Global health workforce strategies to address the COVID-19 pandemic: Learning lessons for the future.

COVID-19 put unprecedented strain on the health and care workforce (HCWF). Yet, it also brought the HCWF to the forefront of the policy agenda and revealed many innovative solutions that can be built upon to overcome persistent workforce challenges. In this perspective, which draws on a Policy Brief prepared for the WHO Fifth Global Forum on Human Resources for Health, we present findings from a scoping review of global emergency workforce strategies implemented during the pandemic and consider what we can learn from them for the long-term sustainability of the HCWF. Our review shows that strategies to strengthen HCWF capacity during COVID-19 fell into three categories: (1) surging supply of health and care workers (HCWs); (2) optimizing the use of the workforce in terms of setting, skills and roles; and (3) providing HCWs with support and protection. While some initiatives were only short-term strategies, others have potential to be continued. COVID-19 demonstrated that changes to scope-of-practice and the introduction of team-based roles are possible and central to an effective, sustainable workforce. Additionally, the use of technology and digital tools increased rapidly during COVID-19 and can be built on to enhance access and efficiency. The pandemic also highlighted the importance of prioritizing the security, safety, and physical and mental health of workers, implementing measures that are gender and equity-focused, and ensuring the centrality of the worker perspective in efforts to improve HCWF retention. Flexibility of regulatory, financial, technical measures and quality assurance was critical in facilitating the implementation of HCWF strategies and needs to be continued. The lessons learned from COVID-19 can help countries strengthen the HCWF, health systems, and the health and well-being of all, now and in the future.

Primary care reforms in Central Asia - On the path to universal health coverage?

This article reviews progress in primary care reforms in the four Central Asian countries Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan. It draws on the country monitoring work of the European Observatory on Health Systems and Policies, a review of the peer-reviewed literature and an analysis of data available in international databases. The retrieved information was organized according to key health system functions (governance, provision, financing and resource generation), as well as key aims of universal health coverage (access to and quality of primary care and financial protection). The article finds that the four countries have made substantial reforms in all of these areas, but that there is still some way to go towards universal health coverage. Key challenges are the overall lack of public funding for primary care, poor financial protection due to prescribed outpatient medications being generally outside of publicly funded benefits packages, the low status and salary of primary care workers, problems of access to primary care in rural areas, and underdeveloped quality monitoring and improvement systems.

Building on value-based health care: Towards a health system perspective.

A variety of methodologies have been developed to help health systems increase the 'value' created from their available resources. The urgency of creating value is heightened by population ageing, growth in people with complex morbidities, technology advancements, and increased citizen expectations. This study develops a policy framework that seeks to reconcile the various approaches towards value-based policies in health systems. The distinctive contribution is that we focus on the value created by the health system as a whole, including health promotion, thus moving from value-based health care towards a value-based health system perspective. We define health system value to be the contribution of the health system to societal wellbeing. We adopt a framework of five dimensions of value, embracing health improvement, health care responsiveness, financial protection, efficiency and equity, which we map onto a society's aggregate wellbeing. Actors within the health system make different contributions to value, and we argue that their perspectives can be aligned with a unifying concept of health system value. We provide examples of policy levers and highlight key actors and how they can promote certain aspects of health system value. We discuss advantages of value-based approach based on the notion of wellbeing and some practical obstacles to its implementation.

Metrics and indicators used to assess health system resilience in response to shocks to health systems in high income countries-A systematic review.

Health system resilience has never been more important than with the COVID-19 pandemic. There is need to identify feasible measures of resilience, potential strategies to build resilience and weaknesses of health systems experiencing shocks. The purpose of this systematic review is to examine how the resilience of health systems has been measured across various health system shocks. Following PRISMA guidelines, with double screening at each stage, the review identified 3175 studies of which 68 studies were finally included for analysis. Almost half (46%) were focused on COVID-19, followed by the economic crises, disasters and previous pandemics. Over 80% of studies included quantitative metrics. The most common WHO health system functions studied were resources and service delivery. In relation to the shock cycle, most studies reported metrics related to the management stage (79%) with the fewest addressing recovery and learning (22%). Common metrics related to staff headcount, staff wellbeing, bed number and type, impact on utilisation and quality, public and private health spending, access and coverage, and information systems. Limited progress has been made with developing standardised qualitative metrics particularly around governance. Quantitative metrics need to be analysed in relation to change and the impact of the shock. The review notes problems with measuring preparedness and the fact that few studies have really assessed the legacy or enduring impact of shocks.

Assessing Recent Efforts to Improve Organization of Cancer Care in Poland: What Does the Evidence Tell Us?

Poland has implemented two major organizational changes in recent years to improve cancer care. In 2015, a dedicated 'fast pathway' to diagnostics and treatment was implemented for patients suspected of having cancer. In 2019, the National Oncology Network began pilots in four regions of care pathways for cancer at five sites. Neither has been evaluated-no baseline information was collected, and what assessments were undertaken were limited to process measures. While the 2019 initiative was at least piloted, a national rollout has been announced even while the pilot is still ongoing and when concerns about certain aspects of the model have been raised. Given that cancer is the second largest cause of death in Poland and that cancer outcomes are worse compared to Western European averages, there is a particular need to ensure that models of care are informed by the evidence and adapted to the realities of the Polish healthcare system.

A reform proposal from 2019 aims to improve coordination of health services in Poland by strengthening the role of the counties.

Numerous attempts have been undertaken over the past two decades to improve the coordination of health services in Poland. These have usually focused on specific groups of patients or conditions, usually encompassing various types of specialist care, with only a few initiatives including a wider range of health services or sectors. These efforts have not been helped by the fragmentation of responsibilities between the various levels of territorial self-government, which are the founding bodies for different types of public providers. In 2019, a new policy initiative of the Ministry of Health proposed the establishment of County Health Centres that would improve integration of primary health care with specialist outpatient care, inpatient care in the county hospitals (hospitals of the 1st reference level), and other services at the level of the county. This would constitute the so-called "core system of health security" and support reorientation of health services towards PHC and the community and away from specialist hospitals. With its focus on health promotion and disease prevention and tailoring provision to the needs of the local populations, the proposal resembles examples of population health models introduced in several other countries, and offers a chance to improve the allocation of resources and to reduce the persisting health disparities across the country.

Health Centres 75+ as a New Model to Improve Care for Older People in Poland.

According to a recent national audit, the cost of treating patients in geriatric wards is 20-30% less compared to those treated in internal medicine wards. Yet, geriatric care remains largely underdeveloped in Poland, with few human, material, and financial resources. Despite numerous attempts to raise the profile of geriatrics over the years, little progress has been achieved. In 2019, experts under the President of Poland proposed the creation of a network of Health Centres 75+ as the first pillar of geriatric care. These are meant to provide ambulatory services for older people and coordinate provision of other health and social care services at the county level. The goal is to create a community model of care, whereby older people would receive needed services close to their place of residence, allowing them to live independently for as long as possible. Although the proposal has been welcomed by the geriatric community and the patients, the acute shortages of human, physical, and financial resources raise concerns about its feasibility. However, the new strategic plans for the health system propose solutions that appear to be supportive of the new proposal, and the Office of the President is discussing joining forces with the Ministry of Health to improve its chances of implementation. Given the increasing pace of population ageing and underdeveloped provision of geriatric services, these efforts are very much needed.

Implementation of Mental Health Centres Pilots in Poland since 2018: A Chance to Move towards Community-Based Mental Health Services.

Provision of mental health care in Poland has long been characterised by an overreliance on psychiatric hospitals and the underdevelopment of community care. The introduction of the first National Mental Health Protection Programme for 2011-2015, with the explicit goal to base provision of mental care on the community mental health centres, failed to achieve any tangible results. The ensuing critique led to the launch of the second National Mental Health Protection Programme for 2017-2022 and the establishment, from mid-2018 onwards, of 41 (33 in operation) mental health centres across Poland. These will be piloted until the end of 2022 but have already shown positive results in terms of access to non-stationary care and a small fall in hospitalisations. They have also performed well during the COVID-19 pandemic, allowing for a quick reorganization of care and continued provision of mental health services. Some of the key innovations of the new model include the introduction of recovery assistants (a new profession) and mental health coordinators (a new role); liaison with social assistance services; and a shift to budget financing. The key obstacles to the national rollout of mental health centres are the low financing of mental health care in Poland, which is among the lowest in Europe, and acute workforce shortages.

The Devil Is in the Data: Can Regional Variation in Amenable Mortality Help to Understand Changes in Health System Performance in Poland?

The contribution of health systems to health is commonly assessed using levels of amenable mortality. Few such studies exist for Poland, with analyses of within-the-country patterns being particularly scarce. The aim of this paper is to analyse differences in amenable mortality levels and trends across Poland's regions using the most recent data and to gain a more nuanced understanding of these differences and possible reasons behind them. This can inform future health policy decisions, particularly when it comes to efforts to improve health system performance. We used national and regional mortality data to construct amenable mortality rates between 2002 and 2019. We found that the initially observed decline in amenable mortality stagnated between 2014 and 2019, something not seen elsewhere in Europe. The main driver behind this trend is the change in ischemic heart disease (IHD) mortality. However, we also found that there is a systematic underreporting of IHD as a cause of death in Poland in favour of heart failure, which makes analysis of health system performance using amenable mortality as an indicator less reliable. We also found substantial geographical differences in amenable mortality levels and trends across Poland, which ranged from -3.3% to +8.1% across the regions in 2014-2019. These are much bigger than variations in total mortality trends, ranging from -1.5% to -0.2% in the same period, which suggests that quality of care across regions varies substantially, although some of this effect is also a coding artefact. This means that interpretation of health system performance indicators is not straightforward and may prevent implementation of policies that are needed to improve population health.

A comparison of health system responses to COVID-19 in Bulgaria, Croatia and Romania in 2020.

This article compares the health system responses to COVID-19 in Bulgaria, Croatia and Romania from February 2020 until the end of 2020. It explores similarities and differences between the three countries, building primarily on the methodology and content compiled in the COVID-19 Health System Response Monitor (HSRM). We find that all three countries entered the COVID-19 crisis with common problems, including workforce shortages and underdeveloped and underutilized preventive and primary care. The countries reacted swiftly to the first wave of the COVID-19 pandemic, declaring a state of emergency in March 2020 and setting up new governance mechanisms. The initial response benefited from a centralized approach and high levels of public trust but proved to be only a short-term solution. Over time, governance became dominated by political and economic considerations, communication to the public became contradictory, and levels of public trust declined dramatically. The three countries created additional bed capacity for the treatment of COVID-19 patients in the first wave, but a greater challenge was to ensure a sufficient supply of qualified health workers. New digital and remote tools for the provision of non-COVID-19 health services were introduced or used more widely, with an increase in telephone or online consultations and a simplification of administrative procedures. However, the provision and uptake of non-COVID-19 health services was still affected negatively by the pandemic. Overall, the COVID-19 pandemic has exposed pre-existing health system and governance challenges in the three countries, leading to a large number of preventable deaths.

Perspective: Lessons from COVID-19 of countries in the European region in light of findings from the health system response monitor.

Introduction: Decision-makers initially had limited data to inform their policy responses to the COVID-19 pandemic. The research community developed several online databases to track cases, deaths, and hospitalizations; however, a major deficiency was the lack of detailed information on how health systems were responding to the pandemic and how they would need to be transformed going forward. Approach: In an effort to fill this information gap, in March 2020, the European Observatory on Health Systems and Policies, the WHO European Regional Office and the European Commission created the COVID-19 Health System Response Monitor (HSRM) to collect and organise up-to-date information on how health systems, mainly in the WHO European Region, were responding to the COVID-19 pandemic. Findings: The HSRM analysis and broader Observatory work on COVID-19 shone light on a range of health system challenges and weaknesses and catalogued policy options countries put in place during the pandemic to address these. Countries prioritised policies on investing in public health, supporting the workforce, maintaining financial stability, and strengthening governance in their response to COVID-19. Outlook: COVID-19 is likely to continue to impact health systems for the foreseeable future; the ability to cope with this pressure, and other shocks, depends on having good information on what other countries have done so that health systems develop adequate policy options. In support of this, the country information on the COVID-19 HSRM will remain available as a repository to inform decision makers on options for actions and possible measures against COVID-19 and other public health emergencies. Building on its previous work on health systems resilience, the European Observatory on Health Systems and Policies will sustain its focus on analysing key issues related to the recovery from the pandemic and making health systems more resilient. This includes policy knowledge transfer between countries and systematic resilience testing, aiming at contributing to an improved understanding of health system response, recovery, and preparedness. Contribution to the literature in non-technical language: The COVID-19 Health System Response Monitor (HSRM) was the first database in the WHO European Region to collect and organise up-to-date information on how health systems were responding to the COVID-19 pandemic. The HSRM provides a repository of policies which can be used to inform decision makers in health and other policy domains on options for action and possible measures against COVID-19 and other public health emergencies. This initiative proved particularly valuable, especially during the early phases of the pandemic, when there was limited information for countries to draw on as they formulated their own policy response to the pandemic. Our perspectives paper highlights some key challenges within health systems that the HSRM was able to identify during the pandemic and considers policy options countries put in place in response. Our research contributes to literature on emergency responses and recovery, health systems performance assessment, particularly health system resilience, and showcases the Observatory experience on how to design such a data collection tool, as well as how to leverage its findings to support cross-country learning.

What is being done to respond to the rise of chronic diseases and multi-morbidity in Czechia, Hungary, Poland, and Slovakia?

Although countries in central and eastern Europe (CEE) have relatively younger populations compared to the West, their populations are often affected by higher prevalence of chronic conditions and multi-morbidity and this burden will likely increase as their populations age. Relatively little is known about how these countries cater to the needs of complex patients. This Perspective piece identifies key initiatives to improve coordination of care in Czechia, Hungary, Poland, and Slovakia, including some pioneering and far-reaching approaches. Unfortunately, some of them have failed to be implemented, but a recent strategic commitment to care coordination in some of these countries and the dedication to rebuilding stronger health systems after the COVID-19 pandemic offer an opportunity to take stock of these past and ongoing experiences and push for more progress in this area.

Nordic responses to Covid-19: Governance and policy measures in the early phases of the pandemic.

This paper explores and compares health system responses to the COVID-19 pandemic in Denmark, Finland, Iceland, Norway and Sweden, in the context of existing governance features. Content compiled in the Covid-19 Health System Response Monitor combined with other publicly available country information serve as the foundation for this analysis. The analysis mainly covers early response until August 2020, but includes some key policy and epidemiological developments up until December 2020. Our findings suggest that despite the many similarities in adopted policy measures, the five countries display differences in implementation as well as outcomes. Declaration of state of emergency has differed in the Nordic region, whereas the emphasis on specialist advisory agencies in the decision-making process is a common feature. There may be differences in how respective populations complied with the recommended measures, and we suggest that other structural and circumstantial factors may have an important role in variations in outcomes across the Nordic countries. The high incidence rates among migrant populations and temporary migrant workers, as well as differences in working conditions are important factors to explore further. An important question for future research is how the COVID-19 epidemic will influence legislation and key principles of governance in the Nordic countries.

A reversal of fortune: Comparison of health system responses to COVID-19 in the Visegrad group during the early phases of the pandemic.

This paper analyses the health policy response to the COVID-19 pandemic in the four Visegrad countries - Czechia, Hungary, Poland, and Slovakia - in spring and summer 2020. The four countries implemented harsh transmission prevention measures at the beginning of the pandemic and managed to effectively avoid the first wave of infections during spring. Likewise, all four relaxed most of these measures during the summer and experienced uncontrolled growth of cases since September 2020. Along the way, there has been an erosion of public support for the government measures. This was mainly due to economic considerations taking precedent but also likely due to diminished trust in the government. All four countries have been overly reliant on their relatively high bed capacity, which they managed to further increase at the cost of elective treatments, but this could not always be supported with sufficient health workforce capacity. Finally, none of the four countries developed effective find, test, trace, isolate and support systems over the summer despite having relaxed most of the transmission protection measures since late spring. This left the countries ill-prepared for the rise in the number of COVID-19 infections they have been experiencing since autumn 2020.

Improved coordination of care after acute myocardial infarction in Poland since 2017: Promising early results.

A new model of complex patient care after acute myocardial infarction (AMI) has been in operation in Poland since late 2017, comprising invasive treatment, cardiac rehabilitation and scheduled outpatient follow-up. Its stated objectives are to improve secondary prevention measures, quality of care and long-term health outcomes in AMI-patients. The model implements all key aspects of post-MI care recommended by the European Society of Cardiology (ESC), representing the first nation-wide model of structured and comprehensive post-MI care that closely follows ESC guidelines. The aim of this paper is to describe the background of this reform, its content and implementation as well as to assess its results. Early outcomes seem promising, with significantly lower mortality rate and lower risk of serious cardiological events in patients participating in the new model of care compared to patients who were not included. A comprehensive assessment of the reform will require further clinical data, covering a larger population and a longer period of time, as well as a holistic analysis of the programme in its wider context, taking into account potential benefits and cost-effectiveness of improved primary prevention implemented outside of this model.

Testing the 2017 PHC reform through pilots: Strengthening prevention and chronic care coordination.

Numerous official reports have highlighted insufficient provision of preventive services within primary health care (PHC) in Poland. Other identified weaknesses include inappropriate referrals to ambulatory care that contribute to long waiting times for specialist consultations. Since mid-2018, a new model of PHC organization has been piloted and can be seen as an attempt to address some of these weaknesses. It draws on the Primary Health Care Act of 2017 and puts much more emphasis on disease prevention and health promotion within PHC as well as shifts management of common chronic conditions to multidisciplinary PHC teams. The implementation of this model has been supported by a range of financial and non-financial measures, including a special grant that helps PHC practices to adapt their IT systems to the requirements of the pilot. Yet, the overall requirements were prohibitive to most PHC practices and only 42 were eventually included in the pilot. In this paper, we describe the content of this model, the difficulties in its implementation and how they were addressed and discuss its possible effects on PHC and the health system more broadly.

Norway: Health System Review.

This analysis of the Norwegian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Norway is among the wealthiest nations in the world, with low levels of income inequality. Norwegians enjoy long and healthy lives, with substantial improvement made due to effective and high-quality medical care and the impact of broader public health policies. However, this comes at a high cost, as the Norwegian health system is among the most expensive in Europe, with most financing coming from public funds. Yet there are several areas requiring substantial co-payments, such as adult dental care, outpatient pharmaceuticals, and institutional care for older or disabled people. Recent and ongoing reforms have focused on aligning provision of care to changing population health needs, including adapting medical education, strengthening primary care and improving coordination between primary and specialist care sectors. There has been an increasing use of e-health solutions, and information and communication technologies. Improvements in measuring performance and a more effective use of indicators is expected to play a larger role in informing policy and planning of health services.

What next after the 'commercialization' of public hospitals? Searching for effective solutions to achieve financial stability of the hospital sector in Poland.

The problem of hospital indebtedness has fraught the Polish health care sector for many decades. While it is largely attributed to the shortcomings of the legal form of the independent public health care unit (SPZOZ), which is the main legal form in which public hospitals operate in Poland, analysis of hospital indebtedness shows that the problem had been apparent before this legal form was introduced in 1999. The problem also did not appear to diminish with the transformation of the SPZOZs into Commercial Code companies, which effectively started in 2011 and was recently halted. While the shortcomings of the legal forms (SPZOZ and others) in which public hospitals operated did contribute to the accumulation of debts in the hospital sector, limited public spending on health and certain reforms were also to blame. Further, repeated rounds of debt reduction financed by the state have likely instilled the conviction among the hospital directors that debts would always be cleared eventually and provided little incentive for prudent financial management. While the government has recently pledged to increase public spending on health, this alone does not guarantee to resolve the problem of hospital indebtedness. Other key changes, such as implementing rational financial management in the hospitals and shifting more care from hospitals to primary and long-term care, are also needed.

Poland: Health System Review.

This analysis of the Polish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In late 2017, the Polish government committed to increase the share of public expenditures on health to 6% of GDP by 2024. If the GDP continues to grow in the years to come, this will present an opportunity to tackle mounting health challenges such as socioeconomic inequalities in health, high rates of obesity, rising burden of mental disorders and population ageing that put strain on health care resources. It is also an opportunity to tackle certain longstanding imbalances in the health sector, including overreliance on acute hospital care compared with other types of care, including ambulatory care and long-term care; shortages of human resources; the negligible role of health promotion and disease prevention vis-a-vis curative care; and poor financial situation in the hospital sector. Finally, the additional resources are much needed to implement important ongoing reforms, including the reform of primary care. The resources have to be spent wisely and waste should be minimized. The introduction, in 2016, of a special system (IOWISZ) of assessing investments in the health sector that require public financing (including from the EU funds) as well as the work undertaken by the Polish health technology assessment (HTA) agency (AOTMiT), which evaluates health technologies and publicly-financed health policy programmes as well as sets prices of goods and services, should help ensure that these goals are achieved. Recent reforms, such as the ongoing reform of primary care that seeks to improve coordination of care and the introduction of the hospital network, go in the right direction; however, a number of longstanding unresolved problems, such as hospital indebtedness, need to be tackled.