Public Health Reform Research Articles

Large scale system transformation: Ukraine

Abstract In the context of the EU-Ukraine Accession agreement, Ukraine started large scale public health systems reform back in 2015. The COVID-19 pandemic tested the response capacity of the national public health system and led to some improvement during the pandemic such as on laboratory capacity. It also generated lessons for strengthening national and subnational health emergency preparedness and response. Multiple interventions, including a Joint External Evaluation led to the adoption of the Public Health System Law in 2022, laying the foundation to bolster health promotion, disease prevention, and health protection. The Ukrainian Public Health Centre was substantially strengthened, partly oriented on models in other European countries. Corresponding centers for diseases control and prevention at the oblast level were reformed and a subnational network of these centers was created. While the war has a significant impact on the public health system, infrastructure, people and more, decision makers and professionals keep working on sustaining and moving forward the achievements on public health reforms, for example with the adoption of the National Health Strategy 2030 and the adoption of the National Health Security Plan. Further legal and strategic preparations are afoot to strengthen public health services governance capacity, financing, institutional innovation and development, and public health workforce development.

Large scale public health system transformation: Ireland

Abstract Ireland has coped comparatively well with the COVID-19 pandemic when considering excess mortality. The reasons are likely complex and multifaceted, but it may be, in part, attributable to a comparatively young population and progress on indicators related to premature mortality and preventable mortality on chronic diseases and lifestyle risk factors. “Healthy Ireland” is a national framework in place since 2013 and utilizes a settings based approach to promote health and wellbeing in communities. It aims to improve collaboration between government, institutions, local communities, and individuals. Sláintecare is an all’party long-term health reform initiative developed in 2017 aimed at delivering the right care, at the right time, in the right place by the right team. In addition, in 2018 Ireland embarked on an ambitious public health reform programme with the implementation of the recommendations of the Crowe Horwath review of Public Health. While challenges exist, including access to services and waiting times, the governments has put in place initiatives to address these and is committed to, amongst other things, promo ting the continued integration of services across a variety of domains including primary to quaternary prevention. As Ireland began to emerge from the COVID-19 pandemic it established “The Public Health Reform Expert Advisory Group” to identify learnings from the public health components of the response, with a view towards strengthening public health and health protection generally and, specifically, future public health pandemic preparedness. The group, made up of national and international public health experts, submitted its final report in September 2023 which outlined a series of recommendations focused on potential improvements to public health policy, structures and governance. The WHO analysis of the Essential Public Health Functions provided complementary results. More work is now ahead to consider and implement these recommendations and foster institutional reforms including at the Health Services Executive, the Department of Health, and at the Health Protection Surveillance Centre.

An Irish public health policy research team: impact and lessons learned, one year on

Abstract Issue In 2023, in Ireland, a public health policy research team was established in the Health Information and Quality Authority to conduct evidence syntheses and provide evidence-based advice to inform national decision-making, at the request of the Department of Health. One year on, we reflect on the impact of this team and outline lessons learned. These findings may support other countries in creating and developing public health policy research teams. Description of the problem We aim to answer the following questions: What impact can a public health policy research team have and what are the lessons learned, one year on? Projects completed by the team in 2023 were reviewed for stakeholder engagement (such as expert and public and patient involvement) and impact (feedback from policymakers, resulting public health actions or policies and online report downloads). Results Seven public health projects were completed in 2023, in areas including: Long COVID, public health reform, rapid multiplex testing, and medical countermeasure stockpiling. National and international stakeholders were engaged with via expert advisory group membership, document review and project presentations. Patient representatives were included from Long COVID Advocacy Ireland and Rare Diseases Ireland. Project reports were downloaded a total of 281 times. Positive feedback was received from all stakeholders. Project findings were presented to policymakers to inform national public health and rare disease strategy development, and the Long COVID model of care in Ireland. Lessons Early and ongoing stakeholder engagement is key when translating research to practice, via policy. Innovative methods of engagement, including public and patient involvement, can ensure meaningful collaboration. Adapting methodologies to meet stakeholder needs, such as rapid evidence synthesis, enhances impact. Lastly, research impact on policy takes time, and an understanding of national policy development is required. Key messages • A public health policy research team provides impactful evidence synthesis to advise national policymakers. • Stakeholder engagement is key to developing impactful policy advice.

10.A. Round table: Transforming public health systems at large scale: no pain, no gain

Abstract The COVID-19 pandemic, acceleration of climate change, and geopolitical turmoil have triggered discussions about how public health systems in Europe need to transform to be adequately equipped for the so-called “permacrisis”. The challenges to policy makers, health institutions and health services have become so multifaceted, that single solutions from the health sector alone no longer work. Yet, despite the complexity, countries seek to get its own house in order whilst building on inter-sectoral and European approaches in parallel. Germany, Ireland, and Ukraine have all embarked upon ambitious public health services and institutional reforms, leading to transformative change in public health systems. WHO has been accompanying these reforms. The workshop will provide a platform to draw insights and lessons on transforming public health systems from all three countries, although their population size, their socioeconomic and political situation and their public health system design is so different. As the smallest of the three countries in population, Ireland created coherence and is aligning public health actors within “Healthy Ireland” and the Sláintecaire and the Crowe Horwath public health reforms. Germany’s “Pact for the Public Health Services” has been one of the greatest public health investment programs in Europe that was initiated following lessons from the COVID-19 pandemic. And Ukraine has undertaken important legal steps to adopt a Public Health System Law, in the middle of a war of aggression on its territory. The workshop will exhibit the process of large-scale public health system transformation in each of the three countries. The purpose is to identify the enablers that make large scale system transformation possible and addressing some of the pains and gains. The workshop will have three parts. Part one consists of three presentations on large scale system reforms from each of the participating countries. Part two consists of a moderated Q&A session. Part three will focus on the synthesis of enablers for large scale public health system reforms through interaction with the workshop participants, using a digital white board. Key messages • Disruptive times can create enabling conditions for large scale public health system transformation. • Designing and implementing large scale public health system reforms is complex, requiring passion, resilience, and collaborative leadership.

Integration of Health Care Modules in Current Health Care Management Systems in India

Health care beyond worldwide boundaries is a critical problem, particularly when the population differs in terms of geographic position, culture, habits, socioeconomic background, medical strategy, and variations in disease burden over time. For countries like India, with a significant percentage of high-end medical experts as well as support and other health care systems, the development and integration of comprehensive and functionally versatile health care management systems are among the most important clinical problems addressed. The central dogma of a country that facilitates adopting a conglomeration will create a dedicated population to provide tailor-made health care in health shield, health protection, and health care delivery; a nation that takes care of a nation. Until now, it has given us E-Health, and offerings have been fine-tuned in research literature. In India, the health care domain is currently breaking the boundaries of knowledge workers in clinical and research domains working with the help of these workhorses (Fletcher-Brown et al. 2021). Many e-governance and public health reform programs in India are under consideration, and many of them are under implementation. This research focuses more on the integration of health care technology relevant to the paper topic within clinical setups, passive provision, and utilization of services for administrative purposes technologically implemented (Das et al. 2023).

Edwin Chadwick: A Pioneer of Public Health Reform and His Role in Sanitary Awakening.

Edwin Chadwick (1800-1890) was a central figure in the 19th-century public health reform movement in Britain. His work was instrumental in the sanitary awakening, a movement that revolutionized public health through the systematic improvement of urban sanitation and hygiene. As a lawyer by training, Chadwick was deeply influenced by Jeremy Bentham's welfare maximization theory, which emphasized the greatest good for the greatest number. His most significant contribution was his 1842 publication, "The Report on the Sanitary Condition of the Labouring Population," in which he documented the deplorable conditions faced by the working class and the link between poor sanitation and disease. Chadwick's advocacy led to the passage of the Public Health Act of 1848, which established local health boards and marked the beginning of modern public health systems. His focus on clean water, efficient sewage systems, and waste management not only reduced the spread of diseases like cholera and typhoid but also set the stage for future public health initiatives globally. The sanitary awakening, largely driven by Chadwick's efforts, highlighted the critical connection between environment and health, a principle that continues to underpin public health practices today. Chadwick's legacy lives on in the ongoing efforts to improve urban living conditions and prevent disease through public health infrastructure.

Economic Analysis of the Public Health Reform——The Mechanism and Policy Design for the Optimal Resource Allocation between Prevention and Treatment

Economic Analysis of the Public Health Reform——The Mechanism and Policy Design for the Optimal Resource Allocation between Prevention and Treatment

A snapshot on a journey from frustration to readiness-A qualitative pre-implementation exploration of readiness for technology adoption in Public Health Protection in Ireland.

In an era of emergent infectious disease, the timely and efficient management of disease outbreaks is critical to public health protection. Integrated technologies for case and incident management (CIM) collect real-time health intelligence for decision making in Public Health. In Ireland, a Public Health reform program is preparing for implementation of a health information system for health protection. Project implementers seek to document and understand the readiness and willingness of future users to adopt the new system, prior to system procurement and implementation. Qualitative key informant interviews were conducted (n = 8) with Public Health personnel from a single regional department of Public Health representing medical, nursing, disease surveillance and administrative roles, at managerial and staff levels. A qualitative thematic analysis was performed. Participants were frustrated by weaknesses in the current practice of CIM and were ready and willing to adopt a digital CIM system if it met their needs. However, they were frustrated by lack of clear timelines. We identified 7 enablers and 3 barriers to readiness and willingness to adopt a CIM system. 'Newness of the workforce' was the main enabler of readiness and willingness, while 'lack of knowledge and familiarity with system' was the main barrier to readiness and willingness. Experiences during the COVID-19 pandemic gave a clear understanding of the problems and need for a digital CIM system and the reform program facilitated a culture of change, readying the workforce for the new health information system. New members of the Public Health departments are a likely ready and eager cohort for adoption of a modern, 'fit for purpose' CIM system and the execution of implementation will likely determine how ready and willing the wider network of departments will be to adopt a national CIMS.

Aboriginal Health Practitioners obtaining, possessing and administering fluoride varnish: self-determination driven regulation amendment for integrated oral health care for Aboriginal children.

Self-determination informed policies are key to improved outcomes for Aboriginal health. Aboriginal leadership must be reflected throughout any public health reform process that affects Aboriginal communities. This paper presents a body of oral health policy work, undertaken under Loddon Mallee Aboriginal Reference Group's (LMARG's) leadership, as an exemplar of a self-determination informed change, that led to an amendment of an Australian state (Victoria) regulation - The Drugs, Poisons and Controlled Substances Amendment (Registered Aboriginal and Torres Strait Islander Health Practitioners [AHPs]) Regulations 2022. A summary of activities undertaken by LMARG, from advocacy to leading the submission, to amend the regulation, is provided. The amendment, now in place, authorises registered AHPs to obtain, possess, and administer fluoride varnish (FV) as a part of health services they provide. FV is a concentrated form of fluoride applied to tooth surfaces to prevent tooth decay. The practical implication of this amendment is delivery of a culturally appropriate integrated oral health promotion FV model that addresses mainstream dental access barriers commonly experienced by Aboriginal people. The model aims at upskilling an Aboriginal workforce to facilitate timely FV application to Aboriginal children.

The Brazilian Center for Health Studies and the Brazilian Association of Collective Health: the issue of the nationalization of health in the Brazilian public health reform, 1976-1988.

An analysis is presented of the approaches taken by the Brazilian Center for Health Studies (Cebes) and the Brazilian Association of Collective Health (Abrasco) towards the nationalization of health during the Brazilian public health reform between 1976 (when Cebes was founded) and the enshrinement of public health in the Federal Constitution (1988). Discussions are presented of the theoretical and strategic principles defended by their intellectuals and the institutions' positions towards the nationalization of health. By positioning themselves against complete nationalization, they did not break away from the privatizing rationale embedded in the prevailing model of healthcare, and endeavored to conciliate private interests within the new framework for public health.

The hopes and stakes of a public health reform. The example of New Caledonia

At a time when many of us desire fundamental reform of our health system, we return to the case of the New Caledonian Do-Kamo project. The proposed model provides interesting elements of reflection, due to it being person-centered and favoring a cultural approach to disease.

Lessons learnt from the COVID-19 pandemic in selected countries to inform strengthening of public health systems: a qualitative study

IntroductionThe COVID-19 pandemic has prompted governments internationally to consider strengthening their public health systems. To support the work of Ireland's Public Health Reform Expert Advisory Group, the Health Information and Quality Authority, an independent governmental agency, was asked to describe the lessons learnt regarding the public health response to COVID-19 internationally and the applicability of this response for future pandemic preparedness. MethodsSemi-structured interviews with key public health representatives from nine countries were conducted. Interviews were conducted in March and April 2022 remotely via Zoom and were recorded. Notes were taken by two researchers, and a thematic analysis undertaken. ResultsLessons learnt from the COVID-19 pandemic related to three main themes: 1) setting policy; 2) delivering public health interventions; and 3) providing effective communication. Real-time surveillance, evidence synthesis, and cross-sectoral collaboration were reported as essential for policy setting; it was noted that having these functions established prior to the pandemic would lead to a more efficient implementation in a health emergency. Delivering public health interventions such as testing, contact tracing, and vaccination were key to limiting and or mitigating the spread of the SARS-CoV-2 virus. However, a number of challenges were highlighted such as staff capacity and burnout, delays in vaccination procurement, and reduced delivery of regular healthcare services. Clear, consistent, and regular communication of the scientific evidence was key to engaging citizens with mitigation strategies. However, these communication strategies had to compete with an infodemic of information being circulated, particularly through social media. ConclusionsOverall, functions relating to policy setting, public health interventions, and communication are key to pandemic response. Ideally, these should be established in the preparedness phase so that they can be rapidly scaled-up during a pandemic.

Prerequisites and practice of introducing integrated systems of medical care in England

The introduction of new conceptual approaches to public health protection is a trend of public health reform in Russia and European countries. The success of the implementation of public health policy in Russia depends both on the development of their own ideas and their implementation, on the study and use of the experience of foreign countries. For example, in England in the last decade, as part of the reform of the public health system, the idea of creating integrated medical care systems (ICS) has been actively developing and the experience of its implementation is of practical interest for Russian healthcare. 
 Goal. To study the experience of England in implementing integrated medical care systems and analyze the possibility of using its individual elements in Russia. 
 Materials and methods. The study was conducted on the basis of a comprehensive study of open reporting data of the Department of Health and Social Security of England, the National Health Service and the National Audit Office of England (NAO), as well as scientific reports on integrated public health management systems. 
 Results. The development of integrated public health management systems being a trend in world practice, contributes to the improvement of public health indicators. The study of the experience of implementing ICS in England showed the presence of a number of risks during its implementation.
 Limitations. When conducting research, there were no restrictions that could influence the preparation of the article.
 Conclusions. Dissatisfaction with the level of management and financing of the healthcare system in England served as an impetus for the start of reforms that contribute to improving the management of medical care to the population, and the introduction of integrated medical care systems. The analysis of the NAO auditors revealed the main risks of the success of the ICS implementation. Studying the experience of implementing ICS is useful for use in the implementation of Russian national projects in the field of healthcare and demography.

Establishing a Platform for Public Health Advocacy in the midst of a Pandemic

Abstract Issue/problem Prior to the COVID-19 pandemic, Doctors working in Public Health Medicine in Ireland lacked a platform to present a collective voice to advocate on issues of public health concern. The aim of this abstract is to describe the establishment of a platform for advocacy through the formation of the Irish Society of Specialists in Public Health Medicine (ISSPHM). Description of the problem An independent society for Public Health Doctors in Ireland was lacking. Models used by other medical specialties in Ireland and international practice was reviewed. The ISSPHM was developed to build capacity and capability for advocacy amongst Public Health Doctors in Ireland by providing indemnity for members and a forum to interact with the media. Results A constitution, mission statement and website for the society were developed. The formal launch of the ISSPHM took place in December 2021. Outputs to date include co-hosting of webinar entitled ‘Public Health and the Law'; contributing to the Irish Public Health Reform Expert Advisory Group; a position paper on pandemic preparedness; a statement on migrant health (published on the ISSPHM website and widely quoted in the media); letters published in Irish media; interviews on national radio and the formation of a Climate Change Working Group. Lessons The ISSPHM successfully creates an environment where Public Health Doctors can advocate on major issues. The establishment of an independent society requires diverse expertise and resources. Future plans for the ISSPHM are to further collaborate and build on existing partnerships and expand eligibility for membership to include other colleagues working in Public Health e.g. nurses, surveillance scientists, data analysts. Key messages • An independent national society for Public Health Doctors is an extremely useful vehicle for advocacy. • The establishment and development of an independent society is a significant undertaking requiring diverse expertise.

Regional public health staff workplace psychosocial risk assessment and health promotion initiative

Abstract Psychosocial work conditions can be detrimental to worker wellbeing with 70% of healthcare workers reporting work related stress, which may lead to burnout. Despite European health and safety legislation, managers rarely assess and manage workplace psychosocial risks. The Public Health workforce in Ireland, already impacted by the pandemic, is currently experiencing major organisational change as a result of the ongoing Public Health Reform Process. This paper describes the structures, processes and outcomes involved in a Public Health staff (n = 56) workplace psychosocial risk assessment, guided by the European Framework for Psychosocial risk Management: PRIMA-EF, using the HSE Work Positive CI psychosocial risk assessment survey. The establishment of a multidisciplinary Health & Wellbeing (H&W) group, under the governance of the Area Senior Management Team, was key to guide the process, including a workplace health promotion initiative, influenced by Positive Psychology framework (PERMA). The response rate to the survey was 70% (n = 40), with half of staff reporting psychological distress. Work stressors included role clarity, demand, change and control, scoring below average compared to Irish organisational norms. Relationships and manager support scored highly. The H&W group shared results promptly with all staff and formulated iterative mitigation measures, including HSE Change Management and HSE Health & Wellbeing consultants, based on the survey action plan and staff feedback. Five months later a repeat survey revealed continuing issues around role clarity and demands, with change and control showing an improvement. Further exploration of these results, and an evaluation, informed by staff feedback is ongoing and iterative. Lessons learnt include the importance of embedding a dedicated H&W multidisciplinary group to lead the continuous process; senior management support; employee involvement and effective utilisation of existing organisational tools and supports. Key messages • It is a public health imperative to promote risk assessment and mitigation of healthcare workplace stressors to safeguard employee wellbeing and ensure health service resilience and patient safety. • Effective workplace psychosocial risk assessment and implementation of targeted mitigation measures requires management support and a continuous iterative collaborative quality improvement process.

Retracted: Balance of Public Medical and Health Services and Reform of Medical Institutions Based on 5G Sensor Technology

Retracted: Balance of Public Medical and Health Services and Reform of Medical Institutions Based on 5G Sensor Technology

Endotoxin quality of ultrapure dialysis fluid for online hemodiafiltration in several hemodialysis centers

Globally, the nephrology community is seeing a rise in the use of high-flux membranes and ultrapure water in hemodialysis (HD) machines. However, data on HD water quality could be more extensive in low- and middle-income countries. The Ministry of Health in Iraq issued a rule requiring a gradual modification in the HD water treatment system to adopt ultrapure water in all dialysis centers. The current study aimed to monitor the endotoxin of ultrapure dialysis fluid at several centers in Iraq and the clinical benefits of its use. This work evaluated the quality of ultrapure water used for dialysis in twenty-one dialysis centers within various Iraqi province hospitals. The samples were collected for 4 months from January to April 2022. Endotoxin tests in ultrapure dialysis fluid were measured by Gel Clot assay. Results showed an unacceptable difference in the ultrapure dialysis fluid's quality compared to the international standard (ANSI/AAMI/ISO-23500). Endotoxin levels in 33% of ultrapure dialysis fluid above 0.03 EU/ml, exceeding recommended international standards. The findings highlight the importance of assessing water quality in medical facilities to ensure patient safety and encourage sanitary monitoring of this procedure as a healthcare promoter. Keywords: Ultrapure water; Hemodiafiltration; Dialysis fluid; Endotoxin; Public Health Reform.

Healthcare Policies and Access: A Behavioural-Ecological Model Analysis

The legacy of apartheid systems continues to be felt, especially in the country’s healthcare systems. Existing policies contribute to the inequality and challenges confronted when navigating healthcare services. This study uses the behavioural-ecological approach to analyse healthcare policy challenges hindering patients from accessing healthcare services in peri-urban communities in Johannesburg, South Africa. In addition, the study examines how poverty, poor infrastructure, and geographic location contribute to challenges facing communities in accessing healthcare services. A mixed-methods research was adopted; semi-structured interviews and field notes were used for data collection. Data were collected from outpatients, administration, and medical personnel. 173 respondents participated in the surveys, 14 participants were interviewed, and 12 respondents for focus groups. Statistical Package for the Social Sciences (SPSS) was used for quantitative data analysis and Nudist Vivo (NVivo) for thematic analysis. The study established that poverty, costly medical services, inability to communicate with healthcare providers, and low literacy were significant hindrances. It was revealed that unemployment contributed significantly to poverty levels, thus impeding access to healthcare services. The study concluded that South Africa needs a comprehensive social security system that provides adequate and sustainable social protection for peri-urban communities. The above remedial actions were recommended, but the public sector health reforms were negatively perceived. Thus, a conceptual model was developed to catalyse behavioural change in the public and private healthcare systems to achieve affordable and sustainable improvement in access and usage of healthcare services.

Review of foreign healthcare systems and ongoing reforms in China and Vietnam

The article is devoted to the review of some aspects of health care reform abroad, the emphasis is placed on the study of measures to achieve universal health coverage (HEU) in China and Vietnam. There is a significant similarity of problematic issues in the health care of most countries, which include ensuring equal access to quality medical care, shortage of medical personnel, financing of medical care. A review of the studied reforms showed that those that are addressed to a specific health problem achieve greater success, especially in the field of public health reform. The experience of reforms in China and Vietnam in the field of increasing the availability of medical care demonstrates the importance of improving the financing of the medical industry in the implementation of most reforms. Both countries have implemented reforms in the field of health insurance, but in China basic health insurance was introduced, while in Vietnam more attention was paid to vulnerable groups of the population. Despite the fact that the two countries have made progress in health coverage, inequality in access to medical care has been significantly reduced in Vietnam. It is concluded that the effectiveness of reforms will be more successful if such measures as the use of strategic procurement, improvement of primary health care, improvement of the quality of services, provision of political support and increased financing of health care are implemented.

Gender, Medicine, and the Creation of a Modern Nation: Calls to End Female Genital Cutting in Egypt, 1940 to 1960

Abstract While considerable research exists on female genital cutting (FGC) in Egypt, debates about its legitimacy prior to the 1970s have barely received any scholarly attention. However, the analysis of Egyptian magazines and newspapers indicates that the 1940s and 1950s witnessed a broad debate over FGC. Drawing on this evidence, the article argues that calls to end female circumcision did not primarily assert the physical and sexual rights of women and girls. Rather, the debate was dominated by a male-centered perspective that conceptualized FGC as a backward practice whose eradication was deemed necessary to create a healthy and progressive nation, while both female sexual satisfaction and the agency of female traditional health practitioners were marginalized. The history of combatting FGC between 1940 and 1960 thus needs to be understood as part of broader debates about public health and social reform that centered on the female and rural population to civilize and modernize the nation.