Sustainability Of Health Systems Research Articles

A proposal to recognize investment in breastfeeding as a carbon offset.

Policy-makers need to rethink the connections between the economy and health. The World Health Organization Council on the Economics of Health for All has called for human and planetary health and well-being to be moved to the core of decision-making to build economies for health. Doing so involves valuing and measuring what matters, more and better health financing, innovation for the common good and rebuilding public sector capacity. We build on this thinking to argue that breastfeeding should be recognized in food and well-being statistics, while investments in breastfeeding should be considered a carbon offset in global financing arrangements for sustainable food, health and economic systems. Breastfeeding women nourish half the world's infants and young children with immense quantities of a highly valuable milk. This care work is not counted in gross domestic product or national food balance sheets, and yet ever-increasing commercial milk formula sales are counted. Achieving global nutrition targets for breastfeeding would realize far greater reductions in greenhouse gas emissions than decarbonizing commercial milk formula manufacturing. New metrics and financing mechanisms are needed to achieve the health, sustainability and equity gains from more optimal infant and young child feeding. Properly valuing crucial care and environmental resources in global and national measurement systems would redirect international financial resources away from expanding carbon-emitting activities, and towards what really matters, that is, health for all. Doing so should start with considering breastfeeding as the highest quality, local, sustainable first-food system for generations to come.

Climate finance opportunities for health and health systems.

Climate change poses significant risks to health and health systems, with the greatest impacts in low- and middle-income countries - which are least responsible for greenhouse gas emissions. The Conference of Parties 28 at the 2023 United Nations Climate Change Conference led to agreement on the need for holistic and equitable financing approaches to address the climate and health crisis. This paper provides an overview of existing climate finance mechanisms - that is, multilateral funds, voluntary market-based mechanisms, taxes, microlevies and adaptive social protection. We discuss these approaches' potential use to promote health, generate additional health sector resources and enhance health system sustainability and resilience, and also explore implementation challenges. We suggest that public health practitioners, policy-makers and researchers seize the opportunity to leverage climate funding for better health and sustainable, climate-resilient health systems. Emphasizing the wider benefits of investing in health for the economy can help prioritize health within climate finance initiatives. Meaningful progress will require the global community acknowledging the underlying political economy challenges that have so far limited the potential of climate finance to address health goals. To address these challenges, we need to restructure financing institutions to empower communities at the frontline of the climate and health crisis and ensure their needs are met. Efforts from global and national level stakeholders should focus on mobilizing a wide range of funding sources, prioritizing co-design and accessibility of financing arrangements. These stakeholders should also invest in rigorous monitoring and evaluation of initiatives to ensure relevant health and well-being outcomes are addressed.

Transitioning to sustainable, climate-resilient healthcare: insights from a health service staff survey in Australia

BackgroundMore than 80 countries, including Australia, have made commitments to deliver climate-resilient and low carbon healthcare. Understanding how healthcare workers view their own and their organization’s efforts to achieve sustainable and climate-resilient healthcare practice is vital to inform strategies to accelerate that transition.MethodsWe conducted an online staff survey in a large state government hospital-and-health-service organisation in Queensland, Australia, to ascertain attitudes and practices towards environmentally sustainable, climate-resilient healthcare, and views about the organizational support necessary to achieve these goals in their workplace.ResultsFrom 301 participants showed staff strongly support implementing sustainable and climate-resilient healthcare but require significantly more organizational support. Participants identified three categories of organizational support as necessary for the transition to environmentally sustainable and climate-resilient health services and systems: (1) practical support to make sustainability easier in the workplace (e.g. waste, energy, water, procurement, food, transport etc.); (2) training and education to equip them for 21st century planetary health challenges; and (3) embedding sustainability as ‘business as usual’ in healthcare culture and systems.ConclusionsThe research provides new insight into health workforce views on how organizations should support them to realize climate and sustainability goals. This research has implications for those planning, managing, implementing, and educating for, the transition to environmentally sustainable and climate-resilient health services and systems in Queensland, Australia, and in similar health systems internationally.

Exploring the inequalities experienced by health and care workforce and their bases - A scoping review protocol.

Planning for investment in human resources for health (HRH) is critical to achieve Universal Health Coverage (UHC) and establish a sustainable health system. Informed planning warrants a better understanding of the health labour market (HLM) to tackle a variety of health and care workforce challenges: from addressing critical supply shortage, to ensuring optimal skills mix and distribution, and addressing motivation and performance challenges. Scant evidence around the overall role of socioeconomic and cultural factors like gender, race, marital status, citizenship (migrant) status, workplace hierarchy etc. in determining workforce composition, deployment, distribution, retention, un- and underemployment, sub-optimal work environments and other factors in the 'HRH crisis' warrants further exploration. This scoping review protocol aims to map and present the available evidence on inequalities experienced by health and care workforce, the socio-economic, cultural and other bases of these inequalities, and their outcomes/ consequences. PubMed, Web of Science, CINAHL and SCOPUS will be used to identify relevant literature. All types of published study designs in English language will be included if they discuss any inequality experienced by any category of health and care workers. Elaborate keyword categories for health and care workers and inequalities context have been developed, tested and reduced to the near-final search string. Eligible articles will be charted using the Joanna Briggs Institute checklist. The sample data extraction chart in JBI manual will be used as a basic skeleton with fields added to it to serve the needs of the scoping review. Descriptive analysis will be performed, depicting basic frequencies. While no further analysis has been advised in the JBI and PRISMA protocol, thematic analysis will be undertaken; following the Braun and Clarke's method with some modification and open coding as suggested by Maquire and Delahunt.

Междисциплинарный подход к оказанию услуг в сфере здравоохранения: российские практики в экспертных оценках в кейсе паллиативной помощи

Public innovations in the development of palliative care within the framework of an interdisciplinary approach introduced by the Federal Law № 18-FZ dated 06.03.2019 "On Amendments to the Federal Law "On the Basics of Public Health Protection in the Russian Federation" on palliative care" require expert assessments, which determines the relevance of the research topic and goal setting – to describe the state and identify changes in the organization of palliative care in the Russian Federation in expert assessments in connection with the introduced public innovations. The research methods are: secondary analysis of foreign model of palliative care organization and longitudinal study with the method of expert assessments of 2017, 2023. The results of the study are as follows. Firstly, it is revealed that under modern conditions, interdisciplinary approach is becoming a methodological basis for ensuring health systems sustainability. Secondly, the results of longitudinal study show that introduced public innovations in transformation of the Russian palliative care model increase expert assessments to satisfactory positioning concerning most components of palliative care organization, which was characterized as "very low" and "low" in 2017. Thirdly, such a component as "exemption from work for persons caring for a seriously ill family member (sick leave for care)", which received low expert ratings, is the growing point in the organizational model of palliative care.

[Shortage of nurses in Spain: from the global case to particular situation. SESPAS Report 2024].

The nursing shortage is a multi-causal phenomenon that affects all countries and currently a global concern. The shortage of nurses jeopardizes the sustainability of health systems and the population health outcomes. Spain has historically had no difficulties in attracting new generations of nurses. The shortage of nurses is caused by the precarious working conditions and lack of professional development that have led to episodes of high international migration and abandonment of the profession. In this paper we focus on the evolution of different indicators of the working conditions of non-specialist nurses, who make up the bulk of the profession. These indicators allow us to analyse the abandonment of the profession, the duration of contracts, their full-time or part-time dedication and the excessive hiring. We have analysed the effect of COVID-19 and the labour reform on these indicators. COVID-19 reduced the abandonment of the profession and is currently at its lowest level, it has also accelerated the need to improve working conditions by increasing the percentage of permanent contracts and reducing the multiplicity of contracts in the same month. The labour reform has helped reduce the percentage of temporary contracts until reaching around 80% of the total contracts, and has reduced the number of nurses in Spain with more than one contract in the same month to below 3000 nurses on a sustained basis.

Quantifying regional low flows under data scarce conditions

Estimating low flow quantiles is essential for regulating minimum flow requirements and ensuring water availability, ecological health, and overall system sustainability. This study aims to quantify regional low flows by analyzing low-flow time series in data-limited environments. We utilized annual minimum 7-day instantaneous streamflow data collected from gaging stations. Discordancy measure assessments revealed that all sites were homogeneous, forming a single region. We employed Easy-Fit Statistical Software to select the best-fit probability distribution model and determine estimation parameter values. Through goodness-of-fit tests (GOFs), the Generalized Pareto model emerged as the most suitable, predicting low flow quantiles for 100-year returns. Rigorous application of GOFs ensures the statistical soundness of the model, capturing underlying data patterns. A correlation coefficient determination (R2) of 0.989 demonstrates the high satisfaction of the selected distribution model. The developed regression line for the region exhibited strong agreement between predicted low flows and catchment area. Thus, accurate estimation proves valuable in environmental and human-influenced decision-making processes, providing insights into low-flow behavior and mitigating drought effects on aquatic ecosystems.

Recommendations of the Spanish-Portuguese Internal Medicine services in the fight against climate change and environmental degradation.

Facing the severity of the impact of climate change and environmental degradation on human health, 32 Internal Medicine societies, colleges, and associations of 29 Spanish and Portuguese-speaking countries issue a consensus document in which they call for the implication of doctors and all health professionals in the global fight against the causes of these changes. This commitment requires the cooperation of health-related organizations, elaboration and implementation of good environmental sustainability practices, greater awareness of professionals and population, promotion of education and research in this area, increasing climate resilience and environmental sustainability of health systems, combating inequalities and protecting the most vulnerable populations, adopting behaviors that protect the environment, and claiming Internal Medicine as a core specialty for empowerment of the health system to respond to these challenges.

Perceptions and Factors affecting Utilization of Primary Health Care Services in a predominantly Urban Community in South-South Nigeria

Background: Primary Health Care is the cornerstone of a sustainable national health system for the attainment of universal health  coverage. There is poor demand for health services at the primary level of care. This study assessed the perceptions and factors affecting  the utilization of primary health care services in a predominantly urban community in South-South Nigeria.
 Methods: This descriptive  cross-sectional study was done in Egor, Benin City, Southern Nigeria. A structured, and interviewer administered questionnaire was  distributed to 371 heads of household who were selected using multistage sampling method. The data were analyzed using IBM SPSS  version 25.
 Results: Majority of the respondents were males 191 (51.6%). More than half, 195 (52.5%) were in the age group of 35-49  years. Less than half, 171 (46.1%)of the respondents had utilized primary health care services. Only, 42 (24.6%) perceived the services  utilized were satisfactory. Immunization, 45 (26.3%), child, 39 (22.8%) and maternal, 32 (18.7%) health care services were the most utilized.  Sex (OR = 0.599; CI = 0.38-0.94, p = 0.027), religion (OR = 2.246; CI = 1.066-4.735, p = 0.033), and occupation (OR = 2.437; CI =  1.106-5.367, p = 0.027) were factors associated with the utilization of health services in the study locale.
 Conclusions: The utilization of the  primary health care services was low, and the perception of services utilized was not satisfactory. The Local Government Health  Authority needs to strengthen the primary health care system. Also, improved community engagement and participation could enhance  health services access and uptake. 

Integrating China in the International Consortium for Personalised Medicine: a position paper on innovation and digitalization in Personalized Medicine

BackgroundThe advent of Personalized Medicine (PM) holds significant promise in revolutionizing healthcare by tailoring treatments to individual patients based on their data. However, its successful implementation requires the seamless integration of innovative technologies and presents formidable challenges in terms of sustainability. To tackle these challenges head-on, the International Consortium for Personalized Medicine (ICPerMed) was established, and the IC2PerMed project, as part of this consortium, seeks to foster collaboration between the European Union (EU) and China in the field of Personalized Medicine. Based on the results collected by the project, the objective of this study is to discern the key priorities for the implementation of Personalised Medicine concerning Information and Communication Technologies (ICT) and Big Data and digital solutions, with a particular emphasis on data management and protection.MethodsA Delphi survey was conducted to gather expert’s consensus on the main priorities for actions on Information and Communication Technologies (ICT) and Big Data and digital solutions in the field of Personalized Medicine.ResultsThe survey identified seven priorities in the area of Big Data and digital solutions, including data interoperability, standards, security measures, and international partnerships. Additionally, twelve priorities were identified for the innovation-to-market process, emphasizing cost-effectiveness, need assessment, and value definition in resource allocation.ConclusionsThe effective implementation of new technologies in Personalized Medicine research and practice is essential for the advancement of healthcare systems in both the European and Chinese contexts. The identified priorities play a pivotal role in promoting the sustainability of health systems and driving innovation in the implementation of Personalized Medicine. Addressing challenges related to data interoperability, standards, security, international collaboration, cost-effectiveness, and value assessment is of utmost importance in order to propel the progress of Personalized Medicine in healthcare systems.

The State School Mental Health Profile: Findings from 25 States.

State-level leadership and conditions are instrumental to local and regional comprehensive school mental health system (CSMHS) quality, sustainability, and growth. However, systematic documentation of state-level school mental health (SMH) policy, infrastructure, funding, and practice is limited. Using a multi-phase, multi-method process, we developed the State School Mental Health Profile (State Profile) to offer a comprehensive landscape of state SMH efforts. State leaders in 25 states completed the State Profile once over a 3-year data collection period. Mixed methods results are reported in 8 domains. State education agencies were reportedly most involved in SMH technical assistance, advocacy, leadership, funding, and service provision, with mental health agencies reported as second most involved. Nearly half of state respondents reported having a state-level SMH director or coordinator. Policies with the greatest perceived impact require implementation of and funding for SMH services and supports. Despite leveraging multiple sources of funding, most states emphasized lack of funding as a primary barrier to establishing CSMHSs. All states reported staffing shortages. The State Profile can assist multi-agency state leadership teams to self-assess policy, infrastructure, and resources to support CSMHSs statewide. Findings point to areas of opportunity to advance equity across resource allocation, service provision, and policy development.

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

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

Sustainability in Internal Medicine: A Year-Long Ward-Wide Observational Study.

Population aging and multimorbidity challenge health system sustainability, but the role of assistance-related variables rather than individual pathophysiological factors in determining patient outcomes is unclear. To identify assistance-related determinants of sustainable hospital healthcare, all patients hospitalised in an Internal Medicine Unit (n = 1073) were enrolled in a prospective year-long observational study and split 2:1 into a training (n = 726) and a validation subset (n = 347). Demographics, comorbidities, provenance setting, estimates of complexity (cumulative illness rating scale, CIRS: total, comorbidity, CIRS-CI, and severity, CIRS-SI subscores) and intensity of care (nine equivalents of manpower score, NEMS) were analysed at individual and Unit levels along with variations in healthcare personnel as determinants of in-hospital mortality, length of stay and nosocomial infections. Advanced age, higher CIRS-SI, end-stage cancer, and the absence of immune-mediated diseases were correlated with higher mortality. Admission from nursing homes or intensive care units, dependency on activity of daily living, community- or hospital-acquired infections, oxygen support and the number of exits from the Unit along with patient/physician ratios were associated with prolonged hospitalisations. Upper gastrointestinal tract disorders, advanced age and higher CIRS-SI were associated with nosocomial infections. In addition to demographic variables and multimorbidity, physician number and assistance context affect hospitalisation outcomes and healthcare sustainability.

Adalimumab Persistence and Its Biosimilar in Inflammatory Bowel Disease: A Real-World Study.

Adalimumab biosimilar experience is still recent. Interchangeability differences could reduce persistence times. Our goal was to compare biosimilar persistence differences with a reference. A retrospective observational study was performed in three groups divided according to the adalimumab received. The primary outcome measure was persistence, represented with Kaplan-Meier analysis, and we secondarily evaluated security, efficacy, and biomarkers. We obtained approval from the regional ethical committee, and the study was conducted following the Helsinki Declaration as revised in 2013. Data from 104 patients were collected: 50 received the biosimilar, 29 received the reference, and 25 switched from the original to the biosimilar. After a follow-up of 12 months, the biosimilar's persistence was higher, without differences in mild adverse events per group. In contrast, there were differences in severe events, with the switched group's frequency being higher. Biomarkers were reduced at similar proportions in all groups, and 43% had a clinical response at week 20 without differences. Adalimumab biosimilars are a valuable option for IBD based on clinical equivalence that are less expensive than the original drug. Their use does not have a detrimental influence on disease, although there are a few nuances in terms of interchangeability. These results support increasing confidence in using biosimilars, thus promoting the better sustainability of health systems.

Comparative price analysis of biological medicines: disparities generated by different pricing policies.

Introduction: Biological medicines have been assuming an important role among the therapeutic options for several diseases, however, due to their complex production process, the products obtained from this technology have a high added value and do not reach the purchasing power of most patients, which overwhelms the budget of health systems. With the development of biosimilars, which have reduced production costs, it is expected that access to biological medicines will become broader. However, in Brazil, the criteria for determining the price of biosimilars, unlike the generic policy in the country, do not foresee a price reduction due to the reduction of development costs. Objective: To understand the impact of the current model of economic regulation on the availability and access of these products in the country, based on a comparative analysis in selected countries, and identify trends that can help to expand the availability and access to biological medicines. Method: Quantitative and qualitative study, to identify the variation between the entry prices of biological medicines in Brazil and in selected countries, as well as the differences in the economic regulation policies established in these countries. Results: The results demonstrate that the current pricing model in Brazil has generated distortions in the prices of biosimilars in the market, which, consequently, makes it difficult for the population to access this category of products, in addition to allowing unsustainable market practices for the systems of public and private health in Brazil. It was also found that most of the analyzed countries, unlike Brazil, seek to harmonize the prices of different brands of the same molecule marketed in the country and with the international market, in addition to establishing incentive policies for indication and replacement by biosimilars, which expands the participation of biosimilars in the market significantly. Conclusion: Based on the data presented, it is concluded that it is essential to build a broader political and regulatory debate on the market for biologicals and biosimilars in the country to guarantee the access of the Brazilian population to more cost-effective technologies, generate a more competitive market and consequently contribute to the financial sustainability of health systems.

Quantification of factors influencing differences in the Case Mix Index and their significance for health systems sustainability

Case Mix Index (CMI) represents a standard indicator of hospital disease seriousness at both the national and international level. CMI is structured to compute hospital payments and not to follow up disease seriousness. It is considerably related to the data accuracy as well as patients’ medical records. The main aim of the study was to quantify the factors influencing the differences in CMI depending on the types of healthcare facilities, their geographical location, as well as the procedural aspects within the Slovak healthcare system. We use data published by the Institute for Economic and Social Reforms, which continuously surveys the quality and outputs of healthcare provided in the Slovak Republic. The data comes from multiple datasets that are issued by healthcare authorities and stakeholders is the Slovak Republic such as insurance companies, the Ministry of Health of the Slovak Republic, the Ministry of Finance of the Slovak Republic, healthcare facilities, the National Health Information Centre etc. Regression analysis indicates that the positive impact on the Case Mix Index is possessed by the Operating experience of doctors and Overall inpatients satisfaction; whilst the negative impact on Case Mix Index values is documented for variables Total rehospitalisation within 30 d, Intensive care unit mortality, Economy, and Transparency.

The Ghana heart initiative - a health system strengthening approach as index intervention model to solving Ghana's cardiovascular disease burden.

Cardiovascular diseases (CVD) are the leading cause of death worldwide, with 80% of these deaths occurring in low-middle income countries (LMICs). In Ghana and across Africa, CVDs have emerged as the leading causes of death primarily due to undetected and under treated hypertension, yet less than 5% of resources allocated to health in these resource-poor countries go into non-communicable diseases (NCD) including CVD prevention and management. Consequently, most countries in Africa do not have contextually appropriate and sustainable health system framework to prevent, detect and manage CVD to achieve Universal Health Coverage (UHC) in CVD care through improved Primary Health Care (PHC) with the aim of achieving Sustainable Development Goals (SDG) in CVD/NCD. In view of this, the Ghana Heart Initiative (GHI) was envisaged as a national strategy to address the identified gaps using a health system and a population-based approach to reduce the national burden of CVDs. The GHI intervention includes the development of guidelines and training manuals; training, equipment support, establishment of a national call/support center, and improvement in the national data capturing system for CVDs and NCD, management of Hypertension, Deep Vein Thrombosis (DVT) and Heart Failure (HF). Following the implementation of the GHI concept, a national CVD Management Guideline was developed and 300-health facilities across the different levels of care including one teaching hospital, was also supported with basic life-saving equipment. In addition, more than 1,500 healthcare workers also reported improvement in their knowledge and skills in the management and treatment of CVD-related cases in their health facilities. These are key contributions to strengthening the health system for CVD care and learning lessons for scale up.

Towards an AI-Enhanced sustainable health system: inferences from healthcare management research

Health management literature is critical in facilitating effective leadership and management in the health sector by imparting the knowledge and understanding required in health service planning, organization, coordination, and management. Through an exhaustive bibliometric examination, the current state of the “healthcare management” literature was assessed in this study, illuminating potential future developments in the field. By utilizing an extensive compilation of articles from the Web of Science (WoS) database, this study endeavors to scrutinize patterns in scientific inquiry, assess advancements made on subjects, and underscore significant fields of cooperation and scholarly input. An in-depth, extensive analysis revealed that three decades of research yielded over 46,000 publications; the number of publications has increased by six, particularly in the last ten years, and the United States and the United Kingdom produced most of the publications. Analysis identifying influential journals and authors in the field revealed that it is the focus of attention of health professionals, especially nurses. Although the COVID-19 pandemic has been recognized as the primary public health concern, scholarly attention has shifted towards a sustainable health system incorporating technology-supported preventive health practices and intelligence. To thoroughly comprehend the theoretical progression of health management research, its capacity to tackle worldwide issues, and its growth potential, the study’s findings are a valuable scholarly resource that offers practitioners, policymakers, and researchers a comprehensive overview.

Responsible leadership actions and achievement of societal purpose: Perspectives from the Kenyan health NGO sector

The primary goal of this study was to provide empirical evidence to improve understanding of how responsible leadership actions drive the societal purpose of health non-governmental organisations (NGOs). What impact have such efforts had on organizational performance in terms of achieving societal goals? Although researchers continue to investigate the domain of responsible leadership, none have focused on the health NGO sector, particularly in developing countries, and with a focus on providing evidence-backed adaptation practices for the future. A cross-sectional mixed study approach was applied, with positivist and constructivist phenomenological viewpoints being incorporated. The study respondents were sustainable health system experts working in health NGOs on a national and international scale as well as the health ministry. The perspectives of 33 randomly selected respondents were gathered using a cross-sectional questionnaire survey and 10 purposively selected key informants using open-ended interview questions were empirically and thematically analysed respectively. The findings indicate that responsible leadership embedded on organisational purpose benefits the organisation and adds value to society. Responsible leaders in the studied organisations built trust, used open communication, mindful actions and collective consciousness to positively and effectively engage with their employees. The prospection and future-orientation of responsible leaderships of health NGOs could stimulate adaptive responses in postmodern society, allowing them to deepen sustainable value for society. Leadership actions are an essential component of these NGO adaptation to change. That must be taken into account by managers for smooth adjustments to the changing context, allowing these NGOs to remain relevant and authentic to their organisations’ societal purpose. Despite the fact that researchers are continuing to investigate the domain of responsible leadership, no one has focused on the health NGO sector in developing countries like Kenya. The empirical evidence in this article shows that responsible purpose-driven leadership, combined with responsible actions, has an impact on organisations’ adaptation to contextual changes.

We Are: Giving citizens control over their data.

Summary: The We Are platform gives citizens control of their own health data and actively involves them in decisions about the platform that manages the data, thereby guaranteeing them that they can manage and share their data in a safe way as a leverage for personal wellbeing and the common good. 
 Challenge: Data about citizens, consumers and patients is collected by the government in order to make policies, by companies to develop new products and for marketing and sales, or by hospitals, universities and knowledge institutions for research and innovation. Smart use of data is leading to new insights, valuable innovative processes and even better medicines and health care. Big data will allow us to have a better understanding of who is at risk from specific diseases and who benefits from particular treatments. 
 This can only happen if the data does not continue to be gathered and stored in separate silos. Bringing together data from a wide variety of sources creates inconceivable opportunities for research and development, but it will also require the data to be handled with extreme care.
 Engaging citizens and technology to do something about it: To this end, a Flemish consortium is building a platform providing a personal digital data safe, based for each Flemish citizen. The SOLID technology, a new way of managing data on the web, provides citizens with their own data safe in which they can store their personal data. Citizens manage this safe themselves. They only must enter their data once and can then immediately reuse it for the applications they prefer. 
 All safes are maintained together by a legal entity like a cooperative society. The cooperative governance structure is socially engaged and, on behalf of citizens, ensures utilisation of personal data for innovations aimed at a sustainable health system. 
 What are the next steps, what is the impact: Hence, the combination of personal health data types of all citizens, ranging from lifestyle to wellbeing, curated by themselves, is an unprecedented resource for sustainable innovation & growth, provided the access is arranged, by design, in an ethical way and compliant with legislation. It provides a way to enrich personal health data in a natural way and to collect citizen generated data which is currently often lost or scattered. 
 The realisation of this system innovation requires various activities in which all possible stakeholders (government, companies, research community, civil society and citizens, cf. the quadruple helix) have an important role to play. Doing so, we believe citizen-centered data management will contribute to the empowerment of the patient as a pilot in integrated care