Integration of migrant and refugee data in health information systems in Europe: advancing evidence, policy and practice.

Coverage of migrant and refugee data is incomplete and of insufficient quality in European health information systems. This is not because we lack the knowledge or technology. Rather, it is due to various political factors at local, national and European levels, which hinder the implementation of existing knowledge and guidelines. This reflects the low political priority given to the topic, and also complex governance challenges associated with migration and displacement. We review recent evidence, guidelines, and policies to propose four approaches that will advance science, policy, and practice. First, we call for strategies that ensure that data is collected, analyzed and disseminated systematically. Second, we propose methods to safeguard privacy while combining data from multiple sources. Third, we set out how to enable survey methods that take account of the groups' diversity. Fourth, we emphasize the need to engage migrants and refugees in decisions about their own health data. Based on these approaches, we propose a change management approach that narrows the gap between knowledge and action to create healthcare policies and practices that are truly inclusive of migrants and refugees. We thereby offer an agenda that will better serve public health needs, including those of migrants and refugees and advance equity in European health systems. Funding: No specific funding received.

The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis.

BACKGROUND: Fiscal decentralisation (FD) is a widely implemented decentralisation policy consisting of the allocation of pooling and spending responsibilities from the central government to lower levels of governance within a country. In 2001, The Italian National Health System (Servizio Sanitario Nazionale, SSN) has introduced a strong element of FD, making regions responsible for their own pooling of resources and for their budgets. Despite the relevance, only few studies exist on health sector-FD in Italy, mostly looking at the effects of FD on infant mortality. METHODS: This study performs a fixed-effects panel data analysis of Italian Regions and Autonomous provinces between the years 2001 and 2017, to investigate the effects of health sector-FD on availability, accessibility, and utilisation of healthcare services in Italy. RESULTS: FD decreases availability of staff and hospital beds, decreases utilisation of care, measured by hospitalisation rates, and increases interregional patients' mobility for healthcare purposes, a finding suggesting increased disparities in access to healthcare. These effects seem to be stronger for public - rather than private - services, and are more prominent in poorer areas. CONCLUSION: This evidence suggest that FD has created a fragmented and unequal healthcare system, in which levels of availability, utilisation of, and accessibility to resources - as well as the extent of public sector's retrenchment - coincide with the wealth of the area.

The impact of the COVID-19 pandemic on refugees and asylum seekers in Greece: A retrospective analysis of national surveillance data from 2020.

BACKGROUND: Migrants globally, including refugees and asylum seekers, have experienced adverse clinical and socioeconomic impacts of the COVID-19 pandemic. For approximately 56,000 refugees and asylum seekers in Reception and Identification Centers (RICs) and Reception Sites (RS) in Greece, living in severely substandard living conditions, prevention measures have been impossible with limited provision in terms of routine testing, surveillance, and access to healthcare. These migrant populations have experienced prolonged lockdowns and restricted movement since the pandemic began. We aimed to assess the impact of COVID-19 on refugees and asylum seekers in reception facilities in Greece and explore implications for policy and practice. METHODS: A retrospective analysis of policy documents and national surveillance data was conducted to identify COVID-19 outbreaks and estimate incidence among asylum seekers and refugees residing in these camps during the first 9 months of the epidemic in Greece (26th February - 15th November 2020). Incidence proportion (IP) of COVID-19 confirmed cases was calculated for three population groups (refugees and asylum seekers in RICs, refugees and asylum seekers in RSs, and the general population in Greece) during three time periods (first wave, second wave, and overall across the 9-month period). FINDINGS: Twenty-five COVID-19 outbreaks were identified in refugee and asylum seeker reception facilities, with 6 (85.7%) of 7 RICs and 18 (56.3%) of 32 RSs reporting at least one outbreak during the study period. The overall 9-month COVID-19 IP among refugee and asylum seeker populations residing in RSs on the Greek mainland was 1758 cases per 100,000 population; in RICs the incidence was 2052 cases per 100,000 population. Compared to the general population the risk of COVID-19 infection among refugees and asylum seekers in reception facilities was 2.5 to 3 times higher (p-value<0.001). The risk of acquiring COVID-19 infection was higher among refugee and asylum seeker populations in RSs on the Greek mainland (IP ratio: 2.45; 95% CI: 2.25-2.68) but higher still among refugee and asylum seeker populations in RICs in the Greek islands and the land border with Turkey (IP ratio: 2.86; 95% CI: 2.64-3.10), where living conditions are particularly poor. INTERPRETATION: We identified high levels of COVID-19 transmission among refugees and asylum seekers in reception facilities in Greece. The risk of COVID-19 infection among these enclosed population groups has been significantly higher than the general population of Greece, and risk increases as living conditions deteriorate. These data have immediate implications for policy and practice. Strategies are now needed to ensure refugee and asylum seeker populations are included in national response plans to reduce transmission in at-risk groups for COVID-19, alongside inclusion in plans for COVID-19 vaccine roll out.

The impact of economic recessions on health workers: a systematic review and best-fit framework synthesis of the evidence from the last 50 years.

Economic crises carry a substantial impact on population health and health systems, but little is known on how these transmit to health workers (HWs). Addressing such a gap is timely as HWs are pivotal resources, particularly during pandemics or the ensuing recessions. Drawing from the empirical literature, we aimed to provide a framework for understanding the impact of recessions on HWs and their reactions. We use a systematic review and best-fit framework synthesis approach to identify the relevant qualitative, quantitative and mixed-methods evidence, and refine an a priori, theory-based conceptual framework. Eight relevant databases were searched, and four reviewers employed to independently review full texts, extract data and appraise the quality of the evidence retrieved. A total of 57 peer-reviewed publications were included, referring to six economic recessions. The 2010-15 Great Recession in Europe was the subject of most (52%) of the papers. Our consolidated framework suggests that recessions transmit to HWs through three channels: (1) an increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.

Impact of economic recessions on healthcare workers and their crises' responses: study protocol for a systematic review of the qualitative and quantitative evidence for the development of an evidence-based conceptual framework.

INTRODUCTION: During economic recessions, health professionals face reduced income and labour opportunities, hard conditions often exacerbated by governments' policy responses to crises. Growing evidence points to non-negligible effects on national health workforces and health systems-decrease in motivation, burnout, migration-arising from the combination of crisis-related factors. However, no theoretical conceptualisation currently exists framing the impacts recessions have on human resources for health (HRH), or on their reactions. METHODS AND ANALYSIS: This paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts' input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970-2019 period-the modern age of global economic recessions-and full texts in English, Spanish, Italian, French, Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A 'best-fit' framework synthesis will be applied to summarise the findings, using an a priori, theoretically driven framework. That preliminary framework was built by the research team to inform the searches, and will be appraised by external experts. ETHICS AND DISSEMINATION: In addition to peer-reviewed publications, the new framework will be presented in global health systems research conferences and inform regional policy dialogue workshops in Latin America on economic recessions and health systems. PROSPERO REGISTRATION NUMBER: CRD42019134165.

International Trade and Health Care in Brazil: An Unpredicted Tale Threatening Health Care Entitlement?

The General Agreement on Trade in Services (GATS), established in 1994, has been a key element of market liberalization of health care services. Brazil had the provision of health care services partially protected from international competition until 2015, when a constitutional change opened the national health care market to international provision. We performed a retrospective and prospective policy analysis based on a systematic policy document review, general literature review, and secondary data analysis mapping, describing and analyzing the international trade agreements signed by Brazil with the World Trade Organization (WTO) and the available legislation relevant to health care services. The provision of health care services was not included in the WTO commitments signed by Brazil during the analyzed period (1994-2018). Financing of private health insurance was part of the agreement since 1994. There was a mild liberalization of the private health insurance sector, while provision of health care services was forbidden to foreign investors until 2015. The mode 3 of GATS presents the greatest potential impact as it exposes health care provision to international competition. The international liberalization of the provision of health care services in Brazil is now legal and an observable consequence of the pressure to gradually lift trade barriers in the health and health care sector.

Economic crisis, restrictive policies, and the population's health and health care: the Greek case.

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a population's well-being. Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Health's total expenditures fell by 23.7% between 2009 and 2011. In a time of economic turmoil, rising health care needs and increasing demand for public services collide with austerity and privatization policies, exposing Greece's population health to further risks.

Payments and quality of care in private for-profit and public hospitals in Greece.

BACKGROUND: Empirical evidence on how ownership type affects the quality and cost of medical care is growing, and debate on these topics is ongoing. Despite the fact that the private sector is a major provider of hospital services in Greece, little comparative information on private versus public sector hospitals is available. The aim of the present study was to describe and compare the operation and performance of private for-profit (PFP) and public hospitals in Greece, focusing on differences in nurse staffing rates, average lengths of stay (ALoS), and Social Health Insurance (SHI) payments for hospital care per patient discharged. METHODS: Five different datasets were prepared and analyzed, two of which were derived from information provided by the National Statistical Service (NSS) of Greece and the other three from data held by the three largest SHI schemes in the country. All data referred to the 3-year period from 2001 to 2003. RESULTS: PFP hospitals in Greece are smaller than public hospitals, with lower patient occupancy, and have lower staffing rates of all types of nurses and highly qualified nurses compared with public hospitals. Calculation of ALoS using NSS data yielded mixed results, whereas calculations of ALoS and SHI payments using SHI data gave results clearly favoring the public hospital sector in terms of cost-efficiency; in all years examined, over all specialties and all SHI schemes included in our study, unweighted ALoS and SHI payments for hospital care per discharge were higher for PFP facilities. CONCLUSIONS: In a mixed healthcare system, such as that in Greece, significant performance differences were observed between PFP and public hospitals. Close monitoring of healthcare provision by hospital ownership type will be essential to permit evidence-based decisions on the future of the public/private mix in terms of healthcare provision.