Abstract
Background
Refugee populations face tremendous psychological, financial, and physical health challenges due to traumatic experiences and the stresses of resettlement. Access to oral healthcare represents a significant challenge due to language barriers, cost, and lack of familiarity with the healthcare system. Robust costing analyses are necessary to inform oral health programs tailored to newly landed refugees. The purpose of this study was to estimate the costs associated with delivering the Government Assisted Populations (GAP) oral health program for refugees settling in Nova Scotia, Canada.
Methods
Using a bottom-up micro-costing method, we calculated the yearly direct and indirect costs associated with the delivery of oral health services via the GAP program between 2016 and 2024 from a healthcare system and societal perspectives. Direct costs consisted of the treatments rendered, and the salaries of a program coordinator and two language interpreters. Indirect costs were measured as opportunity costs. The valuation of costs was done according to published professional documents (i.e., Nova Scotia Dental Association suggested fee guide) and the current market values for goods and services. All costs were adjusted to the 2025 Canadian Dollars (CAD).
Results
Data from nine years of the GAP program data (2016–2024) were analyzed. The number of beneficiaries of the program/year rose from 67 patients in 2016 to 187 in 2024. The average annual treatment costs ranged from CAD 191 (SD 73) in 2016 to CAD 1,188 (SD 1,297) in 2024. The average annual productivity losses incurred by patients also rose from CAD 51 (SD 21) in 2016 to CAD 164 (SD 156) in 2024. Except for the first year, during which only hygiene services were administered, unmet needs were highest for restorative (19%-69%), preventive (13%-48%), and oral surgical (1%-10%). Total direct costs of the program ranged from CAD 53,589 in 2016 to CAD 267,622 in 2024. Over the same period, total indirect costs ranged from CAD 3,411 to CAD 30,561.
Conclusions
The GAP oral health program addressed substantial oral healthcare needs among refugees, with costs increasing alongside service demand. These findings provide evidence to inform resource allocation and support equitable, culturally appropriate oral healthcare programs for newly resettled refugee populations.
Keywords: Costing analysis, Health economics, Refugees and newcomers, Humanitarian migrants, Oral healthcare services
Introduction
According to the United Nations Refugee Agency, Canada is one of the world’s leading refugee-hosting countries. From 1980 to 2017, Canada welcomed over one million refugees from around the world [1]. In 2023 alone, Canada received over 140,000 applications, representing a sharp increase from 92,000 in 2022 [2]. The influx of refugees highlights the need for structured, comprehensive, and sustainable programs to address their unmet health needs and to further facilitate resettlement into their new host communities.
Refugees face multiple barriers that hinder resettlement in their new host countries [3, 4]. One major challenge is the high burden of oral disease, compounded by limited or a lack of access to essential oral healthcare services due in part to financial challenges. A recent scoping review reported high levels of dental caries and resulting tooth loss among refugee populations, regardless of other factors such as age, gender, or nationality [5]. The prevalence of dental caries ranged from 4.6% to 98.7%, with a mean number of decayed, missing, and filled teeth (DMFT) index score of 9.2 (SD 2.3). Similarly, gingivitis prevalence ranged from 5.7% to 100% [6–11], with all but one study [11] indicating significantly higher levels of gingival disease among refugee populations compared to their local host populations. Access to essential oral healthcare services is further complicated by multiple stressors faced by refugees during their resettlement process. Financial hardships, limited awareness of available services, language barriers, and high treatment cost are some of the commonly cited reasons for delayed or absent access to care [12].
People with limited or no access to oral healthcare may have unmet oral health needs, causing pain, impaired daily functioning, low self-esteem, and restricted social interactions, all of which reduce their quality of life [13–17]. Children with poor oral health are further impacted as they are more likely to miss school and subsequently perform worse academically [16]. Children with poor oral health are also more likely to experience bullying compared with peers without oral health issues [18]. The consequences of poor oral health can also extend to families. Research indicates that parents of children and adolescents with oral health issues are more likely to take time off work, need more caregiving, feel guilty and stressed, and have disruptions to their daily routines and sleep compared to parents of children without such issues [19, 20]. Additionally, research indicates that periodontal diseases are linked to several systemic conditions such as diabetes, aspiration pneumonia, and certain cardiovascular conditions [21–24].
Ultimately, severe oral disease places a substantial burden on the healthcare system. Limited access to timely oral healthcare results in unnecessary visits to physicians’ offices and hospitals’ emergency department (EDs) for non-traumatic dental conditions (NTDCs). For example, in Ontario, Canada’s most populous province, an estimated annual average of 70,274 physician visits, 51,861 emergency department visits, and 13,889 hospital day-surgery visits are attributed to NTDCs, at a cost of approximately $29 million per year [25]. These costs highlight the financial burden stemming from limited access to basic oral healthcare services.
Refugees and refugee claimants settling in Canada are eligible for the Interim Federal Health Program (IFHP), which covers basic healthcare including emergency care for dental conditions involving pain, infection or trauma, and limited prescription drug coverage until individuals obtain full provincial health insurance [26]. As of May 1, 2026, IFHP introduced a 30% copayment for eligible supplemental health benefits, including dental services [27]. Although the program has provided limited access for many, researchers have identified several shortcomings, including limited awareness of the program benefits, difficulty navigating the system, and inadequate coverage for many required oral healthcare services [26]. Oral health professionals have expressed concerns about gaps in the program’s coverage, noting that covered services prioritize tertiary care with little to no focus on prevention. Additionally, funding allocated for the services is often insufficient to address existing unmet oral health needs.
Despite the significant oral health challenges faced by refugees, to our knowledge there are no cost analyses for programs targeting refugees and newcomers. This gap highlights the pressing need for more contemporary, detailed cost analysis and economic evaluations to better understand what is required to address the oral health needs of refugees in the region. Given finite healthcare resources and competing funding priorities, robust costing analyses are essential to inform evidence-based resource allocation, program planning, and the long-term sustainability of oral health services for refugee populations. Accordingly, the primary objective of this study was to calculate the cost of implementing a comprehensive oral health program from both healthcare system and societal perspectives, with the intent to inform policy. The secondary objectives were to (1) quantify the normative unmet oral health needs in this population and (2) identify trends in the type and nature of services provided between 2016 and 2024.
Methods
Context of the program
For over a decade, the Faculty of Dentistry at Dalhousie University has partnered with the Immigrant Services Association of Nova Scotia (ISANS) to provide oral healthcare services to hundreds of newly arrived refugees in the province through the Government Assisted Populations (GAP) oral health clinic. Individuals who express interest in receiving care are contacted by the program coordinator for enrollment and scheduling of their initial appointment. Following completion of an Initial Comprehensive Exam (ICE), a collaborative treatment plan is developed between the patient and the oral healthcare team consisting of senior dental and dental hygiene students supervised by dental and dental hygiene faculty. The program offers a comprehensive basket of services including diagnostic, preventive, endodontic, surgical, and removable prosthodontic care without a spending cap and frequency limits. However, it does not include fixed prosthodontics, orthodontic treatment (except for minor bracket repairs), and cosmetic procedures. The goal of the program is to provide oral healthcare aimed at eliminating pain, restoring function, introducing the newcomers to oral healthcare in Canada and assisting them in establishing a dental home. Depending on treatment complexity and the extent of needs, services are provided over multiple appointments. Care through the GAP clinic is comparable to that in a conventional dental setting; however, treatments times are longer because they are provided by students under faculty supervision at the Faculty of Dentistry, Dalhousie university, dental clinic. Language interpreters are present for the full duration of each appointment.
Analysis framework
The framework used for this costing-analysis was based on the recommendations by Drummond et al. [28] and Canada’s Drug Agency (CDA) [29]. This involved: 1) identification of relevant costing items; 2) development of tools to measure resources used; and 3) assignment of monetary values using current market estimates. For estimating the value of the resources reported, we used prevailing market prices or closest available substitutes, where applicable. All costs were calculated in 2025 Canadian dollars (CAD), adjusted for inflation using the Consumer Price Index (CPI) and reflected the provincial prices of goods and services in the respective years [30]. These costs data were obtained from official governmental sources, including the Government of Canada job bank, and professional association documents such as the Nova Scotia Dental Association’s (NSDA) suggested fee guide. The costing analysis was conducted over a one-year time horizon, with annual costs estimated separately for each calendar year between 2016 and 2024. To address the primary objective, we identified and monetized the yearly costs associated with the service delivery at the GAP clinic from both healthcare system and societal perspectives using a bottom-up micro-costing approach. We then categorized costs as direct or indirect. Direct costs included those related to the delivery of care, encompassing all diagnostic, preventive, and treatment services rendered at the GAP clinic, as well as personnel costs for one program navigator and two language interpreters involved in service provision. These direct costs were estimated from the healthcare system perspective using the NSDA’s suggested fee guide.
De-identified data were retrieved from the clinical records of patients who received care at the GAP clinic between 2016 and 2024. Data included codes of services provided, dates of service, and the administering provider. The services provided were valued based on the NSDA’s suggested fee guide for the corresponding year, reflecting fees for dental services provided under standard conditions in a conventional private dental office. The program navigator and language interpreters’ salaries were determined using the current service rates reported provided in the Government of Canada Job Bank for Nova Scotia [31].
Indirect costs comprised expenses incurred by service users attributed to care provision, including both cash and in-kind [29]. For indirect costs, we captured opportunity costs, defined as the forgone benefits associated with choosing one alternative over another [32]. Patients attending the GAP clinic forgo time that could otherwise be spent at work, in routine or leisure activities for the duration of the appointment, resulting in productivity losses. Since employment data, wages, and travel times were not collected, total productivity losses were calculated by multiplying the number of appointments required to complete the treatment plan by the provincial minimum wage for the respective year and three hours per appointment (two hours of treatment and one hour of travel). This method follows the recommendations from standard costing methods outlined by Drummond et al. [28] and Krol and Brouwer [33] that suggest using the minimum wage as one of the valuation methods for individuals without paid work (e.g., students, retirees, and the unemployed) or when data is unavailable. That is:
Productivity losses = provincial minimum wage × number of appointments × 3 h (per appointment).
To address the secondary objectives, and in the absence of diagnostic codes, we used the treatments provided as proxies for the patient’s normative unmet oral health needs. Finally, the cost of services provided was aggregated by the year to identify trends and stratified by category of services (i.e., diagnostic, preventive, restorative, etc.), and by the type of provider (i.e., dentist or dental hygienist) to inform future programs about the type of services required for this patient population. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2, Canada) and was approved by the Dalhousie University Research Ethics Board (REB), #2024–7544.
Results
Data from nine years of the GAP clinic (2016–2024 inclusive), were included in this analysis. Table 1 presents the breakdown of program beneficiaries and the total cost of services. A total of 1,078 patients received care at the GAP clinic. The number of beneficiaries increased substantially from 67 patients in 2016 to 187 in 2024, with a temporary decline in 2020 due to the COVID-19 pandemic and associated restrictions on dental care services.
Table 1.
The number of beneficiaries and cost of services rendered
| Year | No. of patients | Service cost Mean (SD) |
Appointments Mean (SD) |
Minimum cost | Maximum cost | Treatment cost (total) | Direct cost (total) | Indirect cost (total) | Program cost (total) |
|---|---|---|---|---|---|---|---|---|---|
| 2016 | 67 | 191 (73) | 1.2 (0.5) | 41 | 293 | 12,576 | 53,589 | 3,411 | 57,000 |
| 2017 | 72 | 308 (366) | 1.5 (1.0) | 34 | 1,517 | 22,148 | 63,732 | 4,316 | 68,048 |
| 2018 | 128 | 625 (790) | 2.9 (2.1) | 32 | 3,652 | 80,174 | 122,774 | 14,075 | 136,849 |
| 2019 | 120 | 945 (1,191) | 3.7 (3.6) | 32 | 5,257 | 113,349 | 156,384 | 18,869 | 175,253 |
| 2020 | 89 | 569 (565) | 2.4 (1.8) | 36 | 2,557 | 51,165 | 94,845 | 9,699 | 104,544 |
| 2021 | 133 | 795 (1,029) | 3.9 (3.7) | 69 | 4,238 | 105,690 | 151,404 | 23,395 | 174,799 |
| 2022 | 128 | 1,098 (1,025) | 4.2 (3.3) | 112 | 4,745 | 130,722 | 179,580 | 23,933 | 203,513 |
| 2023 | 154 | 996 (1,032) | 4.4 (3.4) | 75 | 5,726 | 151,456 | 201,839 | 30,786 | 232,625 |
| 2024 | 188 | 1,188 (1,297) | 3.5 (3.4) | 116 | 9,476 | 216,222 | 267,622 | 30,561 | 298,183 |
All costs were calculated in 2025 Canadian dollars (CAD), adjusted for inflation
Direct costs
The mean (SD) annual cost of treatment per patient ranged from CAD 191 (± 73) in 2016–when services were exclusively (100%) preventive–to CAD 1,188 (± 1,297) in 2024. The mean number of appointments per patient rose from 1.2 (± 0.5) in 2016 to 3.5 (± 3.4) in 2024. As reported in Table 2, total number of service codes increased from 214 in 2016 to 1,326 in 2024. The total annual service cost increased from CAD 12,576 in 2016 to CAD 216,222 in 2024. As shown in Fig. 1, total direct costs ranged from CAD 53,589 in 2016 to CAD 267,622 in 2024 when personnel salaries were included. Aside from the first year where only preventive services were provided, dental students delivered an average of 78% of services and dental hygiene students provided 22%.
Table 2.
The breakdown of services by treatment type and costs
| Diagnostic | Preventive | Restorative | Endodontic | Periodontic | Prosthetic – removable | Prosthetic – fixed | Oral surgery | Orthodontic | Total | |
|---|---|---|---|---|---|---|---|---|---|---|
| 2016 | ||||||||||
| Number of codes (%) | 0 (0.0) | 214 (100.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 214 |
| Cost of services, CAD (%) | 0 (0.0) | 9,822 (100.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 9,822 |
| 2017 | ||||||||||
| Number of codes (%) | 42 (15.7) | 185 (69.3) | 34 (12.7) | 1 (0.4) | 0 (0.0) | 0 (0.0) | 1 (0.4) | 4 (1.5) | 0 (0.0) | 267 |
| Cost of services, CAD (%) | 1,751 (10.0) | 8,865 (50.5) | 5,817 (33.2) | 436 (2.5) | 0 (0.0) | 0 (0.0) | 79 (0.5) | 591 (3.4) | 0 (0.0) | 17,539 |
| 2018 | ||||||||||
| Number of codes (%) | 147 (21.0) | 299 (42.8) | 238 (34.0) | 4 (0.6) | 0 (0.0) | 0 (0.0) | 1 (0.1) | 10 (1.4) | 0 (0.0) | 699 |
| Cost of services, CAD (%) | 4,669 (7.2) | 15,492 (23.8) | 40,550 (62.3) | 2,980 (4.6) | 0 (0.0) | 0 (0.0) | 84 (0.1) | 1,266 (1.9) | 0 (0.0) | 65,041 |
| 2019 | ||||||||||
| Number of codes (%) | 192 (23.4) | 244 (29.8) | 284 (34.6) | 25 (3.0) | 1 (0.1) | 2 (0.2) | 0 (0.0) | 72 (8.8) | 0 (0.0) | 820 |
| Cost of services, CAD (%) | 8,215 (9.2) | 13,396 (15.1) | 45,389 (51.0) | 12,156 (13.7) | 43 (0.0) | 1,084 (1.2) | 0 (0.0) | 8,679 (9.8) | 0 (0.0) | 88,962 |
| 2020 | ||||||||||
| Number of codes (%) | 88 (20.9) | 205 (48.7) | 105 (24.9) | 8 (1.9) | 0 (0.0) | 1 (0.2) | 0 (0.0) | 14 (3.3) | 0 (0.0) | 421 |
| Cost of services, CAD (%) | 5,001 (11.9) | 10,452 (24.8) | 19,742 (46.9) | 4,701 (11.2) | 0 (0.0) | 350 (0.8) | 0 (0.0) | 1,850 (4.4) | 0 (0.0) | 42,096 |
| 2021 | ||||||||||
| Number of codes (%) | 189 (27.0) | 204 (29.1) | 247 (35.2) | 18 (2.6) | 0 (0.0) | 0 (0.0) | 1 (0.1) | 42 (6.0) | 0 (0.0) | 701 |
| Cost of services, CAD (%) | 15,433 (16.5) | 11,846 (12.6) | 48,038 (51.3) | 12,662 (13.5) | 0 (0.0) | 0 (0.0) | 93 (0.1) | 5,651 (6.0) | 0 (0.0) | 93,723 |
| 2022 | ||||||||||
| Number of codes (%) | 134 (18.0) | 156 (20.9) | 360 (48.3) | 10 (1.3) | 2 (0.3) | 6 (0.8) | 0 (0.0) | 78 (10.5) | 0 (0.0) | 746 |
| Cost of services, CAD (%) | 12,437 (10.4) | 9,758 (8.1) | 75,133 (62.7) | 8,981 (7.5) | 193 (0.2) | 2,650 (2.2) | 0 (0.0) | 10,732 (8.9) | 0 (0.0) | 119,884 |
| 2023 | ||||||||||
| Number of codes (%) | 281 (28.6) | 249 (25.4) | 328 (33.4) | 16 (1.6) | 2 (0.2) | 8 (0.8) | 0 (0.0) | 95 (9.7) | 3 (0.3) | 982 |
| Cost of services, CAD (%) | 22,344 (15.7) | 15,742 (11.1) | 69,718 (49.1) | 17,021 (12.0) | 200 (0.1) | 4,567 (3.2) | 0 (0.0) | 11,954 (8.4) | 534 (0.4) | 142,071 |
| 2024 | ||||||||||
| Number of codes (%) | 460 (34.7) | 247 (18.6) | 477 (36.0) | 27 (2.0) | 2 (0.2) | 16 (1.2) | 0 (0.0) | 97 (7.3) | 0 (0.0) | 1326 |
| Cost of services, CAD (%) | 34,510 (16.6) | 15,180 (7.3) | 108,484 (52.0) | 23,221 (11.1) | 730 (0.4) | 10,828 (5.2) | 0 (0.0) | 15,400 (7.4) | 0 (0.0) | 208,353 |
| Average | ||||||||||
| Number of codes (%) | 170 (21.0) | 223 (42.7) | 230 (28.8) | 12 (1.5) | 1 (0.1) | 4 (0.4) | 0 (0.1) | 46 (5.4) | 0 (0.0) | 686 |
| Cost of services, CAD (%) | 11,594 (13.3) | 12,284 (14.1) | 45,875 (52.6) | 8,831 (10.1) | 130 (0.1) | 2,164 (2.5) | 28 (0.1) | 6,236 (7.2) | 59 (0.1) | 87,201 |
Fig. 1.
Panel A: The total direct and indirect costs of the program. Panel B: The average direct and indirect costs per patient
Indirect costs
Average annual indirect costs per patient ranged from CAD 51 (21) in 2016 to 164 (156) in 2024. Correspondingly, total annual productivity losses rose from CAD 3,411 in 2016 to CAD 30,561 in 2024. Overall, indirect costs accounted for 6% of the total cost in 2016 to 13% in 2021 and 2023.
Treatment needs
We observed substantial diagnostic, preventive, and restorative treatment needs within this population. On average, preventive care accounted for 42.7% of all program codes, primarily including services such as periodontal debridement and fluoride treatments, while restorative services represented 28.8%. Diagnostic services comprised 21.0% of identified needs, whereas surgical procedures (5.4%) and endodontic treatments (1.5%) were required less frequently.
Discussion
This study examined the cost of implementing a comprehensive oral health program from both healthcare system and societal perspectives, while also characterizing unmet oral health needs and service delivery patterns over time. To our knowledge, this is the first costing analysis to capture the direct and indirect costs associated with delivering a comprehensive oral health program for refugees in Canada. This analysis provides an overview of the cost and type of services required by refugees settling in Nova Scotia using patient-level data. Average annual treatment costs per patient increased from CAD 191 (73) in 2016 to CAD 1,188 (1,297) in 2024. Similarly, average annual productivity losses incurred by patients rose from CAD 51 (21) in 2016 to CAD 164 (156) in 2024. Overall, total direct and indirect costs increased significantly between 2016 and 2024, by 399% (CAD 53,589 to CAD 267,622) and 796% (CAD 3,411 to CAD 30,561), respectively. These trends reflect both the expansion of the GAP program, but also the growing oral health needs within the refugee population served.
One of the noteworthy findings was the substantial proportion of preventive services, which, excluding the first year (2016), accounted for an average of 36% of all service codes delivered. These services included debridement, sealants, fluoride therapy, and oral health education. This finding is particularly important because, although the IFHP remains in place, its current coverage is largely limited to emergency treatments aimed at managing pain and infection. Access to preventative oral healthcare is essential in minimizing oral health disparities as preventative oral healthcare and early treatment of oral disease have been shown to improve overall oral health status throughout the life course [34]. The limited emphasis on preventive care under the IFHP may contribute to worsening oral health conditions over time, ultimately resulting in a disproportionate increase in the need for more complex and costly restorative and endodontic treatments. In some cases, untreated oral disease may also result in emergency department visits, which may cost approximately CAD 700 per visit (inflation-adjusted from 2012 estimates) [35], or hospitalization, where a single inpatient day may cost up to CAD 2,000 [36].
Overall, we took a conservative approach to cost estimation. For example, productivity losses were calculated using the provincial minimum wage and did not account for additional time costs such as extended appointment durations, caregiving responsibilities, or variability in employment status, which likely resulted in an underestimation of true productivity losses. Another point worth noting is that due to the diversity of the GAP clinic population, more than two language interpreters are usually present during every GAP clinic. Nonetheless, even with the conservative approach to our analysis, interpreter salaries accounted for an average of 11% of the program’s direct costs, underscoring the importance of integrating linguistic competency into the delivery of care. It is well established in the literature that health outcomes improve when patients receive health care in their own language [37–39], highlighting the importance of incorporating professional language interpretation services into programs designed to improve oral healthcare access for this population. Allocating dedicated funding for interpretation services may enhance the effectiveness of such programs by reducing communication barriers and supporting the delivery of linguistically appropriate care. These findings align with the Government of Canada’s announcement of the Oral Health Access Funds (OHAF) aimed to facilitate access to care and support to creation of inclusive and culturally responsive treatment environments [40].
The findings of this study should be interpreted within the context of their intended policy application. The cost estimates were designed to provide a granular assessment of the resources that would be required, on average, to address the oral health needs of this population within a private, fee-for-service model. As such, they should not be interpreted as the costs that would necessarily be incurred under alternative delivery models. Accordingly, the analysis was intentionally limited to costs directly associated with delivering oral healthcare services within an existing dental care infrastructure rather than the full operational costs of establishing and maintaining an oral health clinic. Therefore, dental personnel salaries and capital costs were not included, and cost estimates may vary across provinces. In addition, administrative costs are likely to be substantially higher under large-scale implementation.
Taken together, these findings support several policy recommendations. First, the IFHP reimbursement structure should be reconsidered to place greater emphasis on preventive oral healthcare, rather than primarily covering emergency treatment after disease has progressed. Expanding coverage for preventive services has the potential to reduce the need for more complex and costly interventions while improving long-term oral health outcomes. Second, professional language interpretation services should be recognized as a core component of oral healthcare delivery for refugee populations, with dedicated funding incorporated into program budgets rather than treated as a supplementary service. Addressing both financial and communication barriers is likely to improve access to care, enhance the effectiveness of publicly funded dental programs, and promote more equitable oral health outcomes among refugees.
The GAP Oral Health Clinic was designed as a one-time service initiative addressing the initial oral health needs of refugees in Halifax, the capital city of Nova Scotia, without longitudinal follow-up; consequently, costs associated with ongoing maintenance care could not be captured. From a costing perspective, indirect costs were limited to productivity losses due to data availability, which likely resulted in an underestimation of total indirect costs. Additional expenses such as travel costs and caregiving responsibilities for individuals with dependents–including children, older adults, or individuals with health conditions–were not captured and may represent substantial unmeasured costs, particularly for patients traveling longer distances. Services were delivered by senior dental (years 3 and 4) and dental hygiene (year 2) students, which may have increased the number of appointments required to complete treatment and, in turn, led to an overestimation of productivity losses. However, this effect is likely modest, as students were nearing program completion and provided care under faculty supervision. Finally, although the sample size was relatively small and excluded privately sponsored refugees, and treatment needs were categorized without capturing frequency or severity, this analysis provides an initial system-level estimate of the types and costs of services required to address the oral health needs of newly arrived refugees.
Strengths of this analysis include the use of robust methodological approaches to capture the direct and indirect costs of the program using patient-level data. The granularity of this approach enhances the precision of our cost calculation and allows for a more nuanced understanding of resource utilization. Additionally, the study contributes valuable insights to the limited body of costing analysis in the dental literature, particularly to examine the costs of services required to eliminate pain and infection and restore oral function among newly arrived refugees in Canada, which ultimately will support their successful resettlement. Finally, the findings help with the ability to track trends in types and cost of services over the last nine years of the GAP Oral Health Clinic which will help inform future oral health program planning and policy decisions.
Future directions include capturing the cost of maintaining access to care, as well as changes in oral health, quality of life, healthcare system and other societal outcomes attributed to the program. Moreover, future work should capture other indirect costs related to care such as travel expenses, caregiving, meals and lodging for individuals coming from distant locations. Additionally, expanding the analysis to include other refugee groups would ensure a more comprehensive picture of the costs and needs of this population group.
Conclusion
Refugees encounter significant challenges when resettling in a new country. Delivering oral healthcare within linguistically competent and culturally responsive settings enhances patient experiences and fosters more positive future interactions within the healthcare system over time. An accurate estimation of the direct and indirect costs of comprehensive dental care programs is paramount for planning sustainable oral health programs.
Acknowledgements
We would like to thank Dr. Vickie Armstrong and Ms. Angela Pitman for facilitating data acquisition.
Abbreviations
- ED
Emergency Department
- NTDCs
Non-Traumatic Dental Conditions
- IFHP
Interim Federal Health Program
- ISANS
Immigrant Services Association of Nova Scotia
- GAP
Government Assisted Population
- ICE
Initial Comprehensive Exam
- CDA
Canada’s Drug Agency
- CAD
Canadian Dollars
- CPI
Consumer Price Index
- NSDA
Nova Scotia Dental Association
- REB
Research Ethics Board
- OHAF
Oral Health Access Fund
Author contributions
AG contributed to the conceptualization of the study, acquisition, analysis, and interpretation of data, and drafted the manuscript. KB contributed to the data analysis substantively revised the manuscript. MH contributed to the conceptualization and substantively revised the manuscript. VD contributed to the conceptualization of the study, analysis and interpretation of the data, and substantively revised the manuscript. HD contributed to the conceptualization of the study, analysis and interpretation of the data, and substantively revised the manuscript. All authors read and approved the final manuscript.
Funding
The project was funded by the Dalhousie University, Faculty of Dentistry Research Fund.
Data availability
All data analysed during this study are included in this published article.
Declarations
Ethics approval and consent to participate
Written informed consent permitting the use and secondary use of clinical data for research was obtained from all participants during their clinic visit. Ethics approval was obtained from Dalhousie University, REB, #2024–7544.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data analysed during this study are included in this published article.