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.

Quality assurance of a diarrhoea control programme in northeastern Brazil.

In this study quality assurance methods were used in an evaluation of a programme for Control of Diarrhoeal Diseases (CDD) in northeastern Brazil. Seventy-eight randomly selected public primary care facilities in four states were assessed by trained surveyors. Problems observed in the facilities were lack of information on target population and coverage, lack of equipment to permit rehydration in the premises, and frequent unavailability of trained professionals. Health workers showed deficiencies in history taking, physical examination and knowledge on diarrhoea management. Many caretakers had difficulties in recalling information given to them in the health facilities. Eighty-four percent of the cases were treated with oral rehydration, but 90% were sent home immediately and not kept in the facilities to practice rehydration under guidance as recommended by the national CDD programme. An overuse of the medical treatment was observed. More than two-thirds of health professionals gave wrong indications for use of antibiotics. The study showed that oral rehydration therapy is well established in the government health services in the region but that the CDD programme needs to take early action to correct deficiencies in logistics, case management and health education.

PIP: The 9 states in the northeast of Brazil were divided into 4 groups based on population size and geographical distribution. In the capital cities of each state, 5-8 health units treating children with diarrhea were chosen at random. Overall, 78 health care units were studied. University-trained nurses evaluated each health care unit regarding diarrhea management and conducted interviews using questionnaires for the data collection. The survey team was split into groups of 4, each group covering 1 state. The field-work was carried out in May 1989 and took 4-6 weeks to complete. 88% of facilities surveyed were health centers, while the rest were outpatient departments in hospitals. In 40% of the facilities, the number of monthly consultations of children was known, while only 22% had information on the number of children attending for diarrhea each month. 62% of facilities had a special oral rehydration therapy (ORT) place for children. Utensils for administration of ORT were available in only half of the facilities. In 1/5 of the facilities the sugar-salt-solution packets were never or seldom available. In 32 of 65 facilities, the most recent shipment of ORS packets had arrived in the last month. 10 facilities had not received ORS for more than 6 months. In 67 facilities (86%) a physician, and in 9 a health auxiliary, was responsible for managing childhood diarrhea. 75 visits for childhood diarrhea were observed in 42 health facilities. 58 of the attendances (77%) were managed by doctors, 12 by health auxiliaries, and 5 by nurses. 90% of the patients were sent home, while the rest were treated. In 84% of cases oral rehydration therapy was prescribed, usually oral rehydration salts (ORS). Antimicrobial drugs were prescribed in 21% of the cases. Other drugs like metochlopramide, caolin-pectin, aspirin and vitamins were prescribed in 41% of the cases.

Cross-sectional household surveys of diarrhoeal diseases--a comparison of data from the Control of Diarrhoeal Diseases and Demographic and Health Surveys programmes.

Cross-sectional household surveys are extensively used for data collection, priority setting and programme evaluation in developing countries. They are now being promoted to assess a number of health care interventions such as Control of Diarrhoeal Diseases (CDD), Expanded Programme on Immunization (EPI), AIDS control and child survival programmes. Few field studies of the validity and precision of data generated from these surveys have been carried out, in part because such work is rather demanding of resources. The purpose of this study was to draw conclusions on validity and reliability of data from household surveys through a comparison of results from large-scale surveys on diarrhoea conducted by CDD and Demographic and Health Surveys (DHS) programmes in developing countries. Diarrhoea prevalence and treatment were compared for nine surveys for which little time had passed in between the CDD and DHS survey. The variation in results between the surveys was in many instances too large to be explained only by a true variation in the variable studied. A literature review suggested that validity problems could be due to response and recall errors. The authors caution the use of frequent household surveys for programme impact evaluation. Their cost-effectiveness should be carefully assessed, especially when services' evaluations already have provided evidence that a programme has had a positive effect on the behaviour of health workers and target groups in the community. It is recommended that more research be carried out on how selection and training of surveyors can be improved to make the quality of household surveys in developing countries better.

Costs of diarrhoeal diseases and the savings from a control programme in Cebu, Philippines.

A control of diarrhoeal diseases programme was set up in Cebu Province, Philippines, in 1986. In order to compare the reduction in treatment costs before and after implementation of the programme, and the potential savings to be made from its continuation, we collected data for 1985 and 1989 in 10 health facilities in Cebu. Since the programme's introduction, household expenditures on drugs for diarrhoea cases have decreased by a total of 1.03 million Philippine pesos (P) (US$ 41,200). At the health centre level, the costs of treating diarrhoea cases were close to optimum, but in the district hospitals treatment of inpatients with diarrhoea changed little between 1985 and 1989. This arose because such hospitals were compensated by the central authorities for inpatients but not for outpatients. Potential savings of around US$ 60,000 could have been made, however, had the district hospitals adopted the practices used in the main referral hospital.

PIP: A program to diarrheal diseases was established jn 1986 in Cebu province, Philippines. The authors calculate the reduction in treatment costs over the course of program its continuation. Findings are based upon data collected for 1985 and 1989 in 10 health facilities in Cebu. It is concluded that households expenditures on drugs for diarrhea declined by 1.03 million. Philippine pesos since the program started. Close to optimum costs have been realized for treating diarrhea cases at the health center level, yet the treatment of inpatients with diarrhea in district hospitals changed little over the period. This latter outcome stems from a structure in which hospitals were compensated by central authorities for inpatients, but not for outpatients. Had district hospitals adopted the practices of the main referral hospital, nearly 1.3 million Philippine pesos could have been saved.

Paying for health care : the household perspective

Public health in developing countries are facing serious problems in terms of quality and maintenance. Staff are underpaid and therefore not motivation; equipment is often missing for functioning poorly and drugs are in short supply. The basis for this deplorable development is lack of funds for health. In Sub-Saharan Africa less 5 per cent of government budgets is usually spent on health care. There is therefore an urgent need to find more fund to finance health services