Motivational interviewing for prevention in Swiss family medicine: Opportunities and challenges.

Health promotion and primary prevention are a priority in a healthcare system characterised by a prevalence of chronic conditions. In this context, motivational interviewing (MI) as provided by family doctors (FDs) seems promising: influential health professionals motivate patients to adopt healthy lifestyles in a patient-centred style that promotes a balanced, horizontal doctor-patient relationship. Based on these assumptions, a pilot project called Girasole was implemented in Switzerland between 2016 and 2018 to train and support 19 FDs in implementing MI in their practices. This paper presents the analysis of implementation of the intervention with the aim of exploring the doctors' experiences with MI through a qualitative research design. Data derive from focus groups and interviews with the participants, and from the observation of collective training sessions and follow-up meetings. A thematic analysis was conducted using the software Atlas.ti. Results show that there is great diversity in how FDs implement MI. FDs can be classified in four groups - convinced, interested, critical, and resistant - based on their adherence to the principles underlying the MI approach. This taxonomy highlights opportunities and challenges for family medicine: MI offers flexible tools and new ways of interacting with patients to meet the challenges of non-communicable and chronic diseases; at the same time, the issues associated with the medicalisation of human everyday problems, physicians' status loss, and low cost-effectiveness should not be underestimated. Any further attempt to promote MI among FDs should take into account their individual attitudes and should establish tailored approaches and training methods.

Changes in private health service utilisation and access to the Italian National Health Service between 2006 and 2019: a cross-sectional comparative study.

OBJECTIVES: Previous research highlighted that in the early 2000s a significant share of the Italian population used and paid out of pocket for private healthcare services even when they could potentially have received the same treatments from the National Health Service (NHS). The decrease in public investments in healthcare and the increase in health needs due to the population ageing may have modified the use of private health services and equity of access to the Italian NHS. This study aims to investigate the change in the prevalence of individuals who have fully paid out of pocket for accessing healthcare services in Italy between 2006 and 2019 and the main reasons behind this choice. DESIGN: Cross-sectional comparative study. PARTICIPANTS AND COMPARISON: Two representative samples of the Italian population were collected in 2006 and 2019. OUTCOME MEASURES: Prevalence of access to fully paid out-of-pocket private health services; type of service of the last fully paid out-of-pocket access; main reasons for the last fully paid out-of-pocket access. RESULTS: We found an increase in the prevalence of people who declared having fully paid out of pocket at least one access to health services during their lifetime from 79.0% in 2006 to 91.9% in 2019 (adjusted OR 2.66; 95% CI 1.98 to 3.58). 'To avoid waiting times' was the main reason and it was significantly more frequent in 2019 compared with 2006 (adjusted OR 1.75; 95% CI 1.45 to 2.11). CONCLUSIONS: This comparative study, conducted the year before the outbreak of the COVID-19 pandemic, highlighted an increase in the prevalence of Italian residents who have fully paid out of pocket for access to health services to overcome long waiting times. Our findings may indicate a reduced access and possible worsening of the equity of access to the public and universalistic Italian NHS between 2006 and 2019.

Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents' hospitalisations.

BACKGROUND: Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care. METHODS: The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies' costs, time and other resources from the NHs' perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs' losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention's effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs' perspective. RESULTS: Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH's needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22'595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate. CONCLUSIONS: As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness. TRIAL REGISTRATION: clinicaltrials.gov ( NCT03590470 ).

Positive effect of the INTERCARE nurse-led model on reducing nursing home transfers: A nonrandomized stepped-wedge design.

BACKGROUND: Unplanned nursing home (NH) transfers are burdensome for residents and costly for health systems. Innovative nurse-led models of care focusing on improving in-house geriatric expertise are needed to decrease unplanned transfers. The aim was to test the clinical effectiveness of a comprehensive, contextually adapted geriatric nurse-led model of care (INTERCARE) in reducing unplanned transfers from NHs to hospitals. METHODS: A multicenter nonrandomized stepped-wedge design within a hybrid type-2 effectiveness-implementation study was implemented in 11 NHs in German-speaking Switzerland. The first NH enrolled in June 2018 and the last in November 2019. The study lasted 18 months, with a baseline period of 3 months for each NH. Inclusion criteria were 60 or more long-term care beds and 0.8 or more hospitalizations per 1'000 resident care days. Nine hundred and forty two long-term NH residents were included between June 2018 and January 2020 with informed consent. Short-term residents were excluded. The primary outcome was unplanned hospitalizations. A fully anonymized dataset of overall transfers of all NH residents served as validation. Analysis was performed with segmented mixed regression modeling. RESULTS: Three hundred and three unplanned and 64 planned hospitalizations occurred. During the baseline period, unplanned transfers increased over time (ß1  = 0.52), after which the trend significantly changed by a similar but opposite amount (ß2  = -0.52; p = 0.0001), resulting in a flattening of the average transfer rate throughout the postimplementation period (ß1  + ß2  ≈ 0). Controlling for age, gender, and cognitive performance did not affect these trends. The validation set showed a similar flattening trend. CONCLUSION: A complex intervention with six evidence-based components demonstrated effectiveness in significantly reducing unplanned transfers of NH residents to hospitals. INTERCARE's success was driven by registered nurses in expanded roles and the use of tools for clinical decision-making.

Preventable hospitalizations from ambulatory care sensitive conditions in nursing homes: evidence from Switzerland.

OBJECTIVES: Reducing nursing home hospitalizations for ambulatory care sensitive conditions (ACSC) has been identified as an opportunity to improve patient well-being and reduce costs. The aim of this study was to identify number of hospitalizations for ACSCs for nursing home residents in a Swiss national sample, examine demographic characteristics of nursing home hospitalizations due to ACSCs, and calculate hospital expenses from these hospitalizations. METHODS: Using merged hospital administrative data with payment data based on diagnosis-related groups (DRGs) for the year 2013, we descriptively examined nursing home residents who were 65 years of age or older and were admitted to an acute care hospital. RESULTS: Approximately 42% of all nursing home admissions were due to ACSCs. Payments to Swiss hospitals for ACSCs can be estimated at between 89 and 105 million Swiss francs in 2013. CONCLUSIONS: A sizable share of hospitalizations for nursing home residents is for ACSCs, and the associated costs are substantial. Programs and policies designed to reduce these potentially avoidable hospitalizations from the nursing home setting could lead to an increased patient well-being and lower costs.

Strengthening Geriatric Expertise in Swiss Nursing Homes: INTERCARE Implementation Study Protocol.

OBJECTIVES: Nursing home (NH) residents with complex care needs ask for attentive monitoring of changes and appropriate in-house decision making. However, access to geriatric expertise is often limited with a lack of geriatricians, general practitioners, and/or nurses with advanced clinical skills, leading to potentially avoidable hospitalizations. This situation calls for the development, implementation, and evaluation of innovative, contextually adapted nurse-led care models that support NHs in improving their quality of care and reducing hospitalizations by investing in effective clinical leadership, geriatric expertise, and care coordination. DESIGN: An effectiveness-implementation hybrid type 2 design to assess clinical outcomes of a nurse-led care model and a mixed-method approach to evaluate implementation outcomes will be applied. The model development, tailoring, and implementation are based on the Consolidated Framework for Implementation Research (CFIR). SETTING: NHs in the German-speaking region of Switzerland. PARTICIPANTS: Eleven NHs were recruited. The sample size was estimated assuming an average of .8 unplanned hospitalizations/1000 resident days and a reduction of 25% in NHs with the nurse-led care model. INTERVENTION: The multilevel complex context-adapted intervention consists of six core elements (eg, specifically trained INTERCARE nurses or evidence-based tools like Identify, Situation, Background, Assessment and Recommendation [ISBAR]). Multilevel implementation strategies include leadership and INTERCARE nurse training and support. MEASUREMENTS: The primary outcomes are unplanned hospitalizations/1000 care days. Secondary outcomes include unplanned emergency department visits, quality indicators (eg, physical restraint use), and costs. Implementation outcomes included, for example, fidelity to the model's core elements. CONCLUSION: The INTERCARE study will provide evidence about the effectiveness of a nurse-led care model in the real-world setting and accompanying implementation strategies. J Am Geriatr Soc 67:2145-2150, 2019.

Skill mix in Swiss primary care group practices - a nationwide online survey.

BACKGROUND: Increasing chronic conditions and multimorbidity is placing growing service pressures on health care, especially primary care services. This comes at a time when GP workforce shortages are starting to be felt across Switzerland, placing a threat on the sustainability of good access to primary care. By establishing multiprofessional teams in primary care, service capacity is increased and the pressures on the GP workforce can be alleviated. The roles of non-medical health professions in primary care are not established so far in Switzerland and the personnel composition of primary care group practices is not known. Therefore this study aims to provide insights into the current composition, educational background and autonomy of the these new professional roles in primary care. METHODS: For this descriptive exploratory study a web-based online survey methodology was used. Group practices were defined as being a medical practice with any specialisation where at least three physicians work together in a team. Based on this restriction 240 eligible group practices were identified in Switzerland. The following four tertiary-level health professions were included in the study: nurses, physiotherapists, occupational therapists and dietitians. Additionally medical practice assistants with couselling competencies were included. RESULTS: A total of 102 practices answered the questionnaire which is equivalent to an answer rate of 43%. The sample included data from 17 cantons. 46.1% of the practices employed non-physician health professionals. Among the tertiary-level health professions, physiotherapists were the most frequent profession with a total of 78 physiotherapists over all group practices, followed by nurses (43), dietitians (34) and occupational therapists (3). In practices which employ those professionals their average number per practice was 3.4. 25.5% of the practices had health professionals employed with advanced roles and competencies. CONCLUSION: The results from this study demonstrate that while nearly 50% of groups practices have established non-physician professionals, only 25% of practices integrate these professionals with advanced roles. Compared with other countries, there would appear to be significant scope to extent and broaden the uptake of non-physician professionals in primary care in Switzerland. Clear policy direction along with supporting regulation and financing arrangements are required.

E-health in Switzerland: The laborious adoption of the federal law on electronic health records (EHR) and health information exchange (HIE) networks.

Within the framework of a broader e-health strategy launched a decade ago, in 2015 Switzerland passed a new federal law on patients' electronic health records (EHR). The reform requires hospitals to adopt interoperable EHRs to facilitate data sharing and cooperation among healthcare providers, ultimately contributing to improvements in quality of care and efficiency in the health system. Adoption is voluntary for ambulatories and private practices, that may however be pushed towards EHRs by patients. The latter have complete discretion in the choice of the health information to share. Moreover, careful attention is given to data security issues. Despite good intentions, the high institutional and organisational fragmentation of the Swiss healthcare system, as well as the lack of full agreement with stakeholders on some critical points of the reform, slowed the process of adoption of the law. In particular, pilot projects made clear that the participation of ambulatories is doomed to be low unless appropriate incentives are put in place. Moreover, most stakeholders point at the strategy proposed to finance technical implementation and management of EHRs as a major drawback. After two years of intense preparatory work, the law entered into force in April 2017.

Swiss popular initiative for a single health insurer once again!

The article describes a recent Swiss popular initiative, aiming to replace the current system of statutory health insurance run by 61 competing private insurers with a new system run by a single public insurer. Despite the rejection of the initiative by 62% of voters in late September 2014, the campaign and ballot results are interesting because they show the importance of (effective) public communication in shaping the outcome of a popular ballot. The relevance of the Swiss case goes beyond the peculiarities of its federalism and direct democracy and might be useful for other countries debating the pros and cons of national unitary health insurance systems versus models using multiple insurers. After this electoral ballot, the project to establish a public sickness fund in Switzerland seems definitely stopped, at least for the next decade. Insurers, who opposed the initiative, have effectively fed the "fear of change" of the population and have stressed the good outcomes of the Swiss healthcare system. However, the political pressure favoured by the popular initiative opened a "windows of opportunity" and led the federal Parliament to pass a stricter regulation of health insurers, improving in this way the current system.

Switzerland: Health System Review.

This analysis of the Swiss health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Swiss health system is highly complex, combining aspects of managed competition and corporatism (the integration of interest groups in the policy process) in a decentralized regulatory framework shaped by the influences of direct democracy. The health system performs very well with regard to a broad range of indicators. Life expectancy in Switzerland (82.8 years) is the highest in Europe after Iceland, and healthy life expectancy is several years above the European Union (EU) average. Coverage is ensured through mandatory health insurance (MHI), with subsidies for people on low incomes. The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times, though managed care type insurance plans that include gatekeeping restrictions are becoming increasingly important. Public satisfaction with the system is high and quality is generally viewed to be good or very good. Reforms since the year 2000 have improved the MHI system, changed the financing of hospitals, strengthened regulations in the area of pharmaceuticals and the control of epidemics, and harmonized regulation of human resources across the country. In addition, there has been a slow (and not always linear) process towards more centralization of national health policy-making. Nevertheless, a number of challenges remain. The costs of the health care system are well above the EU average, in particular in absolute terms but also as a percentage of gross domestic product (GDP) (11.5%). MHI premiums have increased more quickly than incomes since 2003. By European standards, the share of out-of-pocket payments is exceptionally high at 26% of total health expenditure (compared to the EU average of 16%). Low and middle-income households contribute a greater share of their income to the financing of the health system than higher-income households. Flawed financial incentives exist at different levels of the health system, potentially distorting the allocation of resources to different providers. Furthermore, the system remains highly fragmented as regards both organization and planning as well as health care provision.

Switzerland: health system review

This analysis of the Swiss health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Swiss health system is highly complex, combining aspects of managed competition and “corporatism” (the integration of interest groups in the policy process) in a decentralized regulatory framework shaped by the influences of direct democracy. The health system performs very well with regard to a broad range of indicators. Coverage is ensured through mandatory health insurance (MHI), with subsidies for people on low incomes. The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times, though managed care type insurance plans that include gatekeeping restrictions are becoming increasingly important. Public satisfaction is high and quality is viewed to be good or very good. Reforms since 2000 have improved the MHI system, changed the financing of hospitals, strengthened regulations in the area of pharmaceuticals and the control of epidemics, and harmonized regulation of human resources across the country. In addition, there has been a slow process towards more centralization of national health policy-making. Nevertheless, a number of challenges remain: the costs of the health care system are well above the EU average; MHI premiums have increased more quickly than incomes since 2003; by European standards, the share of out-of-pocket payments is exceptionally high; low- and middle-income households contribute a greater share of their income to the financing of the health system than higher-income households; and the system remains highly fragmented as regards both organization and planning as well as health care provision.

Italian public health care organizations: specialization, institutional deintegration, and public networks relationships.

The Italian National Health Service (INHS) has undergone profound changes over the past three decades. With establishment of the INHS in 1978--a tax-based public health care system with universal coverage--one of the underlying principles was integration. The recognition of health and health care as requiring integrated answers led to the creation of a single public organization, the Local Health Unit, responsible for the health status of the population of its catchment area. At the beginning of the 1990s, the scenario radically changed. The creation of hospital trusts, the development of quasi-market mechanisms and management control tools, the adoption of a prospective payment system for reimbursing health care providers--all were signs of deintegration and institutional unbundling. Two structural changes have deeply sustained this deintegration: patients' empowerment and the increased possibilities for outsourcing practices. In more recent years, a new reintegration effort has occurred, often led by regional governments and based on institutional cooperation and network relationships. However, the earlier structural changes require innovative approaches and solutions if public health care organizations want to retain their leading role.

[Nurses and nephrology in Italy]. / Infermieri e nefrologia in Italia.

An acceleration in the professionalization of Italian nurses has taken place in recent years. This pattern, together with the increasing prevalence of kidney diseases and the decreasing number of active nephrologists, makes a new collaborative structure between nurses and nephrologists both possible and welcome. This article describes the recent changes and future prospects of the Italian nursing profession. Observations about nephrology are based on interviews conducted with key opinion leaders of nursing in nephrology and dialysis. Italian nurses have recently acquired a status of professional autonomy. Nursing training is now fully integrated in the university system and nurses have obtained more responsibilities and a higher status within healthcare organizations. Future developments may be related to the internal articulation of the profession, supported by master courses and specialist training. Another possible evolution refers to the ongoing restructuring of the healthcare system with an emphasis on nursing activities and skills rather than medical specialties, which will lead to new and stronger managerial roles for nurses. The increase in the prevalence of kidney diseases and the declining number of nephrologists will result in a change in the distribution and utilization of nephrology services. The professionalization of nurses allows a new work division with a task shift from doctors to nurses. Italian nephrologists should seek a preferential relationship with the nursing profession, also considering the nursing shortage in several regions. Possible means to accomplish this preferential relationship could be, in addition to task shifting, nurses' involvement in research, and support for postgraduate training.

[The demographic profile of Italian nephrologists]. / Il profilo demografico dei nefrologi Italiani.

For many years Italy has had more active physicians than most Western countries. However, the numerus clausus introduced in 1986 for entry into medical schools together with a sharp decrease in places available in specialty training have changed the situation dramatically and today several specialties suffer actual shortages. In such a situation, professional demography is crucial to outline possible developments for the medical profession and nephrology in particular. Our analysis of the medical profession as a whole was based on data from OECD (international comparative analysis) and the yearly estimate of the General Accounts Office (Italian NHS employees). For calculation of the nephrologists we used the administrative data of the members of the Italian Nephrology Society (SIN) and a survey run among nephrology units in the Lombardy region. Data for the university system (medical and specialty schools) were provided by the University Ministry. We found that Italy is no longer an outlier in terms of physician density compared with other Western countries. This ''normalization'' conceals the high concentration of doctors in the older cohorts and the insufficient number of new doctors to replace those leaving the profession for retirement or other reasons. These patterns are similar - and often more severe - in the case of Italian nephrologists. The aging and increasingly female population of Italian nephrologists calls for a major task shift of many activities to nurses and other healthcare professionals.

Ability to pay and equity in access to Italian and British National Health Services.

BACKGROUND: Equity in delivery and distribution of health care is an important determinant of health and a cornerstone in the long way to social justice. We performed a comparative analysis of the prevalence of Italian and British residents who have fully paid out-of-pocket for health services which they could have obtained free of charge or at a lower cost from their respective National Health Services. METHODS: Cross-sectional study based on a standardized questionnaire survey carried out in autumn 2006 among two representative samples (n = 1000) of the general population aged 20-74 years in each of the two countries. RESULTS: 78% (OR 19.9; 95% CI 15.5-25.6) of Italian residents have fully paid out-of-pocket for at least one access to health services in their lives, and 45% (OR 18.1; 95% CI 12.9-25.5) for more than five accesses. Considering only the last 2 years, 61% (OR 16.5; 95% CI 12.6-21.5) of Italians have fully paid out-of-pocket for at least one access. The corresponding pattern for British residents is 20 and 4% for lifelong prevalence, and 10% for the last 2 years. CONCLUSIONS: Opening the public health facilities to a privileged private access to all hospital physicians based on patient's ability to pay, as Italy does, could be a source of social inequality in access to care and could probably represent a major obstacle to decreasing waiting times for patients in the standard formal 'free of charge' way of access.

Как создать для медицинских работников привлекательную и благоприятную рабочую среду

Европейские страны сталкиваются с общими трудностями в обеспечении здравоохранения грамотными и добросовестными работникамив условиях дефицита кадров, который существует сегодня и прогнозируется в будущем. Одним из многих факторов, определяющих обеспеченность медицинскими работниками и качество их работы, является рабочая среда, которая играет исключительно важную роль. В предлагаемом кратком аналитическом обзоре рассматриваютсястратегические подходы, которые можно принять для того, чтобы помочь в создании позитивной рабочей среды и тем самым улучшить положение дел с наймом на работу новых медицинских работников и сохранениемимеющихся кадров и тем самым способствовать достижению высокого качества медико-санитарных услуг. Вопросы, связанные с рабочей средой, обычно касаются всех медицинских работников в службах здравоохранения всех типов (с теми или иными различиями в зависимости от особенностей профессиональных функций и места работы). Не отрицая важности этихвопросов для других профессиональных категорий в секторе здравоохранения, авторы данного аналитического обзора главное внимание уделили подходам, касающимся врачей и медицинских сестер, так как онипредставляют наиболее многочисленный отряд медицинских работников.

Wie lässt sich ein attraktives und unterstützendes Arbeitsumfeld für Fachkräfte des Gesundheitswesens schaffen?

Die europäischen Länder stehen vor der gemeinsamen Herausforderung, in Zeiten bestehender und prognostizierter Personalknappheiten einen gut funktionierenden Fachkräftebestand im Gesundheitswesen sicherzustellen. Von den vielen Aspekten, die Versorgung mit entsprechenden Fachkräften undderen Leistung bestimmen, spielt das Arbeitsumfeld eine entscheidende Rolle. Dieses Grundsatzpapier betrachtet politische Ansätze, die zur Schaffung eines positiven Arbeitsumfelds eingesetzt werden können, und die auf diese Weise die Rekrutierung und Bindung von Fachkräften im Gesundheitswesen verbessernund zum Erreichen hochwertiger Gesundheitsdienstleistungen beitragen. Fragendes Arbeitsumfelds betreffen im Allgemeinen alle Arbeitnehmer in allen Arten von Gesundheitsdienstleistungen – mit Abweichungen, die von den Merkmalen der beruflichen Funktion oder Arbeitssituation abhängen. Dieses Grundsatzpapier beschäftigt sich schwerpunktmäßig mit Ansätzen für Ärzte und Pflegepersonal, da diese den größten Teil der Beschäftigten im Gesundheitswesen ausmachen,ohne dass damit die Relevanz für andere Berufsgruppen ausgeschlossen wird.

Comment créer un environnement de travail attractif et stimulant pour les professionnels de la santé ?

Les pays européens sont confrontés à des défis communs pour garantir un personnel de santé très performant à une époque de pénuries existantes et projetées. L'un des multiples aspects qui déterminent l'offre et les performances des professionnels de la santé est l'environnement de travail, qui joue un rôle essentiel. Cette synthèse envisage les approches politiques qui peuvent être employées pour aider à créer des environnements de travail positifs, améliorant ainsi le recrutement et la fidélisation des professionnels de la santé et contribuant à la réalisation de services de santé d'excellente qualité. Les questions d'environnement professionnel s'appliquent généralement à tous les travailleurs de la santé dans tous les types de services de santé - avec des variations selonles caractéristiques des fonctions professionnelles ou milieux de travail. Sans exclure leur importance pour d'autres catégories professionnelles dans le secteur de la santé, cette synthèse se concentre sur des approches pour les médecins et infirmières étant donné que ces derniers composent majoritairement le personnel de la santé.

How to create an attractive and supportive working environment for health professionals

European countries face common challenges in ensuring a well-performing health workforce in times of existing and projected shortages. Among the multiple aspects that determine the supply and performance of health workers, the work environment plays a critical role. This policy brief considers policy approaches that can be employed to help create positive work environments, thus improving the recruitment andretention of health professionals and contributing to the achievement of high-quality health services. Work-environment issues generally apply to all health workers in all types of health services – with variations according to the characteristics of professional functions or work settings. Without excluding their relevance for other professional groups in the health sector, this policy brief focuses on approaches for physicians and nurses, as they represent the largest constituents of the health workforce.