Review approach and sources

This narrative review synthesizes evidence from multiple sources to examine oral health policies and initiatives implemented across different health systems over the last five years (2019–2024), analyzing their alignment with principles now formalized in the WHO’s Global Oral Health Action Plan. The review methodology encompassed three main components: analysis of primary policy documents, a focused search of academic literature, and synthesis of expert insights⁹. The primary policy documents included the WHO Global Oral Health Status Report 2022¹, the WHO Global Oral Health Action Plan 2023–2030⁵, national oral health policy documents from selected countries, and regional implementation reports. For academic literature, we conducted searches in PubMed, Scopus, and Global Health databases, covering the period from January 2019 to March 2024. The most recent search was conducted in February 2024. The search was limited to English language publications. The search strategy combined terms related to oral health policy implementation and health system integration. Key search terms included variations of ‘oral health policy’, ‘dental health policy’, ‘health system integration’, ‘policy implementation’, ‘health system reform’, and ‘universal health coverage’. These were combined with country and region-specific terms to capture diverse implementation contexts. Additionally expert insights were drawn from the World Federation of Public Health Associations (WFPHA) webinar on future directions in oral health⁹, which provided expert presentations and regional implementation case studies.

Study selection

Studies and documents were included if they: 1) addressed oral health policy implementation at the population level; 2) focused on health system integration or universal health coverage; 3) reported implementation experiences, outcomes, or challenges; and 4) were published between January 2019 and March 2024. Documents were excluded if they focused solely on clinical interventions without policy context or did not relate to the WHO GOHAP framework principles.

The selection of countries for this review followed a purposive selection approach to capture diverse implementation contexts. Countries were selected to represent all six WHO regions (African Region, Region of the Americas, South-East Asia Region, European Region, Eastern Mediterranean Region, and Western Pacific Region), varied healthcare system typologies (tax-based, hybrid public-private, and market-oriented systems), different resource contexts (high, middle, and low-income settings), and varied stages of oral health policy implementation maturity. This selection strategy enabled analysis of how contextual factors influence policy translation and system-level adaptations across diverse global settings.

Data extraction and narrative synthesis

Two reviewers (GS and SM) independently screened titles and abstracts, with disagreements resolved through discussion. From an initial pool of 147 documents identified through database searches and policy sources, 31 publications and policy documents met the inclusion criteria of this narrative review and were included in the final analysis.

Data extraction focused on: 1) universal coverage approaches and financing mechanisms; 2) primary care integration models and structures; 3) health equity strategies and outcomes; 4) implementation barriers and facilitators; and 5) regional disease burden patterns. Information was systematically extracted into a structured framework aligned with GOHAP priorities.

The analysis employed narrative synthesis methods to identify patterns, themes, and lessons learned across different implementation contexts. Key findings were synthesized across the three main themes of universal coverage approaches, primary care integration models, and health equity strategies, with particular attention to contextual factors affecting policy translation and system-level adaptations. Implementation experiences were analyzed with particular attention to contextual factors affecting policy translation and system-level adaptations, offering insights into approaches that may inform future implementation of the WHO Global Oral Health Action Plan.

The search identified 147 potentially relevant documents, of which 31 met the inclusion criteria and were included in this narrative review. These comprised 18 peer-reviewed articles, 12 policy documents and reports from national governments and WHO, and expert insights from the WFPHA webinar on future directions in oral health⁹. Studies represented all six WHO regions and covered diverse healthcare system contexts including high-income countries (n=15), middle-income countries (n=12), and low-income countries (n=8).

Analysis of oral health initiatives over the last five years reveals diverse approaches across healthcare systems that align with principles now formalized in the WHO’s Global Oral Health Action Plan. These approaches have been shaped by regional disease burdens, existing health infrastructure, and socioeconomic contexts^1,5. This section examines how different regions have addressed oral health challenges, analyzing patterns in disease distribution, universal coverage approaches, primary care integration models, and strategies for addressing health inequities that provide valuable insights for future GOHAP implementation.

Global burden and regional distribution

The distribution of oral disease burden reveals significant regional variations that influence policy implementation approaches (Table 1)¹. Analysis of 2019 data show striking contrasts between prevalence rates and absolute case numbers. For primary teeth, while the Western Pacific region reported the highest prevalence (46.2%), South-East Asia had the largest burden with over 135 million cases despite a moderate prevalence rate of 43.8%. Population demographics, including large youth populations in certain regions, significantly influence the scale of public health challenges and resource allocation requirements¹.

For permanent teeth, the European region demonstrated the highest prevalence (33.6%), while South-East Asia dominated in absolute numbers with more than 525 million cases¹. Temporal analysis between 1990 and 2019 reveals complex patterns of progress. The European region achieved a 7.22% reduction in primary teeth caries prevalence, while population growth in the African region led to an 87.2% increase in absolute case numbers for primary teeth and a striking 119.9% increase for permanent teeth, despite relatively stable prevalence rates. The African and Eastern Mediterranean regions experienced the most dramatic increases in absolute case numbers, with permanent teeth caries cases more than doubling over the study period, underscoring the compound effect of population growth on disease burden¹.

These regional variations and demographic influences highlight the complexity of addressing oral health challenges globally. While some regions have made progress in reducing prevalence rates, population growth continues to increase the absolute burden of oral diseases, particularly in Africa and the Eastern Mediterranean regions where case numbers have more than doubled for permanent teeth over the study period¹.

Universal coverage implementation patterns

Healthcare systems worldwide demonstrate diverse approaches to achieving universal oral health coverage, revealing both innovations in funding mechanisms and persistent challenges in implementation. The experiences of Australia, Canada, and Denmark illustrate how different funding models and policy frameworks shape access to oral healthcare. The Australian system highlights the challenges of divided healthcare responsibilities between state and federal governments, particularly in financing oral health care¹⁰. Most treatment costs are borne by individuals, with around 86% of dental care performed in private practices. In 2020–2021, Australia’s total expenditure on dental services reached AUD11.7 billion, with contributions from individuals (AUD 6.49 billion), insurance funds (AUD 2.24 billion) and government sources (AUD 2.29 billion)^10,11.

In Canada, the public health system (Medicare) provides free medical care to citizens, while most dental care is provided and funded by the private sector¹². The recently introduced Canadian Dental Care Plan provides scaled benefits based on household income, offering 100% coverage for families with incomes below CA$70000, demonstrating a targeted approach to addressing access barriers among vulnerable populations¹³. Denmark’s health financing model is predominantly tax-based, ensuring health services, including oral health, are funded by tax revenues². While the system provides comprehensive coverage for children, adults and the elderly face considerable challenges, with limited coverage excluding essential services. A study of vulnerable Danish adults enrolled in special oral care programs found that 94% had untreated cavities, illustrating how coverage gaps affect health outcomes even in well-resourced systems¹⁴.

Primary care integration models

Integration of oral health into primary care systems shows promising results across different contexts¹⁵. Digital innovations, including teledentistry and electronic records, further enhance this integrated approach¹⁶. Brazil’s National Oral Health Policy demonstrates successful systematic integration through Oral Health Teams within the Family Health Strategy¹⁷. This approach has contributed to improved outcomes, with mean decayed, missing, and filled teeth (DMFT) at the age of 12 years decreasing from 2.8 in 2003 to 1.6 in 2020¹⁸.

Globally, an estimated 514 million children are affected by dental caries in primary teeth (early childhood caries, ECC), with a global prevalence of about 43% ⁵. The Pacific region bears the highest burden worldwide, affecting roughly one in two children¹⁹. In the Cook Islands, community screenings reveal marked disparities: 44% of children in Rarotonga, 47% in Aitutaki, 73% in Mangaia, and nearly 100% in some outer islands²⁰.

Recent research highlights strong community support for breastfeeding but also identifies barriers such as limited perinatal support, inadequate workplace accommodations, and sociocultural pressures that influence early-feeding decisions²¹. In response, the Ministry of Health launched the ‘E Puapinga Katoa Te Nio Tamariki’ (Baby Teeth Matter) program in 2024, which integrates oral health into the first 1000 days through community-based nutrition workshops and parent/caregiver education. The program also emphasizes workforce capacity-building and inter-professional collaboration among medical, nursing, midwifery, and dental teams to strengthen preventive practices and improve early-childhood oral-health outcomes^22,23. This small-island approach illustrates how integration within existing maternal–child health services can advance GOHAP priorities in resource-constrained contexts.

Japan’s ‘8020 Campaign’ exemplifies a life-course approach to integration, incorporating mandatory school-based examinations and preventive care emphasis²⁴. All citizens have dental insurance, with direct costs covered by local governments. Annual dental examinations are mandatory in schools from kindergarten to high school, with school dentists responsible for reporting children’s dental conditions to parents and government referral as necessary²⁵.

Health equity approaches

Implementation experiences reveal persistent challenges in addressing health inequities, particularly in resource-constrained settings. South Africa’s experience, where 85% of the population relies on an underfunded public sector, illustrates how structural inequities impact policy implementation^26,27. The absence of mandated water fluoridation and infrastructure limitations significantly affect caries prevention, particularly in disadvantaged communities^5,28.

China’s response through the Healthy China 2030 plan demonstrates a systematic approach to addressing inequities²⁹. With more than 70% of 5-year-olds affected by tooth decay, initiatives focus on school-based interventions and early prevention. The plan aims to reduce tooth decay prevalence to less than 30% by 2025 through targeted programs, though regional implementation variations persist³⁰.

The United States provides evidence of persistent disparities, despite advanced healthcare infrastructure⁶. Untreated caries affect over 40% of low-income groups, with higher prevalence among Black (36%) and Hispanic (23%) populations³¹. These patterns reflect how social determinants of health, including income, education, and access to preventive services, influence oral health outcomes in different population groups. The emerging strategies focus on expanding essential dental benefits in public insurance programs and integrating oral health services into broader healthcare delivery system³².

The analysis of global oral health policy implementation reveals several important patterns and challenges in translating WHO’s strategic framework into effective local action^1,5. The diversity of implementation approaches across healthcare systems demonstrates both the adaptability of the GOHAP framework and the complexity of addressing oral health needs in different contexts^1,15.

Healthcare financing emerges as a fundamental determinant of implementation success. High-income countries like Australia, Canada, and Denmark, despite having robust healthcare systems, struggle with the dichotomy between universal medical coverage and limited dental care access^11,13,33. The persistence of predominantly private financing for dental services, even in well-resourced systems, creates significant access barriers and perpetuates health inequities³⁴. The Canadian Dental Care Plan’s income-based approach represents an innovative solution, though its effectiveness in reducing access barriers requires further evaluation¹³.

Integration of oral health into primary care demonstrates promising results but requires substantial system adaptation¹⁵. Brazil’s success in reducing DMFT scores through integrated Oral Health Teams suggests that systematic integration can improve outcomes when supported by adequate resources and policy commitment^17,18. Similarly, Japan’s life-course approach, incorporating mandatory school-based examinations and universal insurance coverage, provides evidence that sustained preventive strategies can effectively improve population oral health outcomes^24,25. However, the Cook Islands’ experience highlights how resource constraints influence integration approaches, necessitating creative solutions that leverage existing healthcare structures^19,20.

Digital innovation emerges as a potential enabler of improved care delivery, yet implementation faces various barriers³⁵. While teledentistry and electronic health records show promise for enhancing service integration and access, successful implementation requires addressing infrastructure limitations, professional training needs, and data privacy concerns¹⁶. The varying technological readiness of healthcare systems suggests the need for context-specific digital transformation strategies.

Health equity remains a persistent challenge across all implementation contexts^26,28. The experience of South Africa demonstrates how structural inequities and resource limitations can impede policy implementation, while the United States’ situation reveals how social determinants of health influence outcomes even in advanced healthcare systems^6,31. China’s targeted approach through school-based interventions provides insights into addressing inequities through systematic population-level interventions^30,34.

The analysis reveals several important implementation gaps and priorities for strengthening oral health policy implementation. First, workforce distribution and capacity building emerge as important challenges, particularly in resource-constrained settings³⁶. Second, the integration of oral health with other non-communicable disease programs remains limited, suggesting missed opportunities for synergistic interventions³⁷. Third, data systems for monitoring implementation progress and outcomes show considerable variation, hampering effective policy evaluation and adjustment¹⁶.

Implementation success appears to depend on three key factors. Healthcare systems need sustainable financing mechanisms that reduce reliance on out-of-pocket payments while supporting universal coverage^11,13,33. Digital transformation strategies must consider local technological capabilities and infrastructure limitations^16,36. Integration efforts require careful attention to workforce development and system capacity building³⁶. Evidence suggests that successful translation of WHO’s framework requires balancing universal principles with local healthcare contexts while maintaining focus on core principles of universal coverage and health equity^2,3. The experiences documented across different healthcare systems indicate that achieving GOHAP objectives by 2030 will require strengthened commitment to evidence-based preventive approaches¹, enhanced integration of oral health services with broader healthcare systems¹⁵, and sustained focus on reducing health inequities²⁶. The evidence points to the need for fundamental transformation in how oral healthcare is conceived, delivered, and integrated within population health systems^2,34.

Limitations

This narrative review has several limitations that should be considered when interpreting the findings. As a narrative rather than systematic review, the literature selection process, while purposive and structured, may not have captured all relevant publications on GOHAP implementation. The focus on English-language publications may have excluded relevant implementation experiences reported in other languages. The synthesis of results, given the nature of narrative review methodology, provides valuable information on implementation patterns but cannot establish causal relationships or definitively demonstrate the effectiveness of specific policies. The heterogeneity of contexts, health systems, and data sources across included studies limits direct comparisons between regions. Additionally, as many GOHAP initiatives are in early implementation stages, long-term outcomes and sustained impacts remain to be evaluated. Future systematic reviews with meta-analyses, where feasible, could provide more definitive evidence on specific intervention effectiveness.