South Africa is a middle-income country with a population of 46.9 million people [1
], and with a history of massive social and economic inequalities resulting from 45 years of apartheid, which was formally abolished in 1994 [2
]. A reasonably well-established public health system co-exists with a private health sector. Wide disparities in health spending, professional staffing levels and accessibility continue to exist between the public and private health sectors, amid escalating health care costs [3
]. As there are currently no publicly-funded health insurance schemes, the main criterion for access to health insurance and thus to private health care in South Africa is formal employment [4
]. The historically disadvantaged black Africans, who are still more likely than any other race group to be unemployed, continue to be less likely to be insured than Whites in South Africa [5
]. Employers contribute up to two-thirds of an employee’s total monthly health insurance premium as part of a tax deductible benefit [6
]. There are no stand-alone dental insurance plans, but most of the health insurance plans include dental benefits [7
], to a varying extent. However, a visit to a dentist at least once a year for preventive dental care such as dental prophylaxis is covered in most South African health insurance plans and has been recently recommended by the Council for Medical Schemes to be included as part of basic dentistry to be covered under the ‘prescribed minimum benefit’ package, which is recognized by statute in South Africa [8
The use of health services is a function of several factors, which include socio-demographic characteristics such as age, gender, and ethnicity. Other factors include the individual’s means of obtaining the healthcare he or she requires (such as his or her income level and/or being in possession of health insurance), and the perceived need [9
]. Wang and others have demonstrated significantly lowered chances of experiencing a financial barrier to accessing the necessary dental care for children from a low-income family after the implementation of health insurance coverage for eligible children in a US population [10
]. Other studies, mainly from developed countries, have also argued that providing universal insurance coverage increases health service utilization [11
]. Similarly, it has been suggested that since the introduction of “free” primary oral health care in South Africa, the number of dental visits increased by 71% between 1995 and 2002, although such visits are still mainly made to obtain relief from pain and sepsis (symptomatic visits) [13
However, some have suggested that providing universal insurance coverage may not increase dental utilization [14
], and that, even if it did, it may not eliminate disparities in health care utilization [15
]. Considering that addressing social disparities in the use of health services is one of the major justifications for the proposal to introduce National Health Insurance (NHI) in South Africa and that there is only limited empirical evidence of the role that health insurance plays in dental service utilization in South Africa, it is important to evaluate the potential role of health insurance in reducing (if not eliminating) racial disparities in access to preventive dental care in South Africa. Given that a visit to a dental office at least once a year for a check-up and routine professional cleaning has been widely recommended as an effective way to promote oral health [17
], it was the aim of this study to explore socio-economic and racial disparities in preventive dental care utilization, and to quantify the contribution of having a health insurance and the observed racial socio-economic differences in explaining racial disparities in preventive dental visits (PDVs).
This study’s findings demonstrate that there is generally a very low level of routine PDVs in South Africa. Although a significantly higher rate of use was reported among those insured, slightly less than one in five insured South Africans routinely make PDVs. This study also showed that independent of health insurance status, individuals who are of low socio-economic position and are of other racial groups (non-Whites) as compared to Whites were significantly less likely to make PDVs. Furthermore, this study’s findings suggest that addressing racial differences in the socio-economic conditions measured and in health insurance ownership might result in a four-fold increase (i.e.
, a predicted increase from 3.2% to 12.8%) in PDVs by non-Whites, thereby significantly reducing racial disparities in PDVs by about half (i.e.
, from a gap of about 25% to 15%). Nevertheless, the fact that these social determinants also showed direct effects on PDVs further highlights the need to address these potential social determinants of oral health. It has indeed been suggested that the poor are likely to have to forgo food if they were to make a dental visit [20
]. It therefore did not come as a surprise that those with the poorest nutritional status were less likely to make PDVs, particularly in the rural areas
Conceivably, most of this study’s participants’ highest level of educational attainment is likely to have been determined several years before the current survey was carried out. Therefore, the study participants’ levels of educational attainment maybe related to parental socio-economic position, which in turn has been demonstrated to be associated with the level of attendance of dental services by adolescents [27
]. Consequently, the fact that adults with lower levels of educational attainment were less likely to make PDVs, independent of their current material wealth is consistent with the life course theory [28
]. The theory posits that early life events influence later adult health outcomes. In other words, an individual’s disease status or behaviour is a marker of the person’s past social position. Considering that behaviours related to preventive dental care are learnt from childhood, it was not surprising to find that health insurance status did not eliminate the observed disparities associated with educational status. Indeed, experience from the US and France also suggests that patients, particularly those with low educational attainment and low-income, may not necessarily take up the dental care opportunities offered under free, publicly-funded insurance programs [10
The fact that health insurance coverage was not significantly associated with the proportion of those who reported dental problems in the preceding six months, and that particularly those in rural areas who had dental problems were less likely to make routine PDVs, suggest that the potential availability of funds for those with health insurance benefits or the availability of free primary dental care in the publicly-funded dental facilities in these areas was not enough to motivate making PDVs. Indeed, as in several low income countries, the public dental services in South Africa have remained extraction-driven [30
] and opportunities for oral health promotion, such as providing preventive dental care, are missed in very busy and under-staffed publicly-funded clinics [13
]. In general, about two-thirds of South African dental professionals work in private practices and there are much fewer private dental practices in the rural areas than in the urban areas of South Africa [25
]. It is therefore conceivable that even if or when insurance funding is available for private dental care, fewer people would have access to preventive dental care in rural areas.
Although the effect of having health insurance on making PDVs was not as strong among those living in rural areas as the effect on those in urban areas, the availability of health insurance was nevertheless a significant determinant of making PDVs among those in the rural areas. Considering that health insurance is employment-linked, it is possible that those with health insurance who live in rural areas may also be working in small towns, usually not too distant from their place of residence. Therefore, having employment-linked health insurance could provide them with the additional option of visiting private dental practices, which are more likely to be located in these small towns [25
] and are also more likely than the overburdened publicly-funded dental facilities to provide preventive dental care. Nevertheless, considering that most of the effect of racial differences was not explained by differences in the location of the residences of the participants, this study highlights the need for future studies to investigate the direct role of characteristics of where people live on oral health care utilization.
Consistent with findings elsewhere [31
], the fact that most of the White/non-White gap in PDVs was accounted for by racial differences in the distribution of health insurance enrollment suggests that the currently observed racial disparities in PDVs is mostly mediated by racial differences in the level of health insurance coverage. Moreover, consistent with previous observation that health insurance coverage may not eliminate inequities in service utilization [16
], racial differences remained significant after controlling for health insurance status in this study. Although the decomposition analysis suggests that over half of the racial group differences in PDVs is accounted for by the factors considered in this study, about 44% of the White/non-White gap in PDVs remained unaccounted for by the observed characteristics reported in this study. This latter observation suggests that there are perhaps other patient-level or provider-level socio-economic, cultural or environmental factors [32
] that have not been measured in this study but that can explain the observed racial disparities further.
For instance, while the Coloured (those of mixed race) South Africans were more likely than black Africans to have health insurance, the proportion who reported PDVs was not significantly different. This could be related to cultural differences in beliefs on the cause of dental diseases and expectations regarding the benefits of PDVs. Indeed, a previous clinical study among health-insured South Africans demonstrated that differences in the level of education and a combination of the belief in the seriousness of the consequences of dental disease and the expected benefits of PDV significantly differentiated those who were prevention-oriented from those who were symptomatic-oriented in using dental services [33
]. It is pertinent to note that although caries is highest among the Coloured population [34
], a culture of the intentional removal of incisors as a form of dental modification is also predominantly practiced by Coloured South Africans [35
]. It is therefore conceivable that Coloured South Africans, as compared to black Africans, particularly those of low socio-economic status, may be less likely to view the consequences of losing a tooth as being very serious and thus may have lower expectations regarding the benefits or value of PDVs. Furthermore, consistent with the findings of this study, smokers have been shown in other studies to be less likely to make dental visits [23
]. Therefore, the fact that Coloured South Africans have the highest smoking rates [18
] could also partly explain why fewer Coloured South Africans reported PDVs than would have been expected, based on their level of health insurance enrollment, as compared to the level of enrollment among black Africans.
The findings from this study need to be interpreted within the limitations of the study’s design. Firstly, this was a cross-sectional study and therefore inferences on causality need to be made with caution, as there is no evidence of the temporal order of events. Nevertheless, it is likely that the socio-economic variables of race and education preceded dental care utilization. Secondly, the fact that we could not ascertain whether the health insurance coverage held by all those participants who had such coverage included a dental care benefit might explain why some of those who reported having a health insurance do not routinely make PDVs. Nevertheless, it is pertinent to note that most health insurance plans in South Africa include at least one visit to the dentist per year in their cover. However, more recently, some health insurance plans just make available a limited pool of funds that can be used for both out-of-hospital medical and dental care. Conceivably, dental care may be crowded out by medical care demands. Finally, the data presented is dated, and therefore may not represent the current situation. However, given that decreasing coverage of health insurance has been reported [4
], it is less likely that the current situation would be significantly different from what is represented with regard to the role of health insurance. Moreover, this study presents information from the largest survey that could provide the kind of information presented here, given the low level of preventive dental care utilization. Furthermore, we have used the largest and most current nationally representative health survey that is publicly available in South Africa.
Despite this study’s limitations, this study has provided useful information that can inform policy debate and the design of more effective evidence-based interventions to reduce social disparities in preventive dental service utilization, and thus improve the oral health of South Africans.