The dynamics of international health system reforms: Evidence of a new wave in response to the 2008 economic crisis and the COVID-19 pandemic?

Global economic and health shocks, such as the 2008 global financial crisis and the COVID-19 pandemic typically impact healthcare financing and delivery. Cutler found that profound societal changes in the 20th century induced three waves of healthcare reform across seven major OECD countries. Our study investigates whether major crises in the 21st century induced similar reform waves. Through thematic analysis, we systematically compared health system changes in response to these shocks, using data from the Observatory on Health Systems and Policies and the OECD. Our analysis reveals similar overarching reform trends across countries in response to the 2008 economic crisis: a tendency toward re-centralization of health system governance to control and leverage the efficient rationalization of public health resources. This, to some extent, countered the effects of the market-based reforms of the previous wave. The reforms induced by the 2008 crisis were mediated by its repercussions on the countries' economies. In contrast, reforms in response to the pandemic aimed primarily to address the direct impact of the shock on the health system. Despite its negative economic impact, the pandemic resulted in a substantial but temporary increase in public health spending. A better understanding reform dynamics and their impact on overarching conflicting health system objectives may prevent unintended consequences and enhance health systems' resilience in response to future shocks.

Barriers and facilitators to the implementation of digital technologies in mental health systems: a qualitative systematic review to inform a policy framework.

BACKGROUND: Despite the potential for improved population mental health and wellbeing, the integration of mental health digital interventions has been difficult to achieve. In this qualitative systematic review, we aimed to identify barriers and facilitators to the implementation of digital technologies in mental healthcare systems, and map these to an implementation framework to inform policy development. METHODS: We searched Medline, Embase, Scopus, PsycInfo, Web of Science, and Google Scholar for primary research articles published between January 2010 and 2022. Studies were considered eligible if they reported barriers and/or facilitators to the integration of any digital mental healthcare technologies. Data were extracted using EPPI-Reviewer Web and analysed thematically via inductive and deductive cycles. RESULTS: Of 12,525 references identified initially, 81 studies were included in the final analysis. Barriers and facilitators were grouped within an implementation (evidence-practice gap) framework across six domains, organised by four levels of mental healthcare systems. Broadly, implementation was hindered by the perception of digital technologies as impersonal tools that add additional burden of care onto both providers and patients, and change relational power asymmetries; an absence of resources; and regulatory complexities that impede access to universal coverage. Facilitators included person-cantered approaches that consider patients' intersectional features e.g., gender, class, disability, illness severity; evidence-based training for providers; collaboration among colleagues; appropriate investment in human and financial resources; and policy reforms that tackle universal access to digital health. CONCLUSION: It is important to consider the complex and interrelated nature of barriers across different domains and levels of the mental health system. To facilitate the equitable, sustainable, and long-term digital transition of mental health systems, policymakers should consider a systemic approach to collaboration between public and private sectors to inform evidence-based planning and strengthen mental health systems. PROTOCOL REGISTRATION: The protocol is registered on PROSPERO, CRD42021276838.

Preconditions for efficiency and affordability in mixed health systems: are they fulfilled in the Australian public-private mix?

The Australian health system is characterised by high quality care by international standards, produced by a mix of public and private provision and funding of healthcare services. Despite good overall results, three issues are of concern. The first issue relates to the public procurement of healthcare, whose flaws have impacted individuals' access to care, and the high out-of-pocket spending. The second issue concerns the sustainability of the private health insurance market, given the government's goal of relieving cost and capacity from the public scheme, incentivising participation. Third, there are existing inefficiencies and inequities related to the duplication resulting from the interaction between public and private schemes. To ensure a sustainable, efficient and equitable health system, structural reforms are necessary to achieve long-term performance improvements. Using a framework for mixed public-private health systems, we assess the extent to which the Australian healthcare system achieves preconditions for efficiency and affordability in competitive healthcare markets.

Effect of Wastewater on the Composition of Bacterial Microbiota of Phragmites australis Used in Constructed Wetlands for Phytodepuration.

Phytodepuration occurs in the plant-mediated remediation processes exploited to remove pollutants from wastewater, and Phragmites australis is one of the most used plants. This goal is achieved using constructed wetlands (CW), which are engineered systems designed to mimic the natural processes of pollutants removal. The aim of this work was to characterize the bacterial communities associated to P. australis, soils, and permeates of the CW of Calice (Prato, Italy), to evaluate the possible effect of wastewaters on the CW bacterial communities, through a next-generation sequencing-based approach. A total of 122 samples were collected from different tissues of P. australis (i.e., roots, aerial parts, and stem), soil (i.e., rhizospheric and bulk soil), and permeates, and analyzed. All samples were collected during five sampling campaigns, with the first one performed before the activation of the plant. Obtained results highlighted a specific microbiota of P. australis, conserved among the different plant tissues and during time, showing a lower alpha diversity than the other samples and not influenced by the more complex and variable environmental (soils and permeates) bacterial communities. These data suggest that P. australis is able to select and maintain a defined microbiota, a capacity that could allow the plant to survive in hostile environments, such as that of CW.

A vicious cycle of health (in)equity: Migrant inclusion in light of COVID-19.

Objectives: Whilst mass vaccination is suggested as an important means to contain COVID-19 pandemic, vaccination policies across many countries have systematically excluded some groups of population, especially migrants. This study aims to document the impact of diversified vaccination strategies as a preventative and control measure for the health and safety of the wider population within a country. Methods: We selected five countries that have experienced the changes in migrant inflows to the most extreme among OECD countries in 2020: The United States, Australia, Canada, Japan, and South Korea. We conducted an extensive qualitative documentary analysis focused on policies and interventions implemented in these countries since January 2020 till the end of September 2021. We also analyzed publicly available epidemiological data (released by the governments and other international organizations). Results: We find that achieving migrants' health and vaccination equity is not without challenges, and a failure to address those multiplicity of concerns may result in a vicious cycle for the vulnerable population at the fringes of our economy. Migrants continue to face extenuating circumstances with higher risks to their health and safety, when they are excluded or disadvantaged in vaccination policies. The more inclusive and proactive the governments are in consideration of diversity of migrant populations, the better they can manage the pandemic, which leads to overall societal benefit of ensuring public health. Conclusions: Equity-based policies can mitigate disparities in access to vaccination and healthcare, thereby reducing the spread of COVID-19 in the community.

Barriers and facilitators to the integration of digital technologies in mental health systems: A protocol for a qualitative systematic review.

INTRODUCTION: Digital technology has the potential to improve health outcomes and health system performance in fragmented and under-funded mental health systems. Despite this potential, the integration of digital technology tools into mental health systems has been relatively poor. This is a protocol for a synthesis of qualitative evidence that will aim to determine the barriers and facilitators to integrating digital technologies in mental health systems and classify them in contextual domains at individual, organisational and system levels. METHODS AND ANALYSIS: The methodological framework for systematic review of qualitative evidence described in Lockwood et al. will be applied to this review. A draft search strategy was developed in collaboration with an experienced senior health research librarian. A systematic search of Medline, Embase, Scopus, PsycInfo, Web of Science and Google Scholar, as well as hand searching of reference lists and reviews will identify relevant studies for inclusion. Study selection will be carried out independently by two authors, with discrepancies resolved by consensus. The quality of selected studies will be assessed using JBI Critical Appraisal Checklist for Qualitative Research. Data will be charted using JBI QUARI Data Extraction Tool for Qualitative Research. Findings will be defined and classified both deductively in a priori conceptual framework and inductively by a thematic analysis. Results will be reported based on the Enhancing transparency in reporting the synthesis of qualitative research. The level of confidence of the findings will be assessed using GRADE-CERQual. ETHICS AND DISSEMINATION: This study does not require ethics approval. The systematic review will inform policy and practices around improving the integration of digital technologies into mental health care systems.

Closing the loop in a constructed wetland for the improvement of metal removal: the use of Phragmites australis biomass harvested from the system as biosorbent.

Among the numerous clean-up techniques for water treatment, sorption methods are widely used for the removal of trace metals. Phragmites australis is a macrophyte commonly used in constructed wetlands for water purification, and in the last decades, its use as biosorbent has attracted increasing attention. In view of a circularly economy approach, this study investigated improvement of trace metal removal by recycling the biomass of P. australis colonizing a constructed wetland, which operates as post-treatment of effluent wastewater from an activated sludge plant serving the textile industrial district of Prato (Italy). After the annual mowing of the reed plants, the biomass was dried and blended to derive a sustainable and eco-friendly biosorbent and its sorption capacity for Fe, Cu, and Zn was investigated comparing the batch system with the easier-to-handle column technique. The possibility of regeneration and reuse of the biosorbent was also evaluated. The biomaterial showed an interesting sorption capacity for Cu, Fe, and Zn, both in batch and in column experiments, especially for Fe ions. The immobilization of the biosorbent in column filters induced some improvement in the removal efficiency, and, in addition, this operation mode has the advantage of being much more suitable for practical applications than the batch process.

The COVID-19 pandemic in Italy: Policy and technology impact on health and non-health outcomes.

BACKGROUND: Italy was the first Western country to experience a major coronavirus outbreak and consequently faced large-scale health and socio-economic challenges. The Italian government enforced a wide set of homogeneous interventions nationally, despite the differing incidences of the virus throughout the country. OBJECTIVE: The paper aims to analyse the policies implemented by the government and their impact on health and non-health outcomes considering both scaling-up and scaling-down interventions. METHODS: To categorise the policy interventions, we rely on the comparative and conceptual framework developed by Moy et al. (2020). We investigate the impact of policies on the daily reported number of deaths, case fatality rate, confirmation rate, intensive care unit saturation, and financial and job market indicators across the three major geographical areas of Italy (North, Centre, and South). Qualitative and quantitative data are gathered from mixed sources: Italian national and regional institutions, National Health Research and international organisations. Our analysis contributes to the literature on the COVID-19 pandemic by comparing policy interventions and their outcomes. RESULTS: Our findings suggest that the strictness and timing of containment and prevention measures played a prominent role in tackling the pandemic, both from a health and economic perspective. Technological interventions played a marginal role due to the inadequacy of protocols and the delay of their implementation. CONCLUSIONS: Future government interventions should be informed by evidence-based decision making to balance, the benefits arising from the timing and stringency of the interventions against the adverse social and economic cost, both in the short and long term.

Improving the efficiency of wastewater treatment plants: Bio-removal of heavy-metals and pharmaceuticals by Azolla filiculoides and Lemna minuta.

In this study, we investigated the removal of Fe(III), Cr(VI), Al(III), diclofenac, and levofloxacin from treated wastewater in the presence of the free-floating plants Azolla filiculoides and Lemna minuta, to understand whether these species can be effectively used in a surface flow constructed wetland as wastewater refining treatment. Fe and Al were selected owing to their wide use as coagulant agents in wastewater treatment plants for promoting clariflocculation processes, whilst Cr was chosen due to its common use in industry. Diclofenac and levofloxacin, two molecules belonging to the most widely used pharmaceutical classes in the world, were studied as representative anti-inflammatory drugs and antibiotics, respectively. The study was performed at laboratory scale, exposing the plants separately to each individual contaminant at the concentrations of 5 mg L-1 for the metals (i.e. 2.5-5 times higher than the European limits concerning discharge into surface water), and 1 µg L-1 for the pharmaceuticals (concentration levels commonly found in wastewater). Depending on the plant species and contaminant tested, the range of different effects observed included low toxicity (i.e. Cr, Fe and diclofenac in L. minuta) and even a stimulatory effect on plant growth (i.e. for A. filiculoides with Al and for L. minuta with Al and levofloxacin). Moreover, both species proved to be very effective in the removal of Fe, Al and levofloxacin, with A. filiculoides showing the best performance (removal efficiency of 92%, 96%, and 60%, respectively), whereas for Cr and diclofenac the removal was always less than 10%. The higher removal capacity of A. filiculoides compared to L. minuta can be attributed to its superior tolerance of the contaminants, probably in turn related to the presence of nitrogen-fixing microorganism in its fronds.

Removal efficiency and mass balance of polycyclic aromatic hydrocarbons, phthalates, ethoxylated alkylphenols and alkylphenols in a mixed textile-domestic wastewater treatment plant.

In this work the occurrence and fate of polycyclic aromatic hydrocarbons (PAHs), phthalic acid esters (PAEs), mono and diethoxylate alkylphenols (AP1-2EOs) and alkylphenols (APs) have been investigated during a two-weeks period in a facility treating mixed textile-domestic wastewater (Prato, Italy). The wastewater treatment plant (WWTP) consists of primary sedimentation, activated sludge biological oxidation, secondary sedimentation, clariflocculation and ozonation. The sludge is treated within the facility by thickening, dewatering and final incineration, thus providing the almost quantitative removal of the adsorbed micropollutants. Naphthalene (50%), di(2-ethylhexyl) phthalate (74%) and branched 4-nonylphenols (59%) were the individual main representative compounds of each class in the influent wastewater, which showed concentration ranges of 5.6-66, 85-290 and 21-133µg/L for PAHs, PAEs and APs+AP1-2EOs, respectively. The WWTP efficiently removed PAHs, PAEs and APs+AP1-2EOs, providing effluent concentrations of 0.075-0.16ng/L 0.38-9.9µg/L and 0.53-1.4µg/L. All targeted priority and priority-hazardous micropollutants showed effluent concentrations in line with the European environmental quality standards (EQS), even though for di(2-ethylhexyl) phthalate and benzo(a)pyrene after correction for the dilution factor of the recipient. The WWTP performance was evaluated by mass balance, verifying its accuracy by monitoring Pb and Cd as conservative species. The biological treatment sections provided mass losses of 85.5%, 74.5% and 56.8% for APs+AP1-2EOs, PAEs and PAHs, highlighting efficient biotransformation performances of the activated sludge process. However, for the more volatile PAHs (e.g. naphthalene), a significant contribution of stripping cannot be excluded. A remarkable mass loss was also determined in the ozonation stage for PAEs (72.9%) and especially PAHs (97.0%), whereas a lower efficiency was observed for APs+AP1-2EOs (41.3%). The whole plant allowed for obtaining an almost quantitative removal (96.7-98.4%) for all targeted compounds.