Strengthening Governance for Universalising Primary Oral Health Care: Perspectives from Karnataka, India.

Background: Governance is central to health systems, and achieving Universal Health Coverage (UHC) relies on strong, sustainable systems. However, despite UHC's broad health goals, issues like oral health receive inadequate attention, signalling inequity in health systems. In India, oral diseases are rising, yet oral health remains a low political priority, reflecting weak governance and limited state commitment to health equity. This study analysed governance factors within Karnataka's public oral healthcare system through the lens of Siddiqi's health governance assessment framework. Methods: In this exploratory qualitative study, in-depth interviews with twenty stakeholders, including administrators and program implementers, explored enablers and constraints at policy and operational levels. Data analysis was guided by the governance framework developed by Siddiqi and colleagues. Results: The findings indicate that challenges persist while Karnataka's oral health governance benefits from a separate directorate ensuring administrative functionality. These include a lack of strategic vision for oral health, inadequate policy formulation, limited social participation, insufficient budget, workforce shortages, outdated guidelines, and inequitable oral health programs. Power dynamics, particularly with district health officers, further hinder effective governance. The study reveals a siloed approach to oral health with minimal integration into broader health programs. From planning to implementation, weak governance links reflect low political will. Conclusion: Although recent attention has been given to oral health in Karnataka, substantial reforms are necessary. These include appointing oral health personnel at primary health centres, increasing budgets, revising the Indian Public Health Standards to prioritise oral health in primary care, empowering the oral health directorate, and establishing accountability and surveillance systems. Strengthening governance in these areas is essential to advance oral health equity and contribute to UHC goals in Karnataka.