaide Dental School, the University of Adelaide, Australia (david.brennan@adelaide.edu.au);  3Research Associate, ARCPOH, Adelaide Dental School, University of Adelaide, Australia; Honorary Associate, Discipline of Behavioural and Social Sciences in Health, Faculty of Health Sciences, University of Sydney (madhan.balasubramanian@adelaide.edu.au).


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