Social Systems Research Articles

An analytical framework based on social-ecological systems for identifying priority areas for ecological restoration in coastal regions

Owing to rapid urbanization, coastal regions worldwide are experiencing immense resource and environmental stress. Ecological restoration is vital for maintaining and sustainably developing coastal regions. This study proposed a method for delineating priority areas for ecological restoration based on the social-ecological systems (SES) theory. First, an analytical model was established based on three dimensions: ecosystem function, social system pressure, and SES evolution, for analyzing the social and natural systems of coastal regions. Second, based on the modes of land–sea interaction relevant to ecological restoration, auxiliary marine factors were incorporated to aid the delineation of priority areas for ecological restoration. A case study was conducted on the Dapeng New District of Shenzhen City to validate our method. The marine areas of the Dapeng New District have significantly poorer ecosystem function than its terrestrial areas because of the natural geography of this area and human activities. A total of 43.4% of marine areas require artificially assisted ecological restoration, and inland areas 1.5 km from the shoreline are significant for ecological conservation and restoration. Additionally, estuaries and artificial shorelines should be the focus of ecological restoration work in the study area. This case study proved the efficacy of our method. The findings will serve as a reference for the planning and implementation of ecological restoration plans in coastal regions.

Strengthening the pain care ecosystem to support equitable, person-centered, high-value musculoskeletal pain care

Abstract Improving health and wellbeing outcomes for people experiencing chronic musculoskeletal pain requires collective efforts across multiple levels of a healthcare ecosystem. System-wide barriers to care equity must however be addressed (eg, lack of co-designed services; overuse of low value care/underuse of high value care; inadequate health workforce; inappropriate funding models; inequitable access to medicines and technologies; inadequate research and innovation). In this narrative review, utilizing a systems’ thinking framework, we synthesize novel insights on chronic musculoskeletal pain research contextualized through the lens of this complex, interconnected system, the “pain care ecosystem.” We examine the application of systems strengthening research to build capacity across this ecosystem to support equitable person-centred care and healthy ageing across the lifespan. This dynamic ecosystem is characterized by three interconnected levels. At its centre is the person experiencing chronic musculoskeletal pain (micro-level). This level is connected with health services and health workforce operating to co-design and deliver person-centred care (meso-level), underpinned further upstream by contemporary health and social care systems (macro-level context). We provide emerging evidence for how we, and others, are working towards building ecosystem resilience to support quality musculoskeletal pain care: at the macro-level (eg, informing musculoskeletal policy and health strategy priorities); at the meso-level (eg, service co-design across care settings; health workforce capacity); and downstream, at the micro-level (eg, person-centred care). We outline the mechanisms and methodologies utilized and explain the outcomes, insights and impact of this research, supported by real world examples extending from Australian to global settings.

Fighting for Ben, a family’s story

Purpose This paper aims to study themes of abuse and mistreatment of people with a learning disability. Personal stories of lived experience such as this are important pieces of learning and information for practitioners. This case study is intended to add to the limited available knowledge base of lived experience, offering insight into safeguarding in practice. Design/methodology/approach This is a single case study highlighting lived experiences written by and from the perspective of a sibling of a person with a learning disability who has experienced abuse in the social-care system. Findings Structural ongoing abuse occurs and has occurred in the social care system. How we respond to this as a system and societally is a multi-layered challenge that underpins the ability to ensure the safety and well-being of the most vulnerable peers. Originality/value Case studies such as this are limited, with underpinning themes that are all too common. The case study adds to literature that gives insight and perspective into experiences of systems, and of systemic failures to act.

Predictors of mental well-being among family caregivers of adults with intellectual and developmental disabilities during COVID-19.

Internationally, stresses related to the COVID-19 pandemic negatively affected the mental health of family caregivers of adults with intellectual and developmental disabilities (IDDs). This cross-sectional study investigated demographic, situational and psychological variables associated with mental wellbeing among family caregivers of adults with IDDs during the COVID-19 pandemic. Baseline data from 202 family caregivers participating in virtual courses to support caregiver mental well-being were collected from October 2020 to June 2022 via online survey. Mental well-being was assessed using total scores from the Warwick-Edinburgh Mental Wellbeing Scale. Demographic, situational and psychological contributors to mental well-being were identified using hierarchical regression analysis. Variables associated with lower levels of mental well-being were gender (women); age (<60 years old); lack of vaccine availability; loss of programming for their family member; social isolation; and low confidence in their ability to prepare for healthcare, support their family member's mental health, manage burnout and navigate healthcare and social systems. Connection with other families, confidence in managing burnout and building resilience and confidence in working effectively across health and social systems were significant predictors of mental well-being in the final regression model, which predicted 55.6% of variance in mental well-being (P < 0.001). Family caregivers need ways to foster social connections with other families, and support to properly utilise healthcare and social services during public health emergencies. Helping them attend to their needs as caregivers can promote their mental health and ultimately improve outcomes for their family members with disabilities.

The Health-Employment-Longevity Nexus: Implications for Retirement Age Policies in European Countries

Abstract Background Advances in medical knowledge and technology have led to increased general and healthy life expectancy in Europe. Combined with declining fertility rates, these trends have resulted in an aging population. Many European countries have been reluctant to adjust the retirement age, putting pension funds and Pay-As-You-Go social insurance systems at risk. Linking entitlement age to life expectancy could mitigate this risk and extend working life, but such policies are politically unpopular. This study investigates the empirical relationship among self-perceived health, employment, job quality, and life expectancy in the European context. Methods The study analyzes the determinants of self-rated health using the SHARE database, combined with general and healthy life-expectancy data from EUROSTAT and, where missing, the WHO, focusing on European countries. Results In Europe, both past and present employment improve self-rated health. Job quality has a detrimental effect on self-rated health for women and a positive effect on men. Life expectancy and healthy life expectancy raise self-rated health, while poverty rates negatively affect it. Job quality is widespread among European women, and its negative effect on health rises with age. For European men, job quality has a positive effect, peaking around age 56. The effects of employment and job quality on self-rated health are simultaneous. In European countries with an elasticity &amp;gt;1, healthy life expectancy rises faster than general life expectancy at higher ages, suggesting an improved ability to work at older ages. This finding indicates that adjusting the retirement age could be a powerful tool for improving the sustainability of social insurance systems in Europe. Conclusions For younger European women, it may be rational to set higher retirement-age increments and put them on a declining course as they age, considering the gender-specific age dynamics and job quality effects on health. Key messages • In Europe, employment and job quality significantly influence self-rated health, with gender-specific effects that vary with age and impact retirement age policies. • Adjusting retirement age in line with healthy life expectancy could improve the sustainability of European social insurance systems, considering health-employment dynamics.

Leaders’ perceptions of integrating health and social services after a structural reform in Finland

Abstract Background Health and social service system was reformed in Finland at the beginning of 2023. The responsibility for organizing health and social services was transferred from c. 300 municipalities to 22 well-being services counties (WBSCs). One aim of the reform was to support integration between and within health and social services. The purpose of this study is to describe strategic leadership approaches to implementing integrated care. The study highlights the issues that should be paid attention to when integrated care practices are implemented. Methods The qualitative study utilized semi-structured interviews collected from the upper-level leaders of the WBSCs (n = 25) responsible for the implementation of the reform. The interviewees represented 11 WBSCs. The data were collected in May-August 2023. Inductive content analysis was used for data analysis. Results Four strategic leadership approaches to implementing integration were identified: 1) service user-based leadership approach, 2) partnership-based leadership approach, 3) service system-based leadership approach, and 4) knowledge-based leadership approach. Most of the interviewees combined several different leadership approaches in their talk. Each approach emphasized different aspects of implementing integration and the contextual factors that have to be addressed at different levels of the health and social service system. Conclusions While the macro level reform toward more integrated health and social service system was implemented, the findings reveal that more efforts are required at the meso and micro levels of the system to fulfill the goal of integrated services. The paper highlights the importance of strategic leadership and its different aspects in implementing integrated care at different levels of the system. Key messages • The paper provides a way of comprehending integration from the perspective of strategic leadership. • The conceptualization through the different leadership approaches may facilitate forming a shared vision for integration among leaders and managers.

2008 economic crisis impact on perinatal and infant mortality in Southern European countries

Abstract Introduction The study of crisis events provides important lessons to prepare for upcoming events. The Great Recession’s impact on perinatal health in Europe can provide relevant insights into the healthcare and social protection systems’ response to protecting the health of the most vulnerable groups. Objectives To assess time trends and international disparities in perinatal mortality rates (PMR) and infant mortality rates (IMR), following the Great Recession, and their association with socioeconomic indicators in Portugal, Greece, Italy and Spain. Methods Associations were assessed through generalised linear models for all four countries. A Poisson joinpoint regression model was applied to explore PMR and IMR trend changes between 2000 and 2018. Country disparities were analysed using mixed-effects multilevel models. Results IMR and PMR have decreased overall in the four selected countries between 2000 and 2018. Still, whereas in Spain, Italy and Portugal the decreasing pace was attenuated after 2009, in Greece a positive trend was found after the 2008 crisis. IMR and PMR were significantly associated with socioeconomic indicators in all four countries. National disparities in the evolution of IMR and PMR were significantly associated with most socioeconomic indicators between 2000 and 2018. Conclusions Our results confirm the impact of the Great Recession on PMR and IMR trends in all four countries, taking recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility and stagnation of IMR and PMR into account. The association with socioeconomic indicators stresses the need to strengthen social protection and healthcare systems to better protect the population’s health from the earliest days. Key messages • Mortality patterns refer to the internal variability of the crisis’ effect and to persistent spatial regional inequalities appealing to the need for attention in policymaking. • The relevance of considering the political economy of global health finance and macroeconomic volatility as a major influence on the association of mortality rates with socioeconomic indicators.

Enabling effective knowledge sharing through a Knowledge Hub

Abstract The objective of the THCS Knowledge Hub is to facilitate and implement effective knowledge sharing and capacity-building activities for the transformation of health and social care systems in Europe, tailored to the users’ needs and local context in order to prepare the ground for the transformation of health and social care systems. The Hub acts as personalised and interactive “matchmaking” platform which will allow the potential users to (a) access, provide and search for personalised and tailored resources generated in the THCS community but also beyond, reflecting the local maturity and conditions enabling the transformation of health and social care systems; (b) facilitate a support for the potential adaptation and transferability of these resources across the European health and social care settings through the functional use of THCS Innovation Transferability Framework; (c) enable the policy dialogue and capacity-building support for policy-makers in order to enhance their skills, knowledge and experience in health and social care transformation; (d) access and engage with THCS community of experts and ecosystems in order to maximise the access and use of the exiting knowledge and expertise for the transformation of health and social care systems; (e) signpost to existing evidence and resources related to health and social care transformation to enable effective knowledge sharing (educational webinars, peer review activities, study visits, training workshops), exchange of good practices and experience in transforming health and social care systems.

A global adoption of cryptocurrency and blockchain technology into the healthcare system

Abstract Background/Objectives Blockchain technology is revolutionizing various industries by enhancing security, transparency, and efficiency. In healthcare, its small-scale application demonstrates the potential to transform healthcare. This study explores how cryptocurrency and blockchain technology enhance healthcare financial stability, secure medical information exchange, increase payment recovery and interoperability. Methods Guided by the Diffusion of Innovations (DOI) Theory, this study reviews 34 articles on blockchain and cryptocurrency adoption in healthcare. We performed a thematic analysis focusing on empirical data, theoretical analyses, and existing implementations. Data were categorized by DOI elements: relative advantage, compatibility, complexity, trialability, observability, and social system. The findings were synthesized into a detailed framework for adopting these technologies in healthcare. Results Our analysis shows that cryptocurrency offers a secure, decentralized payment platform, eliminating the need for third-party intermediaries. Blockchain adoption enhances payment and patient record protection. Cryptographic methods ensure data integrity, transparency, and security, preventing modifications once recorded. Altering data requires consensus from the network majority, protecting healthcare providers from ransomware attacks. Conclusions Evidence suggests that cryptocurrency and blockchain will disrupt healthcare payments, data management, and accommodate interoperability within the next decade. These technologies promise improved security, improved public health research, and increased trust in the healthcare system. Key messages • Our research will be assessing the challenges of integrating digital coins and blockchain technology into the healthcare system. • Examine the potential benefits and risks of implementing blockchain technology in healthcare settings.

Co-planning as a public health tool: the Milan Health Protection Agencies’s Local Gambling Plan

Abstract Issue/problem Gambling represents a public health, social, and economic problem. Lombardy Region, according with national and regional law, has approved the Regional Plan for the prevention and contrast of Pathological Gambling. The Health Protection Agencies (HPA) of the Metropolitan City of Milan, as the other HPAs, implemented the Local Gambling Plan, based on a context analysis and in synergy with all the actors involved. Description of the problem Since 2019, the Milan HPA’s Local Gambling Plan has been implemented through collaboration with non-profit entities (TSEs), which are involved via public tendering. The implementation of the new Italian ‘Code of the Third Sector’ changed the TSEs engagement modalities. For this reason, a complex co-planning process has been initiated in order to increase the level of active citizenship and to enhance public health, in line with horizontal subsidiarity principle. Results The Co-planning procedure promoted the integration among local health services, non-profit entities and municipalities with the aim of gambling prevention and contrast, ensuring the continuity of prevention programs and the involvement of local stakeholders in addressing a public health issue. During the co-planning, 9 working groups were established to define objectives, project actions, monitoring and evaluation methods, ensuring the common interest of all actors involved. Lessons For the health and social system, the co-planning procedure becomes an opportunity to translate what is foreseen by the regulations into local actions. It allow the active participation of local stakeholders involved into the co-construction and achievement of public health objectives and the promotion of communities’ empowerment. Key messages • Co-planning is both a process and a tool for local welfare. • Co-planning involved multiple actors, among which the public institution that ensures satisfaction of health needs through governance actions.

8.C. Scientific session: Health system resilience: A Planetary Health perspective

Abstract Planetary Health is a collective and unifying approach to balance the interlinkages between human health, political, economic and social systems as well as the natural systems of our planet, the importance of which is growing in the context of climate change in European countries and beyond. Yet, there is a dearth of of research linking Planetary Health to health systems’ resilience, particularly from a public health lens. With the number of studies growing regarding impacts of climate change on health, the question remains how health systems need to be prepared, focusing for example on the emergence of infectious diseases as well as the triple crises of biodiversity loss, pollution and climate change. In addition, tools to assess climate-related risks developed at international level, such as the vulnerability, adaptation and capacity assessment developed by the World Health Organization (WHO) have rarely been piloted in European countries. In this workshop, firstly evidence is presented on the status quo of how climate change impacts health and emerging infections in Europe and at global level. Secondly, the workshop provides insights into how tools to assess vulnerability and resilience of health systems in the context of climate change may be used in the European context. Thirdly, resilience is assessed against evidence emerging from the triple environmental crises of biodiversity loss, pollution and climate change. Key messages • In a planetary health lens, using mixed methods to consider climate change vulnerability of different population groups and adaptation potentials are key to address current complex health challenges. • Synergistic solutions and joint working across climate and health offer opportunities for greater health system resilience and population health impact.

Social Infrastructure and Organizational Resilience - A Theoretical Model

Abstract Background Considering resilience as a necessity for health care organisations (HCOs), many researchers argue that fluidity is a must and that organisational structures (formal and informal) hinder the adaptability and resilience of health care organisations. Contrary to this statement, my thesis posits that fundamental adaptive processes leading to new equilibria depend on a stable core that persists amidst change, enabling and catalysing these transformations. Methods The phenomenon of resilience within healthcare organisations is examined through the lens of sociological systems theory. Rooted in Talcott Parsons’ assertion that social systems, including healthcare organisations, must perform four basic functions (Adaptation, Goal Achievement, Integration, Latency: AGIL) to survive and function, our research uses the deductive method to derive the necessary structural social components required to cope with external demands. Results The application of the methods yields four complex basic structures rooted in the social structure of healthcare organisations: adaptive structures (flexible structures &amp; resource generating structures), goal achievement structures (governance enabling collective goal setting, decision making and persistence), integrative structures (social capital and social networks) and sustainability structures (socialisation structure, knowledge base, organisational culture). Conclusions As the core of stability, this ‘four-component social infrastructure’ is essential for facilitating higher-order forms of resilience, such as new equilibria. In its absence, healthcare organisations would flounder during change, posing risks to the resilience of these HCOs. Thus, structure is indeed inherent in the chaos of resilience activities. In other words, there is order in the chaos of resilience, and it is essential. Key messages • Fundamental adaptive processes leading to new equilibria depend on a stable core that persists amidst change, enabling and catalysing these transformations. • There is order and structure in the chaos of resilience.

Linking Social Protection and Humanitarian Systems to Respond to Forced Displacement

With displacement occurring at record levels and often on a protracted basis, there is increasing interest in the potential to link humanitarian displacement responses with social protection systems. This article discusses how social protection and humanitarian systems can work together to meet the needs of displacement-affected populations, based on the findings of a three-year research project that drew on global literature alongside mixed-methods data collected in 2021 in Cameroon, Colombia, and Greece. The article discusses five lessons: (1) displaced populations’ distinct needs and implications for social protection design and delivery; (2) inadequate social protection for host communities and implications for social cohesion; (3) the priority basis for evaluating linkage approaches; (4) the need for sustained international financing; and (5) the general importance of greater transparency and collaboration. It concludes with recommendations for further research to build the nascent evidence base on this topic.

Hierarchy as a signal of culture and belonging: Exploring why egalitarian ideology predicts aversion to hierarchical organizations

Variation in people's ideological preference for the maintenance of inequality between social groups (i.e., social dominance orientation; SDO) predicts important sociopolitical outcomes, such as endorsement of different social policies, institutions, and belief systems. We argue that SDO may also inform people's engagement with work organizations. Specifically, we propose that SDO may impact attraction to different organizational structures. Across 6 experiments (N = 3034), we find that people with relatively egalitarian values are less attracted to organizations with much (vs. little) managerial hierarchy; this gap in attraction is attenuated for relative anti-egalitarians (Studies 1a-b). These effects are not moderated by whether dominant vs. subordinate group members occupy positions of power in hierarchical arrangements (Study 2a-b) and are driven by signals concerning likelihood of organizational belonging that egalitarians (vs. anti-egalitarians) derive from managerial hierarchy (Studies 3a-b). We discuss implications for social dominance theory and research connecting ideology to organizational attraction.

The Political Economy of Shock-Responsive Social Protection: Analysis from Malawi

Using social assistance systems to address acute needs arising from wide-scale shocks – commonly known as ‘shock-responsive social protection’ (SRSP) – raises significant political economy questions. Previously, acute needs caused by disasters across sub-Saharan Africa have primarily been met by humanitarian actors alone. SRSP disrupts the status quo by reducing humanitarian actors’ access to and control over humanitarian funding. This raises significant political questions; likewise, the introduction by SRSP of greater accountability and transparency into the implementation of humanitarian responses. This article addresses a current gap in the literature: the politics of SRSP. Referencing the concept of political settlements, the article asks what explains the evolution of SRSP in Malawi by examining the actions of domestic and international actors. It finds that there is scant evidence of national ownership of SRSP and that lack of consensus among international actors is a key obstacle to the concept becoming embedded within the political settlement.

3.Y.2. Road traffic injuries, disability burden and implications for compensation schemes in Europe

Abstract Reducing traffic fatalities and injuries is a complex challenge, but it is one that is of paramount importance for public health and safety worldwide. In recent years, there have been improvements in trauma care and injury prevention efforts, which reduced mortality rates and increased survival after serious injury. However, an increased heterogeneity in recovery times is observed with survivors of road traffic injuries differing in their adjustment compared to other traumas in terms of symptoms’ onset, variability and chronicity. The recovery trajectory seems to vary widely with a large percentage of survivors in need of extensive time periods for full recovery. Attention has now been shifted towards the adverse effects of non-fatal injuries on functional, mental health, economic and societal outcomes. The capacity of a person to continue functioning, inability to work, sickness absence and reliance on welfare benefits to compensate for loss of income are some of the injury-related long-term consequences, causing great concern for health and social security systems across Europe, as they have been shown to account for more than one third of total road traffic incident costs. These figures fail to include individuals who sustain “minor” injuries, which do not require hospitalisation, yet still impair their ability to work. Despite the rapidly growing epidemiological and clinical attention, there are still several issues missing from research, policy and practice. A universal definition of recovery after a road traffic injury is still missing, and this has been seen as critical for improved understanding of risk factors of poor recovery as well as improved identification of those in need of welfare benefits. Furthermore, long-term sickness absence and disability following road traffic injury in Europe is still understudied and evidence on the different return to work pathways and compensation schemes is scarce. Evidence is still limited on the context in which return to work occurs, the injury profiles most dependent on long term compensation schemes and the policy settings of injury compensation schemes that impact return to work outcomes post injury. Data availability and data linkage issues often cause misclassification errors when granting disability pensions and this remains unattended long after an injury. Welfare benefits are often poorly connected with the injury or other medical diagnoses and this makes it difficult to assess the contribution of injuries on disability pensions and other welfare benefits, especially in comorbid and multimorbid conditions. The current workshop aims to improve our understanding of the long-term consequences and the challenges faced by those injured in road traffic injuries and aid the development of interventions that seek to enable sustained recovery, and help inform policy and practice of healthcare and injury compensation systems. Key messages • Timely access to quality healthcare, rehabilitation therapies, and assistive technologies can significantly improve outcomes and reduce the strain on social security and compensation systems. • Ensuring equitable access to social security benefits for injured individuals, requires efficient compensation schemes that recognize the full impact of the disability on individuals’ life.

Implementing patient navigation for cancer prevention among individuals with mentally ill-health

Abstract Issue In Europe, over 80 million people experience mental ill-health and there are 4 million new cancer diagnoses each year. Individuals experiencing mental ill-health exhibit higher rates of cancer morbidity and mortality, with this excess attributed to risky health behaviors and obstacles encountered when accessing often fragmented healthcare systems. Description of the problem The aim of Co-CAPTAIN is the pilot implementation and evaluation of the Patient Navigation Model (PNM) for the improvement of primary cancer prevention in individuals with mental ill-health, adapted through participatory co-design in the European context. The project will adopt a cohort-based study design, commencing data collection at baseline and succeeded by three follow-ups (6 weeks, 9 months, 18 months). It will utilize a mixed-methods approach, combining quantitative and qualitative methodologies to assess diverse outcomes of PNM, facilitating both exploratory and confirmatory research. Qualitative data will be obtained through semi-structured interviews, while quantitative data will be collected using validated questionnaires and items developed ad hoc. The project will involve four pilot sites in Europe (Austria, Greece, Poland and Spain), where the PNM will be adapted to the specificities of national healthcare and support systems. The implementation phase is expected to begin in June 2024. Results During implementation, gathering both quantitative and qualitative data will offer valuable insights into feasibility and effectiveness, establishing a baseline for reshaping health and social care policies for individuals with mental ill-health across Europe. Lessons Co-CAPTAIN project aims to reduce health disparities for individuals with mental ill-health by improving overall health and reducing cancer burdens, leading to cost reductions in European health and social care systems. Key messages • The project aims to deliver an innovative solution based on the PNM, to address health disparities among individuals with mental ill-health by reducing cancer burden. • Combination of qualitative and quantitative methodologies to assess diverse outcomes.

Realigning Social Protection Across the Nexus: Reflections from Protracted Crises in the Arab Region

Humanitarian emergencies are increasingly protracted and characterised by multiple compounding crises. International social security standards provide a roadmap for building national social protection systems. In the Arab States region, the International Labour Organization has been critically assessing how to apply these standards across the humanitarian, development, and peace nexus when countries face protracted crises. This article presents case studies in four countries: Iraq, Jordan, Lebanon, and the Occupied Palestinian Territory. It addresses questions on how to strengthen humanitarian–development transitions using international standards, where entry points exist or challenges remain, and how these transitions may contribute to strengthening peace through social cohesion.

Indigenous Peoples and Social Protection: The Case of the Peruvian Amazon

The persistence of indigenous poverty and exclusion is one of the main challenges for social policy in Latin America. Social protection programmes, in particular conditional cash transfers, have been among the main instruments used by governments over the past two decades to respond to the high incidence of poverty in indigenous contexts. The inclusion of indigenous peoples as social protection beneficiaries remains a largely unexplored topic, despite its relevance to understand social policy trajectories in the global South. This article discusses the expansion of poverty alleviation social programmes in the Peruvian Amazon. Although the expansion of these programmes increased the state’s capacity to deliver welfare services in historically excluded areas, it also revealed the limitations of existing social protection instruments to effectively respond to indigenous poverty and vulnerability. Addressing this challenge constitutes a key opportunity to promote transformative approaches in social protection systems in Latin America.

4.D. Scientific session: From policy to implementation: Learnings around health system reforms and Universal Health Coverage

Abstract In this session, the authors and audience have the opportunity to engage in discussions around health policy integrity and reform implementation. Introducing and implementing health system reform has been a perennial issue for countries around the world over the past number of decades. Recently, the introduction and implementation of Universal Health Coverage (UHC) has been of particular focus, with 193 countries committed to introducing UHC by 2030. At the same time, European countries that previously established national health systems are introducing new reforms in the hope of making their health systems more efficient and equitable. However, there are a number of challenges along the path of policy development and implementation with which all countries must grapple, and how individual countries go about reforming their health systems depends on their social, political, cultural and economic contexts. Learnings from around the world have highlighted that reforms can be challenged or stalled in both the design and implementation phases. This workshop, which conceptualises implementation as the “acid test” of a policy, thus explores, through three case studies, the factors that facilitate or challenge the implementation of reforms. At the same time, we discuss policy integrity, exploring reasons for why policies pivot away from original design and intent. Furthermore, we discuss the implications of health reform on equity, cognisant that the primary objective of this collective reform work is to reduce the financial burden of healthcare on households and improve access. The first presentation will provide the framework for audience discussions, outlining international lessons in relation to UHC reforms and equity. The second presentation will provide a snapshot of the Finnish experience of introducing a “big bang” structural reform. The third presentation highlights lessons from the Portuguese experience of primary healthcare reforms, the opportunity these offer for creating patient-centred care and the integral role that politics and governance play in the reform process. Finally, the Irish case study highlights the experiences of a High Income County attempting to introduce UHC much later than its European counterparts, and negotiations between the public and private sectors. Through this, we hope to hold the tensions and stimulate debate about policy robustness and resilience, and reform implementation. Each presenter will be given a strict deadline of 10 minutes each by the chair and then the audience will be invited to debate the problems identified and strategies proposed to discuss: (i) what are the facilitators and barriers to reform implementation, (ii) what are the factors that encourage policy integrity and change and (iii) whether greater cooperation across Europe regarding health reforms can be more effective in supporting robust health systems. Key messages • For reforms to be facilitated, there must be cohesion and commitment across the political, social, economic and cultural systems, and no fragmentation across health system functions. • As policy implementation is attempted, there is a tension between remaining true to key values and adapting to new circumstances.