The healthcare system and the provision of oral healthcare in European Union member states. Part 9: Sweden.

Equally accessible and affordable dental services for all population groups have been a political goal in Sweden for almost a century. All political parties have shared the idea that a person's social background should not have consequences for his or her dental status. Strategic tools to achieve this ambitious goal have been the wide use of publicly provided oral healthcare services, covering even sparsely populated areas, focusing on preventive care and significant subsidies for necessary treatments. Besides free care for children and young adults, oral healthcare is reimbursed from public funds. The public subsidy was particularly generous in 1975-1999 when a 'full clearance' of adults' dentitions was undertaken both by the public and private providers under fixed prices and high reimbursement levels for all treatment measures. Today, preventive oral healthcare for the elderly is given higher priority as most Swedes have been able to keep their natural teeth.

Cost-effectiveness of groin hernia repair from a randomized clinical trial comparing commercial versus low-cost mesh in a low-income country.

BACKGROUND: Over 200 million people worldwide live with groin hernia and 20 million are operated on each year. In resource-scarce settings, the superior surgical technique using a synthetic mesh is not affordable. A low-cost alternative is needed. The objective of this study was to calculate and compare costs and cost-effectiveness of inguinal hernia mesh repair using a low-cost versus a commercial mesh in a rural setting in Uganda. METHODS: This is a cost-effectiveness analysis of a double-blinded RCT comparing outcomes from groin hernia mesh repair using a low-cost mesh and a commercially available mesh. Cost-effectiveness was expressed in US dollars (with euros in parentheses, exchange rate 30 December 2016) per disability-adjusted life-year (DALY) averted and quality-adjusted life-year (QALY) gained. RESULTS: The cost difference resulting from the choice of mesh was $124·7 (€118·1). In the low-cost mesh group, the cost per DALY averted and QALY gained were $16·8 (€15·9) and $7·6 (€7·2) respectively. The corresponding costs were $58·2 (€55·1) and $33·3 (€31·5) in the commercial mesh group. A sensitivity analysis was undertaken including cost variations and different health outcome scenarios. The maximum costs per DALY averted and QALY gained were $148·4 (€140·5) and $84·7 (€80·2) respectively. CONCLUSION: Repair using both meshes was highly cost-effective in the study setting. A potential cost reduction of over $120 (nearly €120) per operation with use of the low-cost mesh is important if the mesh technique is to be made available to the many millions of patients in countries with limited resources. TRIAL REGISTRATION NUMBER: ISRCTN20596933 (http://www.controlled-trials.com).

Prevalence of treated and untreated groin hernia in eastern Uganda.

BACKGROUND: Hernia repair is the most commonly performed general surgical procedure worldwide. The prevalence is poorly described in many areas, and access to surgery may not be met in low- and middle-income countries. The objectives of this study were to investigate the prevalence of groin hernia and the surgical repair rate in a defined sub-Saharan region of Africa. METHODS: A two-part study on hernia prevalence was carried out in eastern Uganda. The first was a population-based prevalence study with 900 randomly selected men in a Health and Demographic Surveillance Site. The second was a prospective facility-based study of all surgical procedures performed in the two hospitals providing surgical care in the region. RESULTS: The overall prevalence of groin hernia (current hernia or scar after groin hernia surgery) in men was 9.4 per cent. Less than one-third of men with a hernia had been operated on. More than half had no pain symptoms. The youngest age group had an overall prevalence of 2.4 per cent, which increased to 7.9 per cent in the age range 35-54 years, and to 37 per cent among those aged 55 years and above. The groin hernia surgery rate at the hospitals investigated was 17 per 100,000 population per year, which corresponds to a surgical correction rate of less than 1 per cent per year. Based on hospital records, a considerable number of patients having surgery for groin hernia were women (20 of 84 patients, 24 per cent). CONCLUSION: Groin hernia is a common condition in men in this east Ugandan cohort and the annual surgical correction rate is low. Investment is needed to increase surgical capacity in this healthcare system.

Coverage and cost of iodized oil capsule distribution in Tanzania.

Distribution of oral iodized oil capsules (IOC) is an important intervention in areas with iodine deficiency disorders (IDD) and low coverage of iodized salt. The mean reported coverage of 57 IOC distribution campaigns from 1986-1994 of people aged 1-45 years in 27 districts of Tanzania was 64% (range 20-96%). This declined over subsequent distribution rounds. However, due to delayed repeat distribution, only 43% of person-time was covered, based on the programme objective of giving two IOC (total 400 mg iodine) at 2-year intervals. Three different capsule distribution strategies used in 20 distribution rounds in 1992-1993 were analyzed in depth. Withdrawal of financial support for district distribution expenses under the 'district team' strategy, and the subsequent change to integrated 'primary health care' distribution, increased delays and capsule wastage. The third, more vertical strategy, 'national and district teams', accomplished rapid distribution of IOC about to expire and subsequently a return to the initial 'district team' allowance strategy was made. Annual cost of 'district team' distribution was 26 cents per person (400 mg iodine/2 years). Cost analysis revealed that the IOC itself accounts for more than 90% of total costs at the levels of coverage achieved. IOC will be important in the elimination of IDD in target areas of severe iodine deficiency and insufficient use of iodized salt, provided that high coverage can be achieved. Campaign distribution of medication with high item cost and long distribution intervals may be more cost-effectively performed if separated from regular PHC services at their present resource level. However, motivating health workers and community leaders to do adequate social mobilization remains crucial even if logistics are vertically organized. Insufficient support of distribution expenses and health education may lead to overall wastage of resources.

PIP: This paper analyzes the experience of using iodized oil capsules (IOCs) in Tanzania as a stopgap measure to control iodine deficiency disorder (IDD) in a target population of 7 million during a 9-year period (1986-94). The article also evaluates the costs and coverages of three different mass distribution strategies used in 1992-93. The assessment revealed that the distribution of oral IOCs was an important intervention in areas with IDD and low coverage of iodized salt. The mean reported coverage of 57 IOC distribution campaigns during 1986-94 of people aged 1-45 years in 27 districts of Tanzania was 64% (range, 20-96%). This declined over subsequent distribution rounds. However, due to delayed repeat distribution, only 43% of person-time was covered, based on the program objective of giving 2 IOCs (total of 400 mg iodine) at 2-year intervals. Further analysis of the 1992-93 data on the three different capsule distribution strategies used in 20 distribution rounds indicates the withdrawal of financial support for district distribution expenses under the "district team" strategy, and the subsequent change to integrated "primary health care" distribution, increased delays and capsule wastage. The third, more vertical strategy "national and district teams", accomplished a rapid distribution of IOCs and subsequently made a return to the initial "district team" allowance strategy. Annual cost of "district team" distribution was 26 cents per person (400 mg iodine per 2 years). Cost analysis revealed that the IOCs themselves account for more than 90% of total costs at the levels of coverage achieved.