'At a tipping point': a comparative analysis of oral health coverage for children across six European countries: Denmark, Germany, Hungary, Ireland, Scotland, and Spain

Dental caries remains a significant public health problem for children with continuing calls to incorporate oral health under the Universal Healthcare domain (UHC). However, there is little knowledge on the variations in the coverage, financing, and access to child oral healthcare across Europe. This inter-country comparative analysis provides a detailed description and mapping of publicly funded child oral health coverage across six European countries: Denmark, Germany, Hungary, Ireland, Scotland, and Spain. A multiple case study approach was adopted encompassing two strands of data collection: a documentary analysis and in-depth interviews with experts from each country. The WHO Universal Health Coverage Cube was used to guide data collection and analysis. Two broad models of child oral health coverage were found: those systems adopting 'universal' approaches (Denmark, Germany, Hungary, and Scotland) and those restricting coverage by 'targeting' children by age or where they live (Ireland and Spain). In countries without universal coverage (Ireland and Spain), the private sector assumed a significant role, leading to substantial out-of-pocket expenses for families. This was also evident in Hungary owing to barriers in accessing its publicly funded oral healthcare system. Preventive oral healthcare was also attributed a lower priority in these countries, however a prominent observation across all countries was the necessity for a stronger focus on prevention. Each country with universal oral health coverage (Denmark, Germany, and Scotland) except for Hungary, demonstrated a trend of expanded coverage and regulatory reform achieved using oral health data, political support and engaging the dental profession. While a failure to implement policy and system reform was evident in the remaining countries with the impact of the 2008 economic crisis particularly evident in Ireland and Spain. This research finds that child oral health coverage in some European countries is 'at a tipping point', with recognition of the need for reform evident in Hungary, Spain and Ireland while most 'universal' systems remain on alert to maintaining the broad coverage in place. To maintain and progress UHC for oral health there must be an emphasis on prevention, on addressing inequalities faced by children excluded from care and on advocacy using quality oral health data to engage both dental professionals and political will.