An ecological study on the association between universal health service coverage index, health expenditures, and early childhood caries

Folayan M.O., Tantawi M.E., Virtanen J.I., Feldens C.A., Rashwan M., Kemoli A.M., Villena R., Al-Batayneh O.B., Amalia R., Gaffar B., Mohebbi S.Z., Arheiam A., Daryanavard H., Vukovic A., Schroth R.J., for the Early Childhood Caries Advocacy Group

Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria; Alexandria University, Alexandria, Egypt; Department of Clinical Dentistry, University of Bergen, Bergen, Norway; Department of Pediatric Dentistry, Univesidade Luterana Do Brasil, Canoas, Brazil; Centre for Oral Bioengineering, Barts and the London, School of Medicine and Dentistry, Queen Mary University of London, Mile End Road, London, E1 4NS, United Kingdom; Department of Conservative Dentistry, Faculty of Dentistry, Alexandria University, Alexandria, Egypt; Department of Paediatric Dentistry and Orthodontics, University of Nairobi, Nairobi, Kenya; Department of Pediatric Dentistry, San Martin de Porres University, Lima, Peru; Department of Preventive Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan; Preventive and Community Dentistry Department, Faculty of Dentistry, Universitas Gadjah Mada Yogyakarta, Yogyakarta, Indonesia; Preventive Dental Sciences Department, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; Research Center for Caries Prevention, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Community Oral Health, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran; Department of Community and Preventive Dentistry, University of Benghazi, Benghazi, Libyan Arab Jamahiriya; Dubai Health Authority, Dubai, United Arab Emirates; Department of Pediatric and Preventive Dentistry, School of Dental Medicine, University of Belgrade, Belgrade, Serbia; Department of Preventive Dental Science, Dr. Gerald Niznick College of Dentistry, and Departments of Pediatrics and Child Health and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada


Background: Universal health care (UHC) may assist families whose children are most prone to early childhood caries (ECC) in accessing dental treatment and prevention. The purpose of this study was to determine the association between UHC, health expenditure and the global prevalence of ECC. Methods: Health expenditure as percentage of gross domestic product, UHC service coverage index, and the percentage of 3–5-year-old children with ECC were compared among countries with various income levels using one-way analysis of variance (ANOVA). Three linear regression models were developed, and each was adjusted for the country income level with the prevalence of ECC in 3–5-year-old children being the dependent variable. In model 1, UHC service coverage index was the independent variable whereas in model 2, the independent variable was the health expenditure as percentage of GDP. Model 3 included both independent variables together. Regression coefficients (B), 95% confidence intervals (CIs), P values, and partial eta squared (ƞ2) as measure of effect size were calculated. Results: Linear regression including both independent factors revealed that health expenditure as percentage of GDP (P < 0.0001) was significantly associated with the percentage of ECC in 3–5-year-old children while UHC service coverage index was not significantly associated with the prevalence of ECC (P = 0.05). Every 1% increase in GDP allocated to health expenditure was associated with a 3.7% lower percentage of children with ECC (B = − 3.71, 95% CI: − 5.51, − 1.91). UHC service coverage index was not associated with the percentage of children with ECC (B = 0.61, 95% CI: − 0.01, 1.23). The impact of health expenditure on the prevalence of ECC was stronger than that of UHC coverage on the prevalence of ECC (ƞ2 = 0.18 vs. 0.05). Conclusions: Higher expenditure on health care may be associated with lower prevalence of ECC and may be a more viable approach to reducing early childhood oral health disparities than UHC alone. The findings suggest that currently, UHC is weakly associated with lower global prevalence of ECC. © 2021, The Author(s).

Early childhood caries; Health expenditure; Universal health coverage


BMC Oral Health

Publisher: BioMed Central Ltd

Volume 21, Issue 1, Art No 126, Page – , Page Count

Journal Link:

doi: 10.1186/s12903-021-01500-8

Issn: 14726831

Type: All Open Access, Gold, Green


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