Meeting the challenges of the 21st century: the fundamental importance of trust for transformation.

BACKGROUND: This paper is one of a collection on challenges facing health systems in the future. One obvious challenge is how to transform to meet changing health needs and take advantage of emerging treatment opportunities. However, we argue that effective transformations are only possible if there is trust in the health system. MAIN BODY: We focus on three of the many relationships that require trust in health systems, trust by patients and the public, by health workers, and by politicians. Unfortunately, we are seeing a concerning loss of trust in these relationships and, for too long, the importance of trust to health policymaking and health system functioning has been overlooked and under-valued. We contend that trust must be given the attention, time, and resources it warrants as an indispensable element of any health system and, in this paper, we review why trust is so important in health systems, how trust has been thought about by scholars from different disciplines, what we know about its place in health systems, and how we can give it greater prominence in research and policy. CONCLUSION: Trust is essential if health systems are to meet the challenges of the 21st century but it is too often overlooked or, in some cases, undermined.

Understanding the Language of Health Reform.

ABSTRACT: COVID-19 has accelerated the dialogue surrounding access to health insurance, including the potential for a public option, "Medicare for All," or modification of the 2010 Affordable Care Act. A dizzying array of terms and assertions surround these health policy discussions, as well as misrepresentation and lack of specificity. This article offers a primer on contemporary reform terms and options that are likely to be prominent over the next several years and outlines some health care-related elements of the American Rescue Plan Act, a massive COVID-relief act passed in March 2021. The aim of this nonpartisan overview is to enhance nurses' understanding of these terms as a basis for effective participation in public policy and patient advocacy.

Policy and vision for community pharmacies in Finland: a roadmap towards enhanced integration and reduced costs

Finland's community pharmacy system provides an example of a privately-owned regulated system being proactively developed by the profession and its stakeholders. Community pharmacists have a legal duty to promote safe and rational medicine use in outpatient care. The development of professionally oriented practice has been nationally coordinated since the 1990s with the support of a national steering group consisting of professional bodies, authorities, pharmacy schools and continuing education centers. The primary focus has been in patient counseling services and public health programs. The services have extended towards prospective medication risk management applying evidence-based tools, databases and digitalization. Research has been essential in informing progress by indicating high-risk patients, medications, practices and processes needing improvement. Despite the commitment of the profession and pharmacy owners, large-scale implementation of services has been challenging because of lack of remuneration, the pharmacy income still consisting primarily of sale of prescription and nonprescription medicines. Policy documents by the Ministry of Social Affairs and Health have supported the extension of the community pharmacists' role beyond traditional dispensing to promote rational pharmacotherapy. The current roadmap by the Ministry of Social Affairs and Health emphasizes ensuring adequate regional availability and accessibility of medicines, regardless of the future pharmacy system. It also emphasizes the importance of strong regulation on pharmacy business operations and sale of medicines to ensure medication safety. At the same time, the roadmap requires that the regulation must enable implementation of new patient-oriented services and procedures, and further promote digitalization in service provision. Competition and balance of funding should be enhanced, e.g., through price competition, but the risk of pharmaceutical market concentration should be managed. The regulation should also consider influence of the new social and health care system on drug delivery. Year 2021 will be crucial for making long-term political decisions on the future direction of tasks and finances of Finnish community pharmacies in this framework. Government-funded studies are underway to guide decision making. Ongoing Covid-19 crisis has demonstrated the readiness of Finnish community pharmacies to adapt fast to meet the changing societal needs

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COVID-19: The Time for Collaboration Between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now.

Policy Points To address systemic problems amplified by COVID-19, we need to restructure US long-term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near-term and long-term policy solutions. Seven near-term policy recommendations include requiring the uniform public reporting of COVID-19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations. Long-term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age-friendly public health system. CONTEXT: The heavy toll of COVID-19 brings the failings of the long-term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID-19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long-term disinvestment and neglect of state- and local-level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes. METHODS: We analyze several impacts of the COVID-19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states' fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems. FINDINGS: We propose seven near-term actions that US policymakers could take: implementing a uniform public reporting of COVID-19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age-friendly public health system. CONCLUSIONS: COVID-19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.

Realizing the right to health in Latin America, equitably.

This special issue "Realizing the Right to Health in Latin America and the Caribbean" provides an overview of one of the most challenging objectives of health systems: equity and the realization of the right to health. In particular, it concentrates on the issues associated with such a challenge in countries suffering of deep inequity. The experience in Latin America and the Caribbean demonstrates that the efforts of health systems to achieve Universal Health Coverage are necessary but not sufficient to achieve an equitable realization of the right to health for all. The inequitable realization of all other human rights also determines the realization of the right to health.

Networks of Care in Rural Madagascar for Achieving Universal Health Coverage in Ifanadiana District.

Health care is most effective when a patient's basic primary care needs are met as close to home as possible, with advanced care accessible when needed. In Ifanadiana District, Madagascar, a collaboration between the Ministry of Public Health (MoPH) and PIVOT, a non-governmental organization (NGO), fosters Networks of Care (NOC) to support high-quality, patient-centered care. The district's health system has three levels of care: community, health center, district hospital; a regional hospital is available for tertiary care services. We explore the MoPH/PIVOT collaboration through a case study which focuses on noteworthy elements of the collaboration across the four NOC domains: (I) agreement and enabling environment, (II) operational standards, (III) quality, efficiency, and responsibility, (IV) learning and adaptation. Under Domain I, we describe formal agreements between the MoPH and PIVOT and the process for engaging communities in creating effective NOC. Domain II discusses patient referral across levels of the health system and improvements to facility readiness and service availability. Under Domain III the collaboration prioritizes communication and supervision to support clinical quality, and social support for patients. Domain IV focuses on evaluation, research, and the use of data to modify programs to better meet community needs. The case study, organized by the domains of the NOC framework, demonstrates that a collaboration between the MoPH and an NGO can create effective NOC in a remote district with limited accessibility and advance the country's agenda to achieve universal health coverage.

Towards universal health coverage: lessons learnt from the COVID-19 pandemic in Africa.

With social distancing being a key preventative measure of COVID-19, proper provision of healthcare services becomes a challenge as healthcare professionals are concerned about the risk of potential infection. Telemedicine, a practice that uses telecommunication networks for the delivery of healthcare services and medical education, has been adopted by several countries and has shown to provide positive outcomes. This concept is poorly practiced in African Countries compared to other countries of the world. This paper reiterates the need for the expansion of telemedical systems in Africa for the dual goals of COVID-19 prevention and provision of quality healthcare services to people.

Determinants of patient satisfaction: Lessons from large-scale inpatient interviews in Vietnam.

Patient satisfaction, a healthcare recipient's reaction to salient aspects of their service experience, has been considered an important metric of the overall quality of healthcare in both advanced and developing countries. Given the growing number of studies on patient satisfaction in developing and transitioning countries, publications using high-quality patient surveys in these countries remain scarce. This study examines factors associated with inpatient satisfaction levels using nationwide, large-scale interview data from 10,143 randomized and voluntary patients of 69 large and public hospitals in Vietnam during 2017-2018. We find that older patients, poor patients, female patients, patients with lower levels of education, patients not working for private enterprises (or foreign enterprises), and rural patients reported higher levels of overall satisfaction. Health insurance is found to have positive influence on overall patient satisfaction, primarily driven by limiting patient concerns about treatment costs, as well as increasing positive perceptions of hospital staff. We further find that patients who paid extra fees for their hospital admission expressed higher scores for hospital living arrangements and medical staff, but were mostly dissatisfied with treatment costs. These findings have important policy implications for current policy makers in Vietnam as well as for other countries with limited healthcare resources and ongoing healthcare reforms.

Is there a silver lining for US health care from COVID-19 pandemic?

The COVID-19 pandemic has had an impact on economy and health care system of every nation. United States has been the hardest hit country both with incidence and absolute mortality from COVID-19. In some of its states the health care system have been stretched to their limits. This has led to a rapid change in the health care practice due to newly approved emergency legislative bills, new state government laws, measures taken by institutions and practices as well as the changing consumer behavior. Some of these adaptations - in particular, the transition of patient care to virtual visits are revolutionary. Increased vigilance by health care organization and workers to minimize the spread of infection to others as well for personal protection may result in lasting behavioral change that will prevent hospital acquired or transmitted infections and may lead to reduced morbidity and mortality from the regular "flu". The recycling of personal protective equipment and the emerging research showing it a safe practice will reduce health care expenditure. It is quite possible that this pandemic may be the silver lining that will save the US health care from its unsustainable consumption of US gross domestic product.

Health Reform in the Midst of a Social and Political Crisis in Chile, 2019-2020.

The protests in Chile in October 2019 raised the issue of health reform to the public agenda again. This article reviews some of the explanations for why there was a widespread protest, including the expectations of continued progress, the emergence of a "fear-based populism" and the decline in legitimacy of most social and political actors. Using the theories of Kingdon to explain how reforms are placed on the political agenda, we describe how the protests raised health reform as a problem to be addressed, discuss the tendency toward consensus on policy options by technical health reform advocates, and examine the uncertain political processes that would be necessary for a consensus reform to be adopted and implemented. A lesson for reformers is the need to pay attention to growing signs of popular resentment over failures of health reforms to address accumulating problems and to try to address them with urgency to avoid populist crises.

First-Line Nurse Managers' Challenges at the Crossroads of Norwegian Health Care Reforms.

Norwegian municipal health care has large public service offerings, funded by tax revenues; however, the current Norwegian welfare model is not perceived as sustainable and future-oriented. First-line nurse managers in Norwegian municipal health care are challenged by changes due to major political and government-initiated reforms requiring expanded utilization of home nursing. The aim of this theoretical study was to describe challenges the first-line nurse managers in a Nordic welfare country have encountered on the basis of government-initiated reforms and to describe strategies to maintain their responsibilities in nursing care. First-line nurse managers' competence, clinical presence, and support from superiors were identified as prerequisites to maintain sight of the patients in leadership when reforms are implemented. The strategies first-line nurse managers in Norwegian municipal health care use to implement multiple reforms, regulations, and new acts require solid competencies in nursing, leadership, and administration. Competence in nursing enables focus on the patient while leading the staff. Supports from superiors and formal leadership networks are described as prerequisites for managing the challenges posed by change and to persist in leadership positions.

From public vs. private to public/private mix in healthcare: lessons from the Israeli and the Spanish cases.

BACKGROUND: Different forms of public/private mix have become a central mode of the privatization of healthcare, in both financing and provision. The present article compares the processes of these public/private amalgams in healthcare in Spain and Israel in order to better understand current developments in the privatization of healthcare. MAIN TEXT: While in both Spain and Israel combinations between the public and the private sectors have become the main forms of privatization, the concrete institutional forms differ. In Spain, these institutional forms maintain relatively clear boundaries between the private and the public sectors. In Israel, the main forms of public/private mix have blurred such boundaries: nonprofit health funds sell private insurance; public nonprofit health funds own private for-profit hospitals; and public hospitals sell private services. CONCLUSIONS: Comparison of the processes of privatization of healthcare in Spain and Israel shows their variegated characters. It reveals the active role played by national and regional state apparatuses as initiators and supporters of healthcare reforms that have adopted different forms of public/private mix. While in Israel, until recently, these processes have been perceived as mainly technical, in Spain they have created deep political rifts within both the medical community and the public. The present article contains lessons each country can learn from the other, to be adapted in each one's local context: The failure of the Alzira model in Spain warns us of the problems of for-profit HMOs and the Israeli private private/public mix shows the risk of eroding trust in the public system, thus reinforcing market failures and inefficient medical systems.