Denmark: health system review

This analysis of the Danish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Population health in Denmark isgood and improving, with life expectancy above the European Union average but is, however, lagging behind the other Nordic countries. Denmark has a universal and tax-financed health system, providing coverage for acomprehensive package of health services. Notable exclusions to the benefits package include outpatient prescription drugs and adult dental care, which require co-payment and are the main causes of out-of-pocket spending. The hospital sector has been transformed during the past 15 years through a process of consolidating hospitals and the centralization of medical specialties. However, in recent years, there has been a move towards decentralization to increase the volume and quality of care provided outside hospitals in primary and local care settings. The Danish health care system is, to a very high degree, based on digital solutions that health care providers, citizens and institutions all use. Ensuring the availability of health care in all parts of Denmark is increasingly seen as a priority issue.Ensuring sufficient health workers, especially nurses, poses a significant challenge to the Danish health system’s sustainability and resilience. While a comprehensive package of policies has been put in place to increase thenumber of nurses being trained and retain those already working in the system, such measures need time to work. Addressing staffing shortages requires long-term action. Profound changes in working practices and workingenvironments will be required to ensure the sustainability of the health workforce and, by extension, the health system into the future.

Elimination of a Postoperative Brace Does Not Increase Complications Following Hip Arthroscopy.

Background The practice of routine postoperative bracing to limit abduction and internal rotation, along with weight-bearing restrictions after hip arthroscopy (HA), varies significantly among surgeons. It is unclear whether the use of a postoperative brace improves short-term outcomes in patients undergoing HA. The purpose of this study was to determine the differences in patient outcomes before and after eliminating routine usage of a postoperative brace. Methods A retrospective review was conducted of 176 adult patients undergoing HA by a single, high-volume surgeon. The no-brace protocol was implemented in October 2020. The patients were divided into two groups: pre-implementation (January-October 2020) and post-implementation (October 2020-April 2021). Twenty-three patients that used a brace during the post-implementation period were excluded. All patients had weight-bearing restrictions with crutches for three weeks postoperatively. The primary endpoint was any complication in the first six weeks postoperatively. Results There were no significant differences in demographics between groups, although the body mass index in the brace group was higher (28.1 vs. 26.4 kg/m2, p = 0.066) and the rate of additional procedures performed was higher in the brace group (55.2% vs. 40.1%, p = 0.056). There was no significant difference in postoperative outcomes between groups when looking at 90-day emergency department visits (1.7% vs. 0%, p = 0.548), complications at two (1.7% vs. 1.7%, p = 1.000) and six weeks (0% vs. 1.7%, p = 0.341) postoperatively, all complications in the first six weeks (1.7% vs. 1.7%, p = 1.000), and continued pain at six weeks (10.3% vs. 16.7%, p = 0.238). Conclusion The brace and no-brace groups were similar demographically. Patients undergoing HA with no brace and crutches experienced no significant differences in pain or complications in comparison to those receiving a traditional bracing protocol. Routine use of a postoperative brace may not be necessary in this population.

What have European countries done to prevent the spread of COVID-19? Lessons from the COVID-19 Health system response monitor.

Although some European countries imposed measures that successfully slowed the transmission of Covid-19 during the first year of the pandemic, others struggled, either because they acted slowly or implemented measures ineffectively. In this paper we consider the European experience with public health measures designed to prevent transmission of COVID-19. Based on literature and country responses described in the COVID-19 Health System Response Monitor from March 2020 to December 2020, we consider some critical aspects of public health policy responses. These include the importance of public health capacity that can scale up surveillance and outbreak control, including effective testing and contract tracing, of clear messaging based on an understanding of human behaviour, policies that address the undesirable consequences of necessary measures, such as support for those isolating or unable to earn, and the ability to implement at pace and scale a major vaccine rollout. We conclude that for countries to be successful at preventing COVID-19 transmission, there is a need for a clear strategy with explicit goals and a whole systems approach to implementation.

Using Targets to Reduce Waiting Times for Elective Care: What Can We Learn from the Russian Experience?

This article explores the potential for maximum waiting times targets to improve access to healthcare in a country with limited financial resources. The study combines policy analysis, off-the-record communications, face-to-face interviews, public opinion surveys and open access patient complaints to create a rich picture of how waiting time targets are monitored and implemented in theory and practice. The study found that most waiting time targets in the Russian Federation are unrealistically low, while institutional and operational arrangements for their implementation have not been built in most regions. Estimates of actual waiting times are fragmented and unreliable. The lack of meaningful regulation and monitoring encourages opportunistic behavior among health providers to meet the targets while there is growing uncertainty among patients. Maximum waiting times targets alone are insufficient to reduce excessive waiting times. Successful implementation relies on robust data systems and standardized measurements for waiting times as well as meaningful regulation and monitoring.

Disability and loneliness in nine countries of the former Soviet Union.

BACKGROUND: People with disabilities (PWD) often face structural and other barriers to community involvement and may therefore be at risk of loneliness. Yet, so far, this issue has received little attention. OBJECTIVE: This cross-sectional study aimed to examine the association between disability and loneliness in nine countries of the former Soviet Union (FSU). METHODS: Data were analyzed from 18000 respondents aged ≥18 that came from the Health in Times of Transition (HITT) survey that was undertaken in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine in 2010/11. Respondents reported on whether they had a disability (no/yes) and its severity. A single-item question was used to assess loneliness. Logistic regression analysis was used to examine the associations. RESULTS: Across the countries, 6.8% of respondents reported being disabled. In a fully adjusted combined country analysis, disability was associated with higher odds for loneliness (odds ratio: 1.30, 95% confidence interval: 1.06-1.60). In an analysis restricted to PWD, individuals in the most severe disability category (Group 1) had over two times higher odds for loneliness when compared to those in the least severe disability category (Group 3). CONCLUSIONS: Disability is associated with higher odds for reporting loneliness in the FSU countries and this association is especially strong among those who are more severely disabled. An increased focus on the relationship between disability and loneliness is now warranted given the increasing recognition of loneliness as a serious public health problem that is associated with a number of detrimental outcomes.

Организация и предоставление услуг вакцинации в Европейском союзе: Подготовлено для Европейской комиссии

В последние годы в Европейском союзе неоднократно отмечались серьезные вспышки болезней, предупреждаемых с помощью вакцин, с увеличением числа заболевших и умерших. В рамках настоящего исследования, проведенного по заказу Европейской комиссии, была собрана информация об организации и предоставлении услуг вакцинации в ЕС, с особым вниманием к вакцинации детей против кори и к вакцинации взрослых против гриппа. В отчете приводятся систематический обзор факторов, имеющих отношение к системе здравоохранения, сравнительный анализ примеров из опыта стран и серия схем с описанием организации и осуществления программ вакцинации в странах ЕС.Авторы отчета отмечают существенные различия между странами ЕС в том, что касается стратегического руководства, предоставления и финансирования услуг вакцинации. В частности, эти различия касаются типов поставщиков услуг вакцинации: например, все большую роль в проведении вакцинации против гриппа для взрослых играют аптеки. Также отмечается, что вакцинация против кори в детском возрасте является обязательной в 9 странах ЕС и при этом осуществляется бесплатно (в месте получения услуги) во всех странах ЕС, в то время как вакцинация против гриппа почти во всех странах ЕС является добровольной, и при этом в 7 странах взрослые, получающие вакцину, должны по крайней мере частично оплачивать эту услугу. Авторы утверждают, что главные препятствия на пути к улучшению охвата вакцинацией связаны с факторами, имеющими отношение к предоставлению и финансированию услуг, а также с недоверием к вакцинам и недостаточной осведомленностью о них. Помимо этого, некоторые сложности отмечаются и в контексте стратегического руководства.

Primary care use and cardiovascular disease risk in Russian 40-69 year olds: a cross-sectional study.

BACKGROUND: The Russian Federation has very high cardiovascular disease (CVD) mortality rates compared with countries of similar economic development. This cross-sectional study compares the characteristics of CVD-free participants with and without recent primary care contact to ascertain their CVD risk and health status. METHODS: A total of 2774 participants aged 40-69 years with no self-reported CVD history were selected from a population-based study conducted in Arkhangelsk and Novosibirsk, Russian Federation, 2015-2018. A range of co-variates related to socio-demographics, health and health behaviours were included. Recent primary care contact was defined as seeing primary care doctor in the past year or having attended a general health check under the 2013 Dispansarisation programme. RESULTS: The proportion with no recent primary care contact was 32.3% (95% CI 29.7% to 35.0%) in males, 16.3% (95% CI 14.6% to 18.2%) in females, and 23.1% (95% CI 21.6% to 24.7%) overall. In gender-specific age-adjusted analyses, no recent contact was also associated with low education, smoking, very good to excellent self-rated health, no chest pain, CVD 10-year SCORE risk 5+%, absence of hypertension control, absence of hypertension awareness and absence of care-intensive conditions. Among those with no contact: 37% current smokers, 34% with 5+% 10-year CVD risk, 32% untreated hypertension, 20% non-anginal chest pain, 18% problem drinkers, 14% uncontrolled hypertension and 9% Grade 1-2 angina. The proportion without general health check attendance was 54.6%. CONCLUSION: Primary care and community interventions would be required to proactively reach sections of 40-69 year olds currently not in contact with primary care services to reduce their CVD risk through diagnosis, treatment, lifestyle recommendations and active follow-up.

Understanding the role of physicians within the managerial structure of Russian hospitals.

This article examines the role of physicians within the managerial structure of Russian hospitals. A comparative qualitative methodology with a structured assessment framework is used to conduct case studies that allow for international comparison. The research is exploratory in nature and comprises 63 individual interviews and 49 focus groups with key informants in 15 hospitals, complemented by document analysis. The material was collected between February and April 2017 in five different regions of the Russian Federation. The results reveal three major problems of hospital management in the Russian Federation. First, hospitals exhibit a leaky system of coordination with a lack of structures for horizontal exchange of information within the hospitals (meso-level). Second, at the macro-level, the governance system includes implementation gaps, lacking mechanisms for coordination between hospitals that may reinforce existing inequalities in service provision. Third, there is little evidence of a learning culture, and consequently, a risk that the same mistakes could be made repeatedly. We argue for a new approach to governing hospitals that can guide implementation of structures and processes that allow systematic and coherent coordination within and among Russian hospitals, based on modern approaches to accountability and organisational learning.

The role of public health organizations in addressing public health problems in Europe: the case of obesity, alcohol and antimicrobial resistance

Growing levels of overweight and obesity, continued harmful consumption of alcohol, and the growing threat of AMR are some of the greatest challenges to the health of European populations. While the magnitude of these problems varies from country to country, they affect all countries in Europe. For each problem, it is clear that public health agencies and organizations must play a part in any response, with intersectoral action beyond the health system needed. What is less clear is what role public health organizations currently play in addressing these problems.This is the gap that this volume aims to fill. It is based on country reports from eight European countries (England, France, Germany, Italy, the Republic of Moldova, the Netherlands, Poland, and Sweden) on the involvement of public health organizations in addressing alcohol consumption and obesity and on reports from nine European countries (England, France, Germany, Italy, the Republic of Moldova, the Netherlands, Poland, Slovenia and Sweden) on their involvement in addressing antimicrobial resistance.This web edition includes Country reports – appendix to The role of public health organizations in addressing public health problems in Europe: the case of obesity, alcohol and antimicrobial resistance (2018; ISBN 9789289051712).

The organization and delivery of vaccination services in the European Union: prepared for the European Commission

In recent years, the European Union has been facing serious outbreaks of vaccine-preventable diseases, with an increasing number of cases and deaths. This study, undertaken at the request of the European Commission, collates information on the organization and delivery of vaccination services in the EU, with a focus on childhood vaccinations against measles and adult vaccinations against influenza. It provides a systematic review of health system related factors, a comparative analysis of country experiences and a suite of fiches that describe the organization and delivery of vaccination programmes in EU member states. The report finds that there are substantial differences in the governance, provision and financing of vaccination services across EU member states. This includes differences in the types of health care providers involved, with, for example, an increasing role for pharmacies in providing adult vaccinations against influenza. The report also notes that childhood vaccination against measles is mandatory in nine EU member states but free at the point of delivery in all EU member states, whilst adult vaccination against influenza is voluntary in almost all EU member states, but in seven countries adults targeted by influenza vaccinations have to pay at least part of the costs of vaccination. The report calls attention to the fact that, despite some challenges in the governance, provision and financing of vaccination services, vaccine hesitancy and lack of awareness are the greatest barriers to improving vaccination coverage.

The role of public health organizations in addressing public health problems in Europe: the case of obesity, alcohol and antimicrobial resistance

Growing levels of obesity (including among children), continued harmful consumption of alcohol and the growing threat of antimicrobial resistance (AMR) are some of the greatest contemporary challenges to the health of European populations. While their magnitude varies from country to country, all are looking for policy options to contain these threats to population health. It is clear that public health organizations must play a part in any response, and that intersectoral action beyond the health system is needed. What is less clear, however, is what role public health organizations currently play in addressing these problems. This is the gap that this volume aims to fill. It is based on detailed country reports from nine European countries (England, France, Germany, Italy, the Republic of Moldova, the Netherlands, Poland, Slovenia and Sweden) on the involvement of public health organizations in addressing obesity, alcohol and antimicrobial resistance. These reports explore the power and influence of public health organizations vis-a-vis other key actors in each of the stages of the policy cycle (problem identification and issue recognition, policy formulation, decision-making, implementation, and monitoring and evaluation). A cross-country comparison assesses the involvement of public health organizations in the nine countries covered. It outlines the scale of the problem, describes the policy responses, and explores the role of public health organizations in addressing these three public health challenges. This study is the result of close collaboration between the European Observatory on Health Systems and Policies and the WHO Regional Office for Europe, Division of Health Systems and Public Health. It accompanies two other Observatory publications: Organization and financing of public health services in Europe and Organization and financing of public health services in Europe: country reports.

Organization and financing of public health services in Europe: country reports

What are “public health services”? Countries across Europe understand what they are, or what they should include, differently. This study describes the experiences of nine countries, detailing the ways they have opted to organize and finance public health services, and train and employ their public health workforce. It covers England, France, Germany, Italy, the Netherlands, Slovenia, Sweden, Poland and the Republic of Moldova, and aims to give insights into current practice that will support decision-makers in their efforts to strengthen public health capacities and services. Each country chapter captures the historical background of public health services and the context in which they operate; sets out the main organizational structures; assesses the sources of public health financing and how it is allocated; explains the training and employment of the public health workforce; and analyses existing frameworks for quality and performance assessment. The study reveals a wide range of experience and variation across Europe and clearly illustrates two fundamentally different approaches to public health services: integration with curative health services (as in Slovenia or Sweden) or organization and provision through a separate parallel structure (Republic of Moldova). The case studies explore the context that explain this divergence and its implications. This study is the result of close collaboration between the European Observatory on Health Systems and Policies and the WHO Regional Office for Europe, Division of Health Systems and Public Health. It accompanies two other Observatory publications: Organization and financing of public health services in Europe and The role of public health organizations in addressing public health problems in Europe: the case of obesity, alcohol and antimicrobial resistance.

Georgia: Health System Review.

This analysis of the Georgian health system reviews developments in its organization and governance, health financing, health care provision, health reforms and health system performance. Since 2012, political commitment to improving access to health care, to protecting the population from the financial risks of health care costs and to reducing inequalities has led to the introduction of reforms to provide universal health coverage. Considerable progress has been made. Over 90% of the resident population became entitled to a tightly defined package of state-funded benefits in 2013; previously, only 45% of the population had been eligible. The package of services has variable depth of coverage depending on the groups covered, with the lowest income groups enjoying the most comprehensive benefits. To finance the broader coverage, the government increased health spending significantly, although this remains low in international comparisons. Out-of-pocket (OOP) payments have fallen as public spending has increased. Nevertheless, current health expenditure (CHE) is still dominated by OOP payments (57% in 2015), two thirds of which are for outpatient pharmaceuticals. For this reason, in July 2017, the package of benefits was expanded for the most vulnerable households to cover essential medicines for four common chronic conditions. The system has retained extensive infrastructure with strong geographical coverage. Georgia also has a large number of doctors per capita, but an acute shortage of nurses. Incentives in the system for patients and providers favour emergency and inpatient care over primary care. There are also limited financial incentives to improve the quality of care and a lack of disincentives to inhibit poor quality care. Future reform plans focus on ensuring universal access to high-quality medical services, strengthening primary care and public health services, and increasing financial protection.

Georgia: health system review

This analysis of the Georgian health system reviews developments in its organization and governance, health financing, health care provision, health reforms and health system performance. Since 2012, political commitment to improving access to health care, to protecting the population from the financial risks of health care costs and to reducing inequalities has led to the introduction of reforms to provide universal health coverage. Considerable progress has been made. Over 90% of the resident population became entitled to a tightly defined package of state-funded benefits in 2013; previously, only 45% of the population had been eligible. The package of services has variable depth of coverage depending on the groups covered, with the lowest income groups enjoying the most comprehensive benefits. To finance the broader coverage, the government increased health spending significantly, although this remains low in international comparisons. Out-of-pocket (OOP) payments have fallen as public spending has increased. Nevertheless, current health expenditure is still dominated by OOP payments (57% in 2015), two thirds of which are for outpatient pharmaceuticals. For this reason, in July 2017, the package of benefits was expanded for the most vulnerable households to cover essential medicines for four common chronic conditions. The system has retained extensive infrastructure with strong geographical coverage. Georgia also has a large number of doctors per capita, but an acute shortage of nurses. Incentives in the system for patients and providers favour emergency and inpatient care over primary care. There are also limited financial incentives to improve the quality of care and a lack of disincentives to inhibit poor quality care. Future reform plans focus on ensuring universal access to high-quality medical services, strengthening primary care and public health services, and increasing financial protection.