Long term care facilities in England during the COVID-19 pandemic-a scoping review of guidelines, policy and recommendations.

BACKGROUND: The disproportionate effect of COVID-19 on long term care facility (LTCF) residents has highlighted the need for clear, consistent guidance on the management of pandemics in such settings. As research exploring the experiences of LTCFs during the pandemic and the implications of mass hospital discharge, restricting staff movement, and limiting visitation from relatives are emerging, an in-depth review of policies, guidance and recommendations issued during this time could facilitate wider understanding in this area. AIMS: To identify policies, guidance, and recommendations related to LTCF staff and residents, in England issued by the government during the COVID-19 pandemic, developing a timeline of key events and synthesizing the policy aims, recommendations, implementation and intended outcomes. METHOD: A scoping review of publicly available policy documents, guidance, and recommendations related to COVID-19 in LTCFs in England, identified using systematic searches of UK government websites. The main aims, recommendations, implementation and intended outcomes reported in included documents were extracted. Data was analysed using thematic synthesis following a three-stage approach: coding the text, grouping codes into descriptive themes, and development of analytical themes. RESULTS: Thirty-three key policy documents were included in the review. Six areas of recommendations were identified: infection prevention and control, hospital discharge, testing and vaccination, staffing, visitation and continuing routine care. Seven areas of implementation were identified: funding, collaborative working, monitoring and data collection, reducing workload, decision making and leadership, training and technology, and communication. DISCUSSION: LTCFs remain complex settings, and it is imperative that lessons are learned from the experiences during COVID-19 to ensure that future pandemics are managed appropriately. This review has synthesized the policies issued during this time, however, the extent to which such guidance was communicated to LTCFs, and subsequently implemented, in addition to being effective, requires further research. In particular, understanding the secondary effects of such policies and how they can be introduced within the existing challenges inherent to adult social care, need addressing.

The role of governance in shaping health system reform: a case study of the design and implementation of new health regions in Ireland, 2018-2023.

BACKGROUND: Effective governance arrangements are central to the successful functioning of health systems. While the significance of governance as a concept is acknowledged within health systems research, its interplay with health system reform initiatives remains underexplored in the literature. This study focuses on the development of new regional health structures in Ireland in the period 2018-2023, one part of a broader health system reform programme aimed at greater universalism, in order to scrutinise how aspects of governance impact on the reform process, from policy design through to implementation. METHODS: This qualitative, multi-method study draws on document analysis of official documents relevant to the reform process, as well as twelve semi-structured interviews with key informants from across the health sector. Interviews were analysed according to thematic analysis methodology. Conceiving governance as comprising five domains (Transparency, Accountability, Participation, Integrity, Capacity) the research uses the TAPIC framework for health governance as a conceptual starting point and as initial, deductive analytic categories for data analysis. RESULTS: The analysis reveals important lessons for policymakers across the five TAPIC domains of governance. These include deficiencies in accountability arrangements, poor transparency within the system and vis-à-vis external stakeholders and the public, and periods during which a lack of clarity in terms of roles and responsibilities for various process and key decisions related to the reform were identified. Inadequate resourcing of implementation capacity, competing policy visions and changing decision-making arrangements, among others, were found to have originated in and continuously reproduced a lack of trust between key institutional actors. The findings highlight how these challenges can be addressed through strengthening governance arrangements and processes. Importantly, the research reveals the interwoven nature of the five TAPIC dimensions of governance and the need to engage with the complexity and relationality of health system reform processes. CONCLUSIONS: Large scale health system reform is a complex process and its governance presents distinct challenges and opportunities for stakeholders. To understand and be able to address these, and to move beyond formulaic prescriptions, critical analysis of the historical context surrounding the policy reform and the institutional relationships at its core are needed.

Characteristics of the health districts in Italy and their implication in primary health care policies: an analysis of socio-demographic trends.

Introduction: The Health District (HD) is a critical component of Italy's National Health Service, responsible for ensuring Primary Health Care (PHC) services in response to community health needs. The Italian government established a national strategic reform program, the National Recovery and Resilience Plan (PNRR), starting in 2022, with a series of health interventions to reorganize the PHC setting, the main reform being the Ministerial Decree 77/2022 (DM77). Our study aimed to provide a description of socio-demographic data and to assess the correlation between HDs, in order to suggest health intervention priorities in PHC reforms. Materials and methods: We conducted our analysis using a cross-sectional record linkage of data from multiple sources to compare organizational and socio-demographic variables. A dataset was created with each of the 21 Italian Regions' HDs data of population, land area, mean age, ageing index, old-age dependency ratio, birth rate and death rate. The Inland Areas Project data was integrated for a socio-economic perspective. Results: Our study identified comparable groups of HDs, considering demographical, socio-economic and geographical aspects. The study provides a baseline understanding of the Italian situation prior to the implementation of DM77. It also highlights that inhabitants number cannot be the only variable to take into account for the definition of Italian HDs organisation and PHC reform, providing intercorrelated variables that take into account geographic location, demographic data, and socio-economic aspects. Conclusion: By acknowledging the interplay of demographic, socio-economic, and geographic factors, policymakers can tailor interventions to address diverse community needs, ensuring a more effective and equitable PHC system.

California's COVID-19 Vaccine Equity Policy: Cases, Hospitalizations, And Deaths Averted In Affected Communities.

In March 2021, California implemented a vaccine equity policy that prioritized COVID-19 vaccine allocation to communities identified as least advantaged by an area-based socioeconomic measure, the Healthy Places Index. We conducted quasi-experimental and counterfactual analyses to estimate the effect of this policy on COVID-19 vaccination, case, hospitalization, and death rates. Among prioritized communities, vaccination rates increased 28.4 percent after policy implementation. Furthermore, an estimated 160,892 COVID-19 cases, 10,248 hospitalizations, and 679 deaths in the least-advantaged communities were averted by the policy. Despite these improvements, the share of COVID-19 cases, hospitalizations, and deaths in prioritized communities remained elevated. These estimates were robust in sensitivity analyses that tested exchangeability between prioritized communities and those not prioritized by the policy; model specifications; and potential temporal confounders, including prior infections. Correcting for disparities by strategically allocating limited resources to the least-advantaged or most-affected communities can reduce the impacts of COVID-19 and other diseases but might not eliminate health disparities.

Protecting Patients And Society In An Era Of Private Equity Provider Ownership: Challenges And Opportunities For Policy.

Private equity (PE) acquisitions in health care delivery nearly tripled from 2010 to 2020. Despite concerns around clinical and economic implications, policy responses have remained limited. We discuss the US policy landscape around PE ownership, using policies in the European Union for comparison. We present four domains in which policy can be strengthened. First, to improve oversight of acquisitions, policy makers should lower reporting thresholds, review sequential acquisitions that together affect market power, automate reviews with potential denials based on market concentration effects, consider new regulatory mechanisms such as attorney general veto, and increase funding for this work. Second, policy makers should increase the longer-run transparency of PE ownership, including the health care prices garnered by acquired entities. Third, policy makers should protect patients and providers by establishing minimum staffing ratios, spending floors for direct patient care, and limits on layoffs and the sale of real estate after acquisition (forms of "asset stripping"). Finally, policy makers should mitigate risky financial behavior by limiting the amount or proportion of debt used to finance PE acquisitions in health care.

Licensure Policies May Help States Ensure Access To Opioid Use Disorder Medication In Specialty Addiction Treatment.

Despite the devastating toll of the overdose crisis in the United States, many addiction treatment programs do not offer medications for opioid use disorder (MOUD). Several states have incorporated MOUD requirements into their standards for treatment program licensure. This study examined policy officials' and treatment providers' perspectives on the implementation of these policies. During 2020-22, we conducted thirty-one semistructured interviews with forty policy officials and treatment providers in nine states identified through a legal analysis. Of these states, three states required treatment organizations to offer MOUD, and two prohibited organizations from denying admission to people receiving MOUD. Qualitative findings revealed that licensure policies were part of a broader effort to transition the specialty treatment system to a model of care more consistent with medical evidence; states perceived tension between raising quality standards and maintaining adequate treatment capacity; aligning other state policies with MOUD access goals facilitated implementation of the licensure requirement; and measuring compliance was challenging. Licensure may offer states an opportunity to take a more active role in ensuring access to effective treatment.

Differential effect of China's Zero Markup Drug Policy on provider-induced demand in secondary and tertiary hospitals.

Following the marketization of China's health system in the 1980's, the government allowed public hospitals to markup the price of certain medications by 15% to compensate for reduced revenue from government subsidies. This incentivized clinicians to induce patient demand for drugs which resulted in higher patient out-of-pocket payments, higher overall medical expenditure, and poor health outcomes. In 2009, China introduced the Zero Markup Drug Policy (ZMDP) which eliminated the 15% markup. Using Shanghai as a case study, this paper analyzes emerging and existing evidence about the impact of ZMDP on hospital expenditure and revenue across secondary and tertiary public hospitals. We use data from 150 public hospitals across Shanghai to examine changes in hospital expenditure and revenue for various health services following the implementation of ZMDP. Our analysis suggests that, across both secondary and tertiary hospitals, the implementation of ZMDP reduced expenditure on drugs but increased expenditure on medical services, exams, and tests thereby increasing hospital revenue and keeping inpatient and outpatient costs unchanged. Moreover, our analysis suggests that tertiary facilities increased their revenue at a faster rate than secondary facilities, likely due to their ability to prescribe more advanced and, therefore, more costly procedures. While rigorous experimental designs are needed to confirm these findings, it appears that ZMDP has not reduced instances of medical expenditure provoked by provider-induced demand (PID) but rather shifted the effect of PID from one revenue source to another with differential effects in secondary vs. tertiary hospitals. Supplemental policies are likely needed to address PID and reduce patient costs.

Methadone Prescribing Regulation for Opioid Use Disorder in Canada: Evidence for an East-West Policy Divide.

Opioid agonist therapy (OAT) is a key element in the response to opioid-related harms in Canada. In May 2018, Health Canada rescinded the requirement for obtaining a federal exemption for methadone prescribing. This comparative analysis examined provincial OAT policies and policy changes in response to this federal policy change. Policies and changes were regionalized; despite having lower rates of opioid-related harms, eastern provinces had looser regulatory regimes compared with western provinces, which became even looser after the federal policy change. Diverse knowledge and policy networks need to be fostered to bridge this east-west divide in substance use care policy.

An unintended consequence of COVID-19 immunity passports-quasi-experimental evidence of moral hazard observed after implementing the domestic Green Pass policy during the second wave of the COVID-19 pandemic in Italy.

Objectives: Amidst the second wave of the COVID-19 pandemic, Italian policymakers mandated to exhibit evidence of vaccination or immunity (the Green Pass) as a condition to access retail premises and public offices. This study aims to offer evidence, in a quasi-experimental setting, suggesting that an unintended consequence of this policy was the emergence of moral hazard. Methods: Google visit duration data measured the time customers typically spend on retail premises or public offices. A pairwise comparison of median visit time per premise was performed at a six-week interval before and after the introduction of the Green Pass. Results: This study is the first to provide evidence of "ex-post" moral hazard associated with introducing a domestic Green Pass policy. The median visiting time on premises that required digital immunity control significantly increased after introducing the domestic Green Pass policy, contrary to other public premises where access remained free of limitations. The increase in median visit time in premises with faster customer turnaround, such as coffee shops (+49%) and fast-food restaurants (+45%), was lower than the increase observed for fine-dining restaurants (+74%) and pizzerias (+163%). No significant increase in median visit time was observed in premises where the Green Pass was not required, such as food supermarkets, retail non-food shops, post offices, banks, pharmacies, and gas stations. Conclusion: The evidence of moral hazard highlights the critical issue of unintended consequences stemming from public health policies. This discovery is pivotal for policymakers, indicating that unforeseen behavioral adjustments could offset the intended benefits despite the intent to reduce risk through measures like the Green Pass.

China's policies: post-COVID-19 challenges for the older population.

On 7 December 2022, the State Council of China released 'Measures to Further Optimize the Implementation of the Prevention and Control of the New Coronavirus Epidemic'. The previous three-year dynamic zero epidemic prevention policy was then replaced with a full liberalization policy. On 5 May 2023, the World Health Organization declared that COVID-19 no longer constituted a 'public health emergency of international concern.' However, given the ongoing prevalence of coronavirus, emerging mutations, and the liberalization of restrictions, there are increased risks of vulnerable people contracting new variants. Low vaccination coverage among older people with compromised immune systems, puts them at further risk. The policy shift will increase pressure on already stretched health infrastructure and medical resources. This short article adds to the current debate arguing that the Chinese government should take commensurate preventive measures, including strengthening medical facilities and equipment and targeting ongoing vaccination in older people.

Paper ContextThe COVID-19 pandemic has disproportionately affected older people.This short paper discusses the consequences of China's liberalization policy on the older population.It suggests that the Chinese government should have taken targeted measures to mitigate health risks occurring under the changed circumstances.

The 988 suicide hotline-Lifeline or letdown? A pre-post policy analysis.

Suicide has emerged as an urgent threat in recent years as COVID-19 impaired the health and economic wellbeing of millions of Americans. According to the Centers for Disease Control and Prevention, the impact of COVID-19 and the ongoing opioid epidemic has "taken a mental, emotional, physical, and economic toll on individuals, families, and communities," increasing the need for innovative solutions to prevent suicide on a national scale. The National Suicide Hotline Designation Act of 2020 established 988 as the universal telephone number for suicide prevention and represents a key federal intervention to address this crisis. However, research on 9-8-8's effectiveness is limited, given the Act's recent enactment and implementation at the federal and state levels. This policy analysis investigates how and to what extent the mental health crisis system in Georgia has improved since the implementation of the 2020 Act as well as the implications of state law on population-level mental health outcomes. Georgia is used as a nationally representative case study for two reasons: (1) Georgia had a robust statewide suicide hotline prior to 2020, providing solid infrastructure on which federal expansion of a suicide hotline number could be built, and (2) the conflicting characteristics of Georgia's mental health system represent several different pockets of the U.S., allowing this analysis to apply to a broad range of states and locales. The paper draws on takeaways from Georgia to propose state and national policy recommendations for equitable interventions to prevent and respond to this form of violence.

Global smoking-related deaths averted due to MPOWER policies implemented at the highest level between 2007 and 2020.

BACKGROUND: In response to the harm caused by tobacco use worldwide, the World Health Organization (WHO) World Health Assembly actioned the WHO Framework Convention on Tobacco Control (FCTC) in 2005. To help countries meet their FCTC obligations, the WHO introduced in 2008 the MPOWER policy package and by 2020 the FCTC had been ratified by 182 parties. The package consists of six evidence-based demand reduction smoking cessation policies to assist countries to achieve best practice. We used published evaluation results and replicated the published model to estimate current policy achievement and demonstrate the impact and equity of the MPOWER policy package in reducing the global number of smokers and smoking-attributable deaths (SADs) between 2007 and 2020. METHODS: We replicated an evaluation model (the Abridged SimSmoke model) used previously for country impact assessments and validated our replicated reduction in SADs for policies between 2014 and 2016 against the published results. The replicated model was then applied to report on the country level SADs averted from achieving the highest level of implementation, that is best practice in MPOWER policies, between 2016 and 2020. The latest results were then combined with past published results to estimate the reduction in SADs since the commencement of the MPOWER policy package. Country level income status was used to investigate the equity in the uptake of MPOWER policies worldwide. RESULTS: Identical estimates for SADs in 41 out of 56 MPOWER policies implemented in 43 countries suggested good agreement in the model replication. The replicated model overestimated the reduction in SADs by 159,800 (1.5%) out of a total of 10.5 million SADs with three countries contributing to the majority of this replication discrepancy. Updated analysis estimated a reduction of 8.57 million smokers and 3.37 million SADs between 2016 and 2020. Between 2007 and 2020, 136 countries had adopted and maintained at least one MPOWER policy at the highest level which was associated with a reduction in 81.0 million smokers and 28.3 million SADs. Seventy five percent of this reduction was in middle income countries, 20% in high income and less than 5% in low income countries. CONCLUSIONS: Considerable progress has been made by MPOWER policies to reduce the prevalence of smokers globally. However, there is inequality in the implementation and maintenance, reach and influence, and the number of SADs averted. Future research to modify the model could provide a more comprehensive evaluation of past and future progress in tobacco control policies, worldwide.

Factors affecting major depression in Iran: a mixed-method study.

Depression is a major cause of disability and, if left untreated, can increase the risk of suicide. Evidence on the determinants of depression is incomplete, making it challenging to interpret results across studies. This study aims to identify the social, economic, environmental, political, and technological factors influencing the great recession in Iran. The study was conducted in two parts. The first step involved a literature review to identify the factors, using PubMed, Scopus, and Web of Science for the search. The reference lists of all identified articles were reviewed to find relevant studies, and the extracted information was summarized and reported descriptively. The second steps involved compiling and consulting 14 experts from different fields, using a framework analysis method. Twenty-four articles were used as primary sources of information, and a total of 28 factors were found to exist. After removing duplicates and related factors, 19 of these were subsequently declared as factors, resulting in a total of 36 determinants being identified. Most of these factors belong to the social category. The health policies implemented have a significant impact on disease risk factors and ultimately their occurrence. Political decisions and policy-making processes play a crucial role in all areas, particularly in addressing disease risk factors. Severe depression can disrupt all aspects of the healthcare system, underscoring the importance of access to care. Policies concerning physical education, transportation, nutrition, employment, green spaces, recreational facilities, and tobacco are vital in this context. The influence of health policies on disease risk factors and disease occurrence is profound. Severe depression can have far-reaching effects on the healthcare system, emphasizing the critical need for access to care. The formulation of policies to combat depression must be thoroughly evaluated in terms of economic, political, social, technological, and environmental factors. The findings suggest that addressing social inequalities and emphasizing the role of political action, as highlighted by the social determinants of health, should be top priorities in addressing depression. Efforts to prevent depression should incorporate ecological approaches that consider the impact of the socioeconomic environment on depressive symptoms.

Colorectal cancer prevention in Central, Eastern European and South Caucasus countries: a review of policy approaches.

PURPOSE: This study aims to examine the availability and comprehensiveness of policies pertaining to colorectal cancer (CRC) in Central, Eastern European and South Caucasus countries, as it is a major public health concern in these regions and the second most common cause of cancer deaths among women. DESIGN/METHODOLOGY/APPROACH: We performed a scoping review using the Arksey and O'Malley methodology, searching for publicly available policy documents from 18 countries. We described the prevention methods and activities in each country based on the World Health Organization guidelines for CRC screening. FINDINGS: Our research found that most countries had at least five policies related to CRC prevention, which most commonly included primary, secondary and tertiary prevention measures. Elements such as promoting healthy lifestyle choices and implementing screening methods such as fecal occult blood tests, fecal immunochemical tests or colonoscopy were frequently mentioned in these policies. However, target age ranges varied among countries. Our analysis revealed a pressing need to increase the availability and utilization of CRC screening in these countries. RESEARCH LIMITATIONS/IMPLICATIONS: One of the main limitations of this study is that it is a desk review conducted using internet-based resources, which may have missed important sources or recent policy documents that are not yet available online. Despite our efforts to include all relevant policies, it is possible that we overlooked other policies that contain relevant information, such as those that cover cancer treatment methods. Additionally, our search excluded primary healthcare and universal healthcare coverage policies, which could include important information on CRC prevention and control activities. Additionally, as a scoping review approach was used, no critical assessment of the included studies or literature was conducted. Furthermore, due to the limited number of countries included, the comparability of the findings is limited. In future research, it would be beneficial to expand the study and collect new data from decision-makers and stakeholders to further investigate these hypotheses. It is also important to note that the presence of a policy document is not the end goal, as it is simply a step toward better outcomes. PRACTICAL IMPLICATIONS: In summary, our research highlights the need for improved and unified efforts toward preventing and detecting CRC in Central, Eastern European and South Caucasus countries. This knowledge can be used to focus efforts on developing a standardized policy document and national screening program that can be adapted to meet the unique needs of each country. The importance of CRC screening, regardless of need, must be emphasized in order to aid in the transition from curative to preventive cancer care. Our study highlights the need for more detailed and science-based policies for CRC prevention and screening in Central, Eastern European and South Caucasus countries. While many countries have policies in place, they often lack key components and do not fully reflect current evidence-based guidelines. To improve population health outcomes, further research is needed to understand the implementation and enforcement of these policies as well as their impact on cancer incidence and survival. As the screening landscape evolves, countries may learn from each other and a better understanding of the complex policy frameworks that impact CRC screening is needed so that countries can update and tailor policy documents to their specific situations. SOCIAL IMPLICATIONS: In conclusion, policymakers in Central, Eastern European and South Caucasus countries have implemented various policy approaches to prevent and control the CRC. The effectiveness of these approaches varies across countries and depends on several factors, including the availability of resources, the level of public awareness and the political will to implement effective policies. Further research is needed to determine the most effective policy approaches for CRC prevention in these regions and to ensure that the right policies are in place to reduce the incidence and impact of this disease. ORIGINALITY/VALUE: The study aimed to identify gaps in existing research and areas for future work by mapping, categorizing and organizing existing evidence on CRC policies in Central, Eastern European and South Caucasus countries. Additional research is necessary to understand the implementation and enforcement of these policies and how they impact health outcomes such as cancer incidence and survival. HIGHLIGHTS: CRC policy is heterogeneous in Central and Eastern Europe and the South Caucasus region.There are particularly important differences regarding the implementation of CRC screening.Cancer screening and palliative care approaches were less frequently included.Variations exist in the comprehensiveness of policy by prevention level and country.

Policies for expanding family planning coverage: lessons from five successful countries.

Background: Enhancing the design of family planning interventions is crucial for promoting gender equality and improving maternal and child health outcomes. We identified, critically appraised, and synthesized policies and strategies from five selected countries that successfully increased family planning coverage. Methods: We conducted a policy analysis through a scoping review and document search, focusing on documents published from 1950 to 2023 that examined or assessed policies aimed at enhancing family planning coverage in Brazil, Ecuador, Egypt, Ethiopia, and Rwanda. A search was conducted through PubMed, SCOPUS, and Web of Science. Government documents and conference proceedings were also critically analyzed. National health surveys were analyzed to estimate time trends in demand for family planning satisfied by modern methods (mDFPS) at the national level and by wealth. Changes in the method mix were also assessed. The findings of the studies were presented in a narrative synthesis. Findings: We selected 231 studies, in which 196 policies were identified. All countries started to endorse family planning in the 1960s, with the number of identified policies ranging between 21 in Ecuador and 52 in Ethiopia. Most of the policies exclusively targeted women and were related to supplying contraceptives and enhancing the quality of the services. Little focus was found on monitoring and evaluation of the policies implemented. Conclusion: Among the five selected countries, a multitude of actions were happening simultaneously, each with its own vigor and enthusiasm. Our findings highlight that these five countries were successful in increasing family planning coverage by implementing broader multi-sectoral policies and considering the diverse needs of the population, as well as the specific contextual factors at play. Successful policies require a nuanced consideration of how these policies align with each culture's framework, recognizing that both sociocultural norms and the impact of past public policies shape the current state of family planning.

Leadership, regulatory approaches and policy to re-orientate health services towards health promotion.

Globally, oral conditions remain the most prevalent of all non-communicable diseases. Among the broad range of target goals and recommendations for action by the World Health Organization's Global Oral Health Strategy, we call out three specific actions that provide an enabling environment to improve population oral health including: (i) enabling population oral health reform through leadership, (ii) enabling innovative oral health workforce models, (iii) enabling universal health coverage that includes oral health. The aim of the article is to outline how leadership, regulatory approaches and policy in Australia can strengthen health promotion practice and can inform global efforts to tackle the complex wicked problems associated with population oral health. Examples in Australia show that effective leadership, regulatory approaches and well-designed policies can address the growing burden of non-communicable diseases, and are made possible through public health advocacy, collaboration and research.

Universal health coverage and equal access in Sweden: a century-long perspective on macro-level policy.

BACKGROUND: When today's efforts to achieve universal health coverage are mainly directed towards low-income settings, it is perhaps easy to forget that countries considered to have universal, comprehensive and high-performing health systems have also undergone this journey. In this article, the aim is to provide a century-long perspective to illustrate Sweden's long and ongoing journey towards universal health coverage and equal access to healthcare. METHODS: The focus is on macro-level policy. A document analysis is divided into three broad eras (1919-1955; 1955-1989; 1989-) and synthesises seven points in time when policies relevant to overarching goals and regulation of universal health coverage and equal access were proposed and/or implemented. The development is analysed and concluded in relation to two egalitarian goals in the context of health: equality of access and equal treatment for equal need. RESULTS: Over the past century, macro-level policy evolved from the concept of creating access for the neediest and those reliant on wages for their survival to a mandatory insurance with equal right to healthcare for all. However, universal health coverage was not achieved until 1955, and individuals had to rely on their personal financial resources to cover the cost at the time of care utilization until the 1970s. It was not until 1983 that legislation explicitly stated that access to healthcare should be equal for the entire population (horizontal equity), while a vertical equity-principle was not added until 1997. Subsequently, ideas of free choice and privatization have gained significance. For instance, they aim to increase service access, addressing the Swedish health system's Achilles' heel in this regard. However, the principle of equal access for all is now being challenged by the emergence of private health insurance, which offers quicker access to services. It can be concluded that there is no perpetual Swedish healthcare model and various dimensions of access have been the focus of policy discussion. The discussion on access barriers has shifted from financial to personal and organizational ones. Today, Sweden still ranks high in terms of affordability and equity in international comparisons: although not as well as a decade ago. Whether this marks the beginning of a new trend intertwined with a decline in Sweden's welfare 'exceptionalism', or is a temporary decline remains to be assessed in the future.

Strategies for Effective Capacity-Building in the Fight Against Commercial Tobacco.

The Center for Black Health & Equity's approach to addressing health inequities relies on the inherent ability within community-based organizations to respond to public health priorities while addressing the political and social determinants of health. By using Dr. Robert Robinson's Community Development Model as a foundational framework, communities can address systemic barriers that impede optimal health outcomes. The model includes community engagement and mobilization activities that motivate communities to achieve equity-centered policy change and offers milestones that show progress made toward their goals and objectives. We operationalized the Community Development Model into the Community Capacity Building Curriculum to train community partners to form a multicultural coalition through asset mapping as a tool for community mobilization. This curriculum is both cost effective and efficient because it enables communities to address health disparities beyond tobacco control, such as food and nutrition, housing, and environmental issues. Coalitions are prepared to identify and make recommendations to address policies that perpetuate health disparities. Facing off against a powerful tobacco industry giant is challenging for small grassroots organizations advocating for stricter tobacco regulations and policies. Such organizations struggle for resources; however, their passion and dedication to the mission of saving Black lives can promote change.