Health System Development Research Articles

Lessons from COVID-19

COVID-19 was one of the costliest and deadliest pandemics in the recent history of pandemics. Despite many warnings, the world was not prepared for it. The complexity of the nature of the virus and weak national health systems made monitoring of its progress difficult, despite the leadership that the World Health Organization displayed. This paper reviews the origins of COVID-19 and the human and financial costs of its spread, even among developed countries. Vaccines were an important innovation emerging from the tragedy that illustrated the importance of international cooperation between developed and developing countries and offered important lessons for the future. This paper makes the case for continued development and investment of health systems both in developing and developed countries as a critical pillar of development.

Developing an ISO 45001-based OHSMS for a Bogotá, Colombia real estate and property development company

Today, many organizations are seeking to implement continuous improvement plans not only to achieve greater economic benefits but also to improve the quality of life for their employees. The importance of reducing and preventing workplace accidents, protecting the health and well-being of employees, and preventing work-related illnesses has increased. This article focuses on the development of an Occupational Health and Safety Management System (OHSMS) for an organization in the real estate and property development services sector in Bogotá. The design of the OHSMS is based on the identification of the deficiencies of the current system and the proposal of continuous improvement, according to the ISO 45001: 2018 standard. The design process included three stages of research: 1. initial diagnosis, 2. hazard and risk assessment, and 3. management system performance assessment with appropriate controls and indicators. This article evaluates working conditions in production and in enclosed spaces, such as offices. The integration of these aspects ensures a comprehensive vision of occupational health and safety in real estate and property development companies. The design of the OHSMS is an essential step towards the continuous improvement of working conditions and the well-being of employees. Compliance with the ISO 45001: 2018 standard aims to ensure a safe and healthy working environment for all members of the organization.

SmartEUS: An Integrated Dynamic Platform For The Innovation Of Healthcare Emergency-Urgency Services

The SmartEUS project aims to design, develop, and test a highly innovative model for the provision of Emergency Urgency Services (EUS) based on the concept of clinical pathway (i.e., the entire emergency care chain). The project is innovative both from an organizational and technological point of view. It is based on an e-Health approach, capable of exploiting new digital technologies in a coordinated way to support the evolution of emergency health systems towards dynamic and safer processes. The paper presents the SmartEUS platform which can integrate the information from all the key players in medical emergency response (emergency operation center, emergency medical service, hospital emergency department) improving their coordination. The most relevant innovations of the proposed solution are data integration and interoperability, advanced communication and collaboration, knowledge-based resource allocation, telemedicine integration to support decision making in dispatching and resource assignment. In fact, a Decision Support System is integrated into SmartEUS cloud platform to suggest to the emergency operation center which emergency medical service and hospital emergency department. In fact, information on the patient status can include results from ambulance’s on board telediagnosis equipment, alerting the hospital emergency department even before the arrive of the patient, thus guaranteeing the appropriateness of care according to patient needs (e.g., patient pre-triage index, potential pre-hospital diagnosis) and reducing emergency department overcrowding and resources saturation.

The evolution of health system planning and implementation of maternal telehealth services during the COVID-19 Pandemic.

Differential access to healthcare is associated with disparities in maternal outcomes. Telehealth is one approach for improving access to maternal services. However, little is known regarding how health systems leverage telehealth to close the access gap. This study examines how health systems have approached decisions about using telehealth for maternal services before and during the COVID-19 public health emergency and what factors were considered. We conducted semi-structured interviews with 15 health system leaders between July and October 2021 and June and August 2022. We used a rapid analysis followed by a content analysis approach. Five health systems did not provide maternal telehealth services before the PHE due to a lack of reimbursement. Two health systems provided limited services as research endeavors, and one had integrated telehealth into routine maternity care. During the PHE, all transitioned to telehealth, with the primary consideration being patient and staff safety. At the time of the interview, key considerations shifted to patient access, patient preferences, patient complexity, return on investment, and staff burnout. However, several barriers impacted telehealth use, including coverage of portable devices and connectivity. These issues were reported to be common among underinsured, low-income, and rural patients. Health systems with particularly advanced capabilities worked on approaches to fill access gaps for these patients. Some health systems prioritized telehealth to improve access to high-quality maternal services for patients at the highest risk of adverse outcomes. However, policy and patient-level barriers to equitable implementation of these services persist.

Comparative Analysis of Primary Health Care Organization Models: Global Experience and the Republic of Kazakhstan

At present, the Republic of Kazakhstan is facing an increase in chronic diseases and an aging population, which presents new challenges to the healthcare system. A comparative analysis of primary health care organization models based on global experience and the experience of the Republic of Kazakhstan can contribute to the improvement of the primary health care system, increasing its accessibility and quality, and improving the health of the country's population. The purpose of this study is to evaluate and compare the primary health care systems of leading countries to improve the understanding and effectiveness of population health care at the global level.In recent years, significant achievements have been observed in global health, such as an increase in life expectancy, a decrease in child mortality, and increased access to drugs and vaccines. However, XXI century healthcare systems require innovative approaches and significant investments to overcome challenges such as aging populations and the growth of chronic diseases. In this context, primary health care becomes a key component of sustainable health system development, playing an important role in the prevention, diagnosis, and treatment of common diseases. The importance of a comparative analysis of primary health care organization models in different countries lies in identifying unique features, achievements, and barriers of each. Through analysis and research, effective strategies can be developed to improve population health and increase accessibility and quality of medical care, providing a basis for the development of effective public health strategies.

Introducing an Antenatal Care Electronic Health System for Low and Middle Income Countries: A Cross-Sectional Study on 1217 Iranian Pregnant Women.

Maternal health care is one of the main challenges worldwide, especially in low- and middle-income countries (LMICs) such as Iran. In this cross-sectional study, we introduce an electronic health software for maternal care that is active under the supervision of the Valiasr Reproductive Health Research Center of Tehran University of Medical Sciences in providing maternal health education to Iranian pregnant women. In addition to describing the details of this open-source software and encouraging LMICs health policymakers to develop such software, this manuscript also provides a cross-sectional report and statistical analysis on anonymous Iranian pregnant women who registered in this system. Since 2015, we have launched an electronic health software in Iran called "niniMED Pregnancy Calendar" in Persian. This system has multiple educational and motivational features for pregnant women, including momentary weight recommendations based on pregnancy week and recommended dates for common tests during pregnancy according to the first day of the last menstrual period in Jalali calendar format. Additionally, we measured user satisfaction with this system using a questionnaire. From 2015 to 2017, 1,217 anonymous Iranian pregnant women registered in this system. The average age of pregnant Iranian women was 30.67 years (30 years and 8 months). Users had a body mass index (BMI) of 24.68 kg.m-2, which had a significant direct relationship with their gestational age (P=5.81e-05) and indicated an improvement in appropriate weight for Iranian women compared to previous studies. We showed that there was a significant direct relationship between the age of Iranian pregnant women and the likelihood of a high-risk pregnancy (P=0.008). We also observed a significant inverse relationship between pregnancy week and their tendency to receive pregnancy-related education (P=0.018). Finally, we found that more than 88% of pregnant Iranian women assessed membership in such systems as completely useful for pregnancy. The development of such electronic health systems for informing pregnant women can provide low-cost maternal education to LMICs pregnant women and potentially assist in managing weight gain during pregnancy and reducing associated risks. It can also be widely accepted by pregnant women.

Lessons on chronic care organisation during the COVID-19 pandemic in Cambodia, Slovenia, and Belgium. COVID as a magnifying glass on primary health care.

Introduction: Primary health care (PHC) systems worldwide have been challenged by the COVID-19 pandemic. Some patients couldn’t access care or services were not available.
 Background: Fuelled by different health systems, the impact on NCD care has been different in the three countries under research: Cambodia (a developing health system in a middle-income country), Slovenia (a centrally-steered health system in a high-income country), and Belgium (a publicly-funded privatised health system in a high-income country). As crises can uncover both the strengths and weaknesses of a PHC system, we can use them as an opportunity to pinpoint weak and strong areas and translate this knowledge into recommendations to strengthen the PHC system. This study aims to answer two research questions: ‘How has COVID-19 influenced NCD care within PHC?’ and ‘Under which circumstances does a crisis lead to health system strengthening in which types of countries?’.
 Methods: Interviews were conducted with 58 key stakeholders including policy makers or influencers, patient and provider representatives, researchers and primary care providers. These interviews were supplemented with document reviews. A qualitative thematic analysis was performed and results were discussed with the international research team. This study is part of the SCUBY project, funded by the EU Horizon 2020 programme.
 Results: COVID-19 had different impacts on key organizations in the three countries. In Belgium, general practitioners got overburdened with COVID-19 testing and accompanying administration, highlighting the chronic lack of auxiliary staff such as nurses or assistants. In Cambodia, some private PHC facilities, serving the majority of the patients with NCDS were closed by the owners to prevent transmission. This led to the increased burden of NCD on the public sector which has a duty to maintain essential services in the crisis circumstance. However, it pointed to the importance of strengthening the public sector for NCD care to cope with future crises. In Slovenia, the high COVID-19 burden in nursing homes revealed vulnerabilities in the long-term care system, such as lack of staff and fragmented service provision.
 
 In relation to health system strengthening opportunities, the current crisis also provides a unique chance to move forward in the three countries. In Cambodia, the successful vaccination campaign renewed trust in the public health sector, whereas in Slovenia new investments in the health care sector were announced. In Belgium, the Minister of Health planned to reform the financing system and to strengthen primary care.
 Conclusions: The COVID pandemic caused disruption of care in all three countries. However, it also creates important chances to accelerate the scale-up of high-quality care for all patients with NCDs. When taking the time to analyse how COVID-19 impacted the health care system we can boost it faster than before.

Towards local health system development in Wallonia: experiences with the HSO toolkit for integrated people centred health systems.

Since 2008 Belgium has been developing a more integrated care system. Today, the Belgian healthcare system is undergoing significant reform at national and sub-national levels. In primary care, at the federal level, the New Deal for general practice aims to improve the organisation of general practice and a new inter-federal plan for integrated care is currently under development. At the regional level, there are many initiatives. In Wallonia several projects are working towards greater inter-professional collaboration and clear territorial delimitations in order to cater for the needs of local populations in a more integrated fashion. 
 The project Proxisanté has been exploring the needs of professionals and patients by conducting consultations and workshops with actors within primary care to feed into a decree which will be presented at the end of 2022. Based on the outcome of this process, actions will be undertaken, starting in 2023, to implement this vision and develop a territorial network of local health systems. Our team is responsible for following and supporting this process of implementation by developing a transdisciplinary and innovative bottom-up methodological approach. For this we intend to rely, among other things, on the Integrated People-Centred Health Systems (IPCHS) Standard developed by the Health Standards Organisation (HSO), as well as the various tools created to facilitate the implementation of this standard. 
 The presentation will describe the preliminary work done to prepare for concrete support for the creation of local networks starting in 2023. Specifically, we will detail the methodology used to identify the priorities that need to be focused on to ensure successful implementation, Finally, we will present the key messages from meetings with different existing subsystems concerning their strengths and weaknesses, and the inspiring practices identified that will allow us to build a regional learning system dynamic.

Utility and Evaluation of Applied Project Management Processes Within a Large Multicountry Health Systems Development Project Conducted During the Coronavirus Disease 2019 (COVID-19) Pandemic.

The increasing trends in antimicrobial resistance (AMR) continue to pose a significant threat to human health, with grave consequences in low- and middle-income countries. In collaboration with local governments and microbiology laboratories in South Asian and Southeast Asian countries, the Capturing Data on Antimicrobial Resistance Patterns and Trends in Use in Regions of Asia (CAPTURA) project worked to identify gaps and expand the volume of existing AMR data to inform decision-makers on how to best strengthen their national AMR surveillance capacity. This article describes overall project management processes and the strategies implemented to address the disruptive impact of the coronavirus disease 2019 (COVID-19) pandemic on the project activities across diverse contexts in different countries. Also, it assesses in-country team's feedback on the conduct of activities and their overall impact on project completion. The strategies employed were tailored to the specific context of each country and included increased communication and collaboration among consortium partners and in-country teams, as well as hiring of additional in-country team members. This paper highlights the importance of local representation and capacities as well as real-time (virtual) engagement with stakeholders, ensuring close monitoring of the local situation and ability to tailor context-specific mitigation strategies to continue project implementation during disruptive external circumstances.

International legal regulation of the circulation of dual-use biotechnologies

The COVID-19 pandemic has demonstrated the vulnerability of each country, regardless of the economic well-being and health system development, highlighting the need for further rethinking of the global security and human security concepts. The need to sustain the spread of infectious diseases, as well as the treatment of life-threatening diseases, determine the relevance of scientific research on all key aspects related to the development of technologies, both by states and non-state actors. In view of the efforts made over the past decades, significant advances have been made in the field of biotechnology, which allows to detect the vulnerability of viruses, as well as to influence the genes responsible for the development of diseases. Such trends not only contribute to ensuring the human right to health and the right to enjoy the benefits of scientific progress, but also bring humanity closer to executing Sustainable Development Goals. The reverse side of the scientific research increase is the expansion of the availability of scientific data, as well as the simplification of the reproduction of various technological solutions, which leads to the risk of their use for military and terrorist purposes. The development of technologies, the use of which can not only counteract life-threatening diseases, but also create new threats to human security, has influenced the formation of the term “dual-use technologies” in the scientific literature and documents of international organizations. The article presents a systematic analysis of biotechnologies impact on the formation of “human security” concept, as well as the definition of “biological security” concept. The authors consistently consider international treaties, as well as documents of international intergovernmental organizations and non-governmental organizations in the field of regulating the circulation of technologies that pose a threat to state security. Special attention is paid to the consideration of the features of control over the spread of biological agents in the context of the activities of the European Union, as well as ensuring the implementation of the national security strategy of the Russian Federation.

MEDICAL AND SOCIAL REASONING FOR IMPROVING THE ORGANISATION OF PREVENTING AND FIGHTING SKIN CANCER IN THE CONDITIONS OF THE PUBLIC HEALTH SYSTEM DEVELOPMENT

Introduction. Scientific reasoning for improving the organisation of cancer prevention and the providing onco-dermatological care to the population in the conditions of the public health system development.
 Materials and methods. The article includes the method of system approach as well as bibliosemantic, epidemiological, medical and statistical, sociological, expert assessment, content analysis, structural and logical analysis, modelling methods. Sources of information are the data from scientific literature, the Center for Medical Statistics of the Ministry of Health Care of Ukraine, the National Cancer Registry of Ukraine, the sociological research among various groups of participants in providing healthcare services and strategic documents of the national and international levels.
 Results. Unfavourable trends in skin malignancies spread, an increase in their contribution to the burden of the disease and the imperfection of the organisation of skin cancer prevention and the onco-dermatological care to the population were revealed. According to the principles of the state policy and the recommendations of the international organisations the directions of improving the preventive, therapeutic and diagnostic services were reasoned out on the basis of the data from the scientific literature, epidemiological research, spread, locational, gender and age peculiarities of skin cancer among the population, risk factors for their development, estimating the health care resource support, scale and results of the activities, studies of the patients, doctors and health care professionals' opinions. The modern functional-organisational model of the prevention system and control of skin cancer in the conditions of the public health system development with the definition of its principles, structures and functions was reasoned and worked out.
 Conclusions. The practical implementation of the measures for improving the prevention organisation and therapeutic and diagnostic work to fight skin cancer and the developed functional and organisational model of the system of prevention and control of onco-dermatological pathology in conditions of the public health development will effectively prevent onco-dermatological diseases, reduce the burden of skin cancer, improve people’s health and health care performance indicators and contribute to the health care sustainable development and the population’s well-being.

Assessing the readiness of health facilities to provide family planning services in low-resource settings: Insights from nationally representative service provision assessment surveys in 10 Countries.

Many low-income countries continue to have high fertility levels and unmet need for family planning (FP) despite progress in increasing access to modern contraceptive methods and in reducing the total fertility rate (TFR). Health facilities in sub-Saharan Africa (SSA) and South Asia (SA) are thought to be unable to adequately deal with the burden of high unmet FP demands due to their weaker health systems. As a result, determining the readiness of health facilities that offer FP services is critical for identifying weaknesses and opportunities for continued development of FP health systems in those regions. Service Provision Assessment (SPA) tools-which break down health systems into measurable, trackable components-are one useful way to assess service readiness and the ability of health institutions to deliver FP services. Using data from nationally representative SPA surveys, we conducted a study that aimed to: (1) evaluate healthcare facilities' readiness to provide FP services; and (2) identify the factors that affect FP service readiness. Using a cross-sectional survey design, we used data from SPA surveys conducted in 10 low-resource SA and SSA countries: Afghanistan, Bangladesh, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and the Democratic Republic of the Congo (DRC). We analyzed data from public and private health facilities in Afghanistan (84), Bangladesh (1,303), Kenya (567), Malawi (810), Namibia (357), Nepal (899), Rwanda (382), Senegal (334), Tanzania (933), and the DRC (1,061) for a total of 6,730 facilities. We used 17 items/indicators recommended by the Service Availability and Readiness Assessment to measure a health facility's readiness to provide FP services across four domains. Only 3.6% to 34.1% of the health facilities were reporting at least 75% (12-13 of 17) of the relevant items for FP service provision. Most of the health facilities in the countries under investigation suffered from lack of readiness, meaning that they did not fulfill at least 75% of the standards (12-13 items of 17 items on the availability of trained staff and guidelines, equipment, and commodities components). The factors associated with higher readiness scores varied among the 10 countries analyzed. Regression models showed that increases in the number of FP healthcare providers available at a health facility and infection control measures for FP exams were factors linked to increased readiness scores in all 10 countries. The low readiness of health facilities to provide FP services in the countries studied showed that the health systems in these low-resource settings faced significant problems with providing FP services. Differences in country-specific variability in the characteristics linked with better preparedness ratings could be attributed to data collected across different years in different nations or to country-specific healthcare financing policies. To increase a health facility's readiness to offer FP services, country-specific factors must be addressed, in addition to common factors found in all 10 countries. Further research is required to determine the causes of country-level differences in FP tracer item availability to develop targeted and effective country-specific strategies to improve the quality of FP services in the SA and SSA regions and address unmet need for FP.

Setting an agenda for a national pediatric trauma system: Operationalization of the Pediatric Trauma State Assessment Score.

Pediatric trauma system development is essential to public health infrastructure and pediatric health systems. Currently, trauma systems are managed at the state level, with significant variation in consideration of pediatric needs. A recently developed Pediatric Trauma System Assessment Score (PTSAS) demonstrated that states with lower PTSAS have increased pediatric mortality from trauma. Critical gaps are identified within 6 PTSAS domains: Legislation & Funding, Access to Care, Injury Prevention and Recognition, Disaster, Quality Improvement & Trauma Registry, and Pediatric Readiness. For each gap, a recommendation is provided regarding the necessary steps to address these challenges. Existing national organizations, including governmental, professional, and advocacy, highlight the potential partnerships that could be fostered to support efforts to address existing gaps. The organizations created under the U.S. Administration are described to highlight the ongoing efforts to support the development of pediatric emergency health systems.It is no longer sufficient to describe the disparities in pediatric trauma outcomes without taking action to ensure the health system is equipped to manage injured children. By capitalizing on organizations that intersect with trauma and emergency systems to address known gaps, we can reduce the impact of injury on all children across the United States.

COMPLICATIONS ASSOCIATED WITH PRIMARY REVERSE SHOULDER ARTHROPLASTY IN THE PUBLIC SECTOR: A RETROSPECTIVE STUDY, 2011 TO 2021

In reverse shoulder arthroplasty (RSA), a high complication rate is noted in the international literature (24.7%), and limited local literature is available. The complications in our developing health system, with high HIV, tuberculosis and metabolic syndrome prevalence may be different from that in developed health systems where the literature largely emanates from. The aim of this study is to describe the complications and complication rate following RSA in a South African cohort.An analytical, cross-sectional study was done where all patients’ who received RSA over an 11 year period at a tertiary hospital were evaluated. One-hundred-and-twenty-six primary RSA patients met the inclusion criteria and a detailed retrospective evaluation of their demographics, clinical variables and complication associated with their shoulder arthroplasty were assessed. All fracture, revision and tumour resection arthroplasties were excluded, and a minimum of 6 months follow up was required.A primary RSA complication rate of 19.0% (24/126) was noted, with the most complications occurring after 90 days at 54.2% (13/24). Instability was the predominant delayed complication at 61.5% (8/13) and sepsis being the most common in the early days at 45.5% (5/11). Haematoma formation, hardware failure and axillary nerve injury were also noted at 4.2% each (1/24).Keeping in mind the immense difference in socioeconomical status and patient demographics in a third world country the RSA complication rate in this study correlates with the known international consensus. This also proves that RSA is still a suitable option for rotator cuff arthropathy and glenohumeral osteoarthritis even in an economically constrained environment like South Africa.

An empirical study on secure usage of mobile health apps: The attack simulation approach

: Mobile applications (apps) have proven their usefulness in enhancing service provisioning across a multitude of domains that range from smart healthcare, to mobile commerce, and areas of context-sensitive computing. In smart healthcare context, mobile health (mHealth) apps - representing a specific genre of mobile apps that manage health information - face some critical challenges relating to security and privacy of device and user data. In recent years, a number of empirically grounded, survey-based studies have been conducted to investigate secure usage of mHealth apps. However, such studies rely on self-reported behaviors documented via interviews or survey questions that lack practical approaches that can simulate attack scenario for monitoring users’ actions and behaviors while using mHealth apps. : Our objective was to conduct an empirical study - engaging participants with attack simulation scenarios and analyze their actions - for investigating the security awareness of mHealth app users. : We simulated some common security attack scenarios in mHealth context and engaged a total of 105 app users to monitor their actions and analyze their behavior. We analyzed users' data with statistical analysis including correlations test, descriptive analysis, and qualitative data analysis (i.e., thematic analysis method). : Our results indicate that whilst the minority of our participants perceived access permissions positively, the majority had negative views. Users provide their consent, granting permissions, without a careful review of privacy policies that leads to undesired or malicious access to health data. Findings also indicated that 73.3% of our participants had denied at least one access permission, and 36% of our participants preferred no authentication method. : The study complements existing research on secure usage of mHealth apps, simulates security threats to monitor users’ actions, and provides empirically grounded guidelines for secure development and usage of mobile health systems.

Strengthening community health worker program in Belize

Community health workers (CHWs) have been identified as effective workforce that can improve access to primary health care particularly for underserved and hard to reach populations. The contributions of CHWs have not been limited to low-income countries. More recently, the use of CHWs has attracted attention in some high-income countries where despite more developed health systems there are large inequities in healthcare access and outcomes amongst different population groups. Belize is an upper middle-income country located in Central America and its health system is based on a primary health care model with community health workers actively involved in health service delivery. A descriptive study through review of grey literature detailing the process for strengthening the community health worker program in the country using the Community Health Worker Assessment and Improvement Matrix (CHW AIM) tool. The results were thematically analysed based on Community Health Worker Assessment and Improvement Matrix (CHW AIM) conceptual framework on factors influencing the performance of community health worker program. Community health workers in Belize are recognized as part of the formal health system with policy and strategy in place that define their roles, tasks, relationship to the health system. They are provided with monthly financial incentives, opportunities for further studies, career advancement and employment opportunities within the health system. The study contributes to the existing literature on strengthening of community health worker program to enhance the primary health care system and build a more resilient health system for better preparedness and response for future pandemics with focus on an upper middle income country.

Outcomes of out-of-hospital cardiac arrest in Ireland 2012-2020: Protocol for an observational study

Background Out-of-hospital cardiac arrest (OHCA) is a leading cause of preventable mortality that now affects almost 3,000 people each year in Ireland. Survival is low at 6–7%, compared to a European average of 8%. The Irish Out-of-Hospital Cardiac Registry (OHCAR) prospectively gathers data on all OHCA in Ireland where emergency medical services attempted resuscitation. The Irish health system has undergone several developments that are relevant to OHCA care in the period 2012–2020. OHCAR data provides a means of exploring temporal trends in OHCA incidence, care, and outcomes over time. It also provides a means of exploring whether system developments were associated with a change in key outcomes. This research aims to summarise key trends in available OHCAR data from the period 2012 – 2020, to explore and model predictors of bystander CPR, bystander defibrillation, and survival, and to explore the hypothesis that significant system level temporal developments were associated with improvements in these outcomes. Methods The following protocol sets out the relevant background and research approach for an observational study that will address the above aims. Key trends in available OHCAR data (2012 – 2020) will be described and evaluated using descriptive summaries and graphical displays. Multivariable logistic regression will be used to model predictors of ‘bystander CPR’, ‘bystander defibrillation’ and ‘survival to hospital discharge’ and to explore the effects (if any) of system level developments in 2015/2016 and the COVID-19 pandemic (2020) on these outcomes. Discussion The findings of this research will be used to understand temporal trends in the care processes and outcomes for OHCA in Ireland over the period 2012-2020. The results can further be used to optimise future health system developments for OHCA in both Ireland and internationally.

In with the good, out with the bad – Investment standards for external funding of health?

In recent decades, external financing of health systems in low- and middle-income countries has helped achieve remarkable improvements across the world. However, these successes have not come without problems. There are a growing number of areas where external assistance can cause harm and even undermine the development of national health systems. Recent decades have seen a surge of knowledge on investing in health systems. We propose the setting up of investment standards for external assistance that aim to incentivize a more efficient evidence-based investment in a country’s health system, led by decision-makers in country. Using a more standardized process would lead to a better use of precious external assistance resources. The long-term goal would be fully functioning health systems with all the necessary essential public health functions in all countries.

Exploring reasons why South African dental therapists are leaving their profession: A theory-informed qualitative study.

Dental therapy is a category of mid-level oral health professional that was introduced to address inequities in oral health service provision in South Africa within a constrained human resource for health context. However, low numbers of registered dental therapists and attrition threaten this strategy. This study explored reasons for this attrition, building on the Hertzberg Two-Factor Theory. Through a qualitative exploratory study design, in-depth interviews were conducted with former dental therapists to explore their reasons for leaving the profession. They were recruited using snowball sampling. All interviews were audio recorded, transcribed verbatim, and coded in NVIVO12. A team of researchers applied thematic analysis to agree on themes and sub-themes, guided by Hertzberg's ideas of intrinsic and extrinsic factors. All 14 former dental therapists interviewed expressed their passion for the profession, even though their motivations to join the profession varied. Many of their reasons for leaving aligned with extrinsic and intrinsic factors defined in Hertzberg's Two-Factor Theory. However, they also spoke about a desire for a professional identity that was recognized and respected within the oral health profession, health system, and communities. This is a novel study contribution. Dental therapist attrition in South Africa is mainly caused by job dissatisfaction and motivation issues resulting from health system level factors. While the Hertzberg Two-Factor Theory helped identify extrinsic and intrinsic factors at an individual level, we used the Human Resources for Health System Development Analytical Framework to identify solutions for dental therapist production, deployment, and retention. Addressing these issues will enhance retention and accessibility to oral health services in the country.

Migrant healthcare workers: exploring resilience and capacity for circular migration

Abstract Background This study focuses on migrant healthcare workers’ experiences and explores mobility patterns in the middle of a global health crisis, aiming to explore the capacity for circular migration and support effective equitable healthcare workforce policy. Methods Romanian physicians working in Germany served as an empirical case study. We applied a qualitative explorative approach; interviews (n = 21) were collected from mid of September to early November 2022 and content analysis was performed. Results Migrant physicians showed strong resilience during the COVID-19 crisis and rarely complained. Commitment to high professional standards and career development were major pull factors towards Germany, while perceptions of limited career choices, nepotism and corruption in Romania caused strong push mechanisms. We identified two major mobility patterns that may support circular migration policies: well-integrated physicians with a wish to give something back to their home country, and mobile cosmopolitan physicians who flexibly balance career opportunities and personal/family interests. Conclusions Health policy must establish systematic monitoring of the migrant healthcare workforce including actor-centred approaches, support integration in destination countries as well as health system development in sending countries, and invest in evidence-based circular migration policy. Key messages • Effective retention policy must consider mobility patterns of healthcare workers and motivational factors, calling for systematic data and research evidence. • Major push and pull factors reveal strong interconnectedness of healthcare systems and policy in sending and receiving countries, calling for more equitable health workforce policy.