In a landmark ruling earlier this year, the Bhisho high court ruled that the Eastern Cape Department of Health would not need to make lump sum payments for future medical expenses in medico-legal claims cases. The case involved a mother of a child who was born with severe cerebral palsy and who had turned to the courts for justice, citing medical negligence. The ruling may have provided the government with some relief, considering that medico-legal claims ran up to billions and put a strain on service delivery. That said, one outcome of this case was that the government committed to providing all the healthcare required by the litigants free of charge.

The services would include medical consultations, medication, surgery, and any other healthcare required by the client. Oral health services would be amongst the services that the client would require. 

Oral health is an integral part of general health and well-being and oral diseases disproportionately affect people living with disabilities, especially those that impact neuro-muscular and intellectual functioning. In an earlier piece I wrote, I shared a first-hand account of the difficulty of providing oral healthcare services to patients with intellectual and physical disabilities and placed emphasis on the need for state and private players to make comprehensive oral health services accessible. 

There is a severe shortage of dental specialists and poor access to oral health services across provinces. (Photo: Danjo Paluska / Flickr / Spotlight)

Intersectionality between oral health and disability

While I was lamenting the state of the intersectionality between oral health and disability in South Africa, the Gauteng Health Department has been hard at work with an attempt to build multidisciplinary teams at various “centres of excellence” to respond to the healthcare needs of children with special needs. On 2 April 2023, the Gauteng Department released a media statement highlighting the need for more to be done to care for children with special needs. The department further released the names of more than 20 centres where parents of children with special needs can access a basket of services across the province’s districts. In the statement, oral health services were included. 

In response, the Public Oral Health Forum, a network of public oral health professionals committed to improving state oral health services, released a statement welcoming the Gauteng government’s commitment to integrating oral health services as part of a multi-disciplinary basket of services for children with special needs. However, the Forum was clear on its position regarding several gaps in oral health service delivery for people living with severe disabilities, listing amongst others, the fact that people with severe intellectual disabilities often presented with severe oral disease that was difficult to manage during routine chairside consultation and that oral healthcare was better delivered under general anaesthesia or conscious sedation in these clients.  

Gaps remain

While there is relative access to preventative and promotive oral healthcare services, these do not go far enough to address the vast oral health-related issues that peoplewith disabilities present with. Most of the clients who present with special needs require oral healthcare under general anaesthesia or conscious sedation. These services are scarce to come by in the public sector and if the government is to truly care for the oral health needs of people with special needs, it will have to take bold steps to invest in building the requisite secondary and tertiary oral health service capacity. 

The Gauteng Department of Health remains the biggest investor in government oral health services, as the province houses three of the country’s four oral health centres and has a significant investment in the oral health workforce and services across its health districts. The oral health centres, two in Tshwane and one in Johannesburg are responsible for the training of the majority of our country’s oral health workforce and also provide oral healthcare services, but only one of these has a dedicated special needs unit. 

While this investment by the department should be celebrated, it still has not gone far enough to effectively respond to a rising oral disease burden and more needs to be done, especially in building the requisite capacity for oral health services for people with special needs. 

Despite Gauteng’s attempts to provide these much-needed services, concerns remain that other provinces are not coming to the party to ensure that adequate capacity exists to provide secondary and tertiary-level care to their populations, let alone persons with special needs. In the Eastern Cape, for example, there isn’t a single specialist oral health centre. The province has little to no specialist capacity for a province that is home to approximately 7 million people. Following the court judgement, how will they manage the complex specialist oral healthcare needs of the child if no capacity exists in the state? 

The severe shortage of dental specialists and the poor availability of specialist oral health services is not unique to the Eastern Cape — it is a widespread challenge across many provinces. While many who cannot access this care in the public service look to the private sector, it is important to note that the distribution of these services is also disproportionate with many dental specialists operating predominantly in urban areas, leaving rural provinces to fend for themselves. 

Much still needs to be done to respond to the oral healthcare needs of persons with special needs. While Gauteng seems to be turning its focus to addressing these, questions remain about the commitments of other provincial health departments. After all, oral health has always been a neglected or poorly understood component of general healthcare. Government cannot commit to the management of the complex healthcare needs of persons with special needs without ensuring that the integration of oral healthcare in the multi-disciplinary mix of services is indeed of a standard and quality that improves their quality of life. DM/MC

*Dr Vava is the founder and national organiser of the Public Oral Health Forum, a growing network of public oral health professionals with a commitment to building a better, more dignified public oral healthcare service.

*This article was published by Spotlight – health journalism in the public interest.