Universal Health System Research Articles

The role of income in the lives of people with long-term disabilities: A multi-country analysis

Abstract Background Health is a fundamental human right. Yet, people become ill and die because they do not have enough money to access the necessary healthcare. Studies confirm that on average, more income translates to better health status. The magnitude of this relationship and its consequences beyond health like reintegration or spillovers are not widely understood but are expected to be significantly different among countries. This is especially the case in vulnerable populations like those with a spinal cord injury (SCI). This study aims to better understand the role that income plays in promoting health in people with SCI and their differences across countries. Methods The research focus on three aspects, one, the estimation of the health income gap using years after the injury and a comorbidity index, two, the decomposition of different factors of this inequality with a special interest in the unmet healthcare needs, and three, their consequences in their social participation measured by the reasons of unemployment. Results There are significant differences in health status by income and between countries. On average, the poorest income groups with SCI are up to 40 times more likely to be ill than people in the richest groups and live 4-6 years less after the injury. The working conditions and the unmet health care needs are important factors that explain that differences. In addition, the health status, the lack of sustainable employment opportunities, and workplace accessibility issues are the main issues to reintegrating into the labor market. Conclusions Health inequalities are a global problem that affects people with long-term health conditions disproportionately to others without. Even in more equal and high-income countries with a universal health system, there are different realities for the people according to their income, where the estimations and solutions for the ‘average’ individual do not target the needs of people in the extremes. Key messages • This study generates evidence about the role of income in health, lack of health services, and consequences in people with SCI across and within countries. • To achieve the goal of health equity, it is important to target the different realities focusing on the needs of people who most need which goes beyond the health system and changes by income level.

7.C. Workshop: Towards a true European Health Union: milestones, drivers and barriers

Abstract European health system responses to the COVID-19 pandemic have also demonstrated that European integration in health and health systems add value beyond what individual Member States can do: ranging from the joint purchase of medicines to providing large budgets for building back better. With a true European Health Union we will strengthen our health systems beyond crisis preparedness and response, which is necessary as we are facing the evolving perma-crisis, We will need to strengthen our health systems in general always with a view to Universal Health Coverage and improving health system performance. The European Health Union can work to help strengthen health systems, which may include support for Member States research, learning from best practices, investment but also common solutions including new or extended EU mandates, new arms-length bodies, as well as more coordination or harmonization. It has also taught us that we cannot wait to strengthen our health systems as we are in Europe in a perma-crisis. The panel will address the following questions: • Where are we with our progress towards a true European Health Union? • What policy change is needed to create a true European Health Union? • What would be the role of the true European Health Union strengthening and supporting Member States? We will zoom in on the 1) existing public health mandate of the EU, 2) the impact of other EU-policies on health and health systems, 3) the new economic governance and, 4) the role of the EU in global public health Key messages • A true European Health Union will strengthen universal health coverage and health system performance. • A true European Health Union goes beyond crisis-preparedness and respons. Speakers/Panellists Scott Greer University of Michigan, European Observatory on Health Systems and Policies, Ann Arbor, USA Anniek de Ruijter University of Amsterdam, Amsterdam, Netherlands Eleanor Brooks University of Edinburgh, Edinburgh, UK Thibaud Deruelle University of Lausanne, Lausanne, Switzerland

Health services gaps experienced by non-standard workers in Ontario, Canada: Policy implications

Abstract Background While the Canadian universal health system provides access to basic services, key health benefits are employer dependent. Given that non-standard workers (NSWs) only rarely have access to such benefits they have increased vulnerability to the many insecurities derived from their precarious employment, as clearly seen during the pandemic. The growing problem of non-standard work and workers’ heightened risk for health status deterioration, followed by a possible accentuation of health inequities, is a population health concern. This study summarizes several health services gaps experienced by NSWs and discusses policy implications and possible solutions. Methods From January to July 2021, we conducted semi-structured interviews with a purposive sample of 40 NSWs in Ontario, Canada, part of a larger mixed-methods six-country study, including three European countries. The target population consisted of workers aged 25 to 55 who, at the time of the survey, were in non-standard employment or lost their job due to the COVID-19 pandemic. Results Our findings highlight complex physical and mental health problems and an overall high burden of disease facing NSWs during the pandemic as linked to a combination of constant stress and worry arising from their employment insecurity, the limited and inconsistent income available to cover their basic needs, and the inadequate and unsafe working conditions they are afraid to challenge. Despite their increased health needs, given that specialized health services are not available to them for free they face financial barriers in accessing much needed health services that could help improve their health status and as a result, delay seeking care or avoid it altogether. Conclusions Sustainable multi sectorial policy solutions are needed including the adoption of relevant labour market legislation and increases in social and health expenditures along with re-adjustments in the ways in which health services are delivered. Key messages • During the pandemic non-standard workers in Ontario, Canada experienced complex health problems and, despite increased health needs, encountered barriers in accessing specialized health services. • The growing problem of non-standard work and workers’ heightened risk for health status deterioration, followed by a possible accentuation of health inequities, is a population health concern.

Changes in the utilisation of acute hospital care in Ireland during the first wave of the COVID-19 pandemic in 2020.

Reduced and delayed presentations for non-COVID-19 illness during the COVID-19 pandemic have implications for population health and health systems. The aim of this study is to quantify and characterise changes in acute hospital healthcare utilisation in Ireland during the first wave of COVID-19 to inform healthcare system planning and recovery. A retrospective, population-based, observational study was conducted using two national datasets, Patient Experience Time (PET) and Hospital In-Patient Enquiry (HIPE). The study period was 6th January to 5th July 2020. Comparison between time periods pre- and post-onset of the COVID-19 pandemic within 2020 showed there were 81,712 fewer Emergency Department (ED) presentations (-18.8%), 19,692 fewer admissions from ED (-17.4%) and 210,357 fewer non-COVID-19 hospital admissions (-35.0%) than expected based on pre-COVID-19 activity. Reductions were greatest at the peak of population-level restrictions, at extremes of age and for elective admissions. In the period immediately following the first wave, acute hospital healthcare utilisation remained below pre-COVID-19 levels, however, there were increases in emergency alcohol-related admissions (Rate Ratio 1.22, 95% CI 1.03, 1.43, p-value 0.016), admissions with self-harm (Rate Ratio 1.39, 95% CI 1.01, 1.91, p-value 0.043) and mental health admissions (Rate Ratio 1.28, 95% CI 1.03, 1.60, p-value 0.028). While public health implications of delayed and lost care will only become fully apparent over time, recovery planning must begin immediately. In the short-term, backlogs in care need to be managed and population health impacts of COVID-19 and associated restrictions, particularly in relation to mental health and alcohol, need to be addressed through strong public health and health system responses. In the long-term, COVID-19 highlights health system weakness and is an opportunity to progress health system reform to deliver a universal, high-quality, sustainable and resilient health system, capable of meeting population health needs and responding to future pandemics.

Teleconsultations in neurology in a universal health system amid COVID-19: a descriptive study.

This study aimed to characterize teleconsultations in neurology executed by Regula+Brasil project in Recife, a capital city in northeastern Brazil. A descriptive study carried out by four private hospitals, in a partnership with the Ministry of Health in Brazil. Teleconsultation was performed preferably in the video modality. Conditions eligible for teleconsultation were headache, epilepsy, and cerebrovascular disorders. Period of analysis was May to September 2020. A total of 243 teleconsultations were analyzed, of which 76.95% was a first appointment. In 48.97% of cases, the teleconsultation represented the first opportunity for the patient to be consulted with the specialist. Among cases of first appointment, 20.16% were further referred to a face-to-face consultation and 21.81% could be redirected to primary health care. Headache disorders were the most predominant clinical conditions. The implementation and development of telemedicine by Regula+Brasil during the COVID-19 pandemic represented an opportunity to assess the value of having teleconsultations added along the line of care from primary care to a medical specialty, promoting the coordination of care across different levels of complexity of care in the health system and improving access to specialized care.

Profile of judicialization in access to antineoplastic drugs and their costs: a cross-sectional, descriptive study based on a set of all lawsuits filed between 2016 and 2018 in a state in the Northeast Region of Brazil.

BackgroundThe judicialization of the acquisition of medication for healthcare is not restricted to Brazil but can also be found in other Latin American countries, despite the existence of a universal health system in the case of Brazil, the Unified Health System (known as the SUS). Right-to-medicines litigation has existed ever since the emergence of a high demand for treatment of Acquired Immuno-deficiency Syndrome (AIDS) but the current focus is on cancer. Pharmaceutical Assistance (PA) is the area within the SUS that is responsible for ensuring access to medication and the aim of this article is thus to draw up a profile of litigation related to PA in one economically significant state in the Northeast Region of Brazil, in terms of the following characteristics of lawsuits: the plaintiff filing the lawsuit; medical and health information; the cost of acquiring the requested medications; and the proportion accounted for by spending on antineoplastic drugs.MethodsA cross-sectional, descriptive study was conducted of lawsuits filed between 2016 and 2018 at the Litigation Center of the State of Pernambuco Department of Health.ResultsA total of 2,947 lawsuits containing at least one requested medication were analyzed. The majority of the plaintiffs were male (51.7%); 49.8% of the requests originated in the Unified Health System (SUS), and plaintiffs were primarily patients in the Metropolitan region of the State capital, Recife. The most frequent cancers involved were those classified by the ICD as C61, C71 and C50. The median general expense on medications for the actions was U$1,734.94. Considering antineoplastic drugs alone, the cost exceeded U$7,500 per lawsuit over the three years, given that the median unit price for antineoplastic drugs is approximately US$65 compared to US$4 for non-antineoplastic drugs.ConclusionThe present study is of relevance to the field of public health and examines how a profile of such healthcare litigation can be used as a tool for managing and improving decision-making in times of economic austerity.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12889-022-14199-1.

Assessment of the Impact of the Implementation of a Pre-Hospital Ambulance System on Acute Myocardial Infarction Mortality in a Developing Country.

The effective management of patients with acute myocardial infarction (AMI) is time-dependent. To assess the impacts of the implementation of prehospital care on admission rates and mortality associated with AMI. Retrospective, ecological study, which assessed data from the Brazilian Universal Health System, from all 853 municipalities of Minas Gerais, from 2008 to 2016. Excessive skewness of general and in-hospital mortality rates was smoothed using the empirical Bayes method. This study assessed the relationship between Mobile Emergency Care Service (SAMU) in each municipality and the following 3 outcomes: mortality rate due to AMI, AMI in-hospital mortality, and AMI hospitalization rate, using the Poisson hierarchical model. Rates were corrected by age structure and detrended by seasonality and temporal influences. A confidence interval of 95% was adopted. AMI mortality rates decreased throughout the study, on average 2% per year, with seasonal variation. AMI in-hospital mortality also showed a decreasing trend, from 13.81% in 2008 to 11.43% in 2016. SAMU implementation was associated with decreased AMI mortality (odds ratio [OR] = 0.967, 95% confidence interval [CI] 0.936 to 0.998) and AMI in-hospital mortality (OR = 0.914, 95% CI 0.845 to 0.986), with no relation with hospitalizations (OR = 1.003, 95% CI 0.927 to 1.083). SAMU implementation was associated with a modest but significant decrease in AMI in-hospital mortality. This finding reinforces the key role of prehospital care in AMI care and the need for investments on this service to improve clinical outcomes in low- and middle-income countries.

Virtual Care and the Inverse Care Law: Implications for Policy, Practice, Research, Public and Patients.

Virtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This “perspective” paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations’ access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the “solution to everything”. In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial “Direct-To-Consumer” services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to “capabilities” supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing “public health value” through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.

The Feedback Loop Between the Demand for Voluntary Private Insurance and the Burden of Healthcare System: An Explanatory System Dynamics Model of Hong Kong.

Many countries with universal healthcare have a parallel private healthcare sector due to the waiting time in the public sector. People purchase individual health insurance to pay for private services. Past studies on the relationship between the public sector's waiting time and the demand for health insurance have two limitations: not considering the capacity of the private sector, and subsequently, the omission of a feedback loop. These limitations are also present in the health insurance policy discussion in Hong Kong, where the public sector is overstretched. A lack of understanding of market dynamics might lead to unrealistic expectations of public policy. This study highlights these limitations, and tries to answer the research question: whether the historical dynamics between the intersectoral imbalance of burden and the demand for health insurance in Hong Kong could be quantitatively explained. A system dynamics model was created based on a negative feedback loop. The model's initial input was the percentage of population with health insurance in 2009, and to simulate the percentage continuously until 2019. Results from 2015 to 2019 were compared with actual figures to examine the model's explanatory power. Multivariable sensitivity analysis was performed. With initial fluctuation, the simulated result stabilized and was within the acceptable error range from 2015 to 2019. The mean absolute percentage error (MAPE) was 0.94%. At the end of 2019, the simulated percentage of population with health insurance is 36.6% versus the "real value" of 36.7%. Simulated patient admissions and occupancy rates also approximate the reality. Sensitivity analysis demonstrates the robustness of the model. We can quantitatively explain the feedback loop between health system burden and demand for health insurance. With local parameterization, this model should be transferable to other universal health systems for a better understanding of the system dynamics and more informed policy-making.

Equity in the use of physician services in Canada's universal health system: A longitudinal analysis of older adults

This study presents longitudinal evidence on the trends and determinants of income-related inequities in general practitioner (GP), specialist, and any physician visits among older adults (aged 65+) in Canada. Using the Canadian National Population Health Survey between 1998/99 and 2010/11, random effect probit and negative binomial models were employed to model the probability of visit and the total number of visits, respectively. The concentration index-based horizontal inequity (HI) approach was used to measure income-related inequities in physician services. The decomposition technique was applied to explain the factors contributing to the observed inequities. The mobility index (MI) was also calculated to compare short-run and long-run estimates of inequities. The HI indices reveal significant pro-rich inequities in both the probability and the number of specialist visits. Inequities in the likelihood of GP visits and any physician visits were pro-rich but trivial in magnitude. The MI shows that upwardly income mobile individuals contribute to inequity in specialist visits in the long run. After income, education was the most important contributor to inequity in specialist visits, while unobserved heterogeneity explained most of the pro-rich inequity in the total number of GP and any physician visits. Although physician services are free at the point of the provision in Canada, this study demonstrates that poorer older adults utilized fewer specialist services than richer older adults for the same level of need. Specific policies are needed to ensure equity in specialist care use among the older adults in Canada.

Changes in the utilisation of acute hospital care in Ireland during the first wave of the COVID-19 pandemic in 2020

Reduced and delayed presentations for non-COVID-19 illness during the COVID-19 pandemic have implications for population health and health systems. The aim of this study is to quantify and characterise changes in acute hospital healthcare utilisation in Ireland during the first wave of COVID-19 to inform healthcare system planning and recovery. A retrospective, population-based, observational study was conducted using two national datasets, Patient Experience Time (PET) and Hospital In-Patient Enquiry (HIPE). The study period was 6th January to 5th July 2020. Comparison between time periods pre- and post-onset of the COVID-19 pandemic within 2020 showed there were 81,712 fewer Emergency Department (ED) presentations (-18.8%), 19,692 fewer admissions from ED (-17.4%) and 210,357 fewer non-COVID-19 hospital admissions (-35.0%) than expected based on pre-COVID-19 activity. Reductions were greatest at the peak of population-level restrictions, at extremes of age and for elective admissions. In the period immediately following the first wave, acute hospital healthcare utilisation remained below pre-COVID-19 levels, however, there were increases in emergency alcohol-related admissions (Rate Ratio 1.22, 95% CI 1.03, 1.43, p-value 0.016), admissions with self-harm (Rate Ratio 1.39, 95% CI 1.01, 1.91, p-value 0.043) and mental health admissions (Rate Ratio 1.28, 95% CI 1.03, 1.60, p-value 0.028). While public health implications of delayed and lost care will only become fully apparent over time, recovery planning must begin immediately. In the short-term, backlogs in care need to be managed and population health impacts of COVID-19 and associated restrictions, particularly in relation to mental health and alcohol, need to be addressed through strong public health and health system responses. In the long-term, COVID-19 highlights health system weakness and is an opportunity to progress health system reform to deliver a universal, high-quality, sustainable and resilient health system, capable of meeting population health needs and responding to future pandemics.

Changes in the utilisation of acute hospital care in Ireland during the first wave of the COVID-19 pandemic in 2020

Background: Reduced and delayed presentations for non-COVID-19 illness during the COVID-19 pandemic have implications for population health and health systems. The aim of this study is to quantify and characterise changes in acute hospital healthcare utilisation in Ireland during the first wave of COVID-19 to inform healthcare system planning and recovery. Methods: A retrospective, population-based, observational study was conducted using two national datasets, Patient Experience Time (PET) and Hospital In-Patient Enquiry (HIPE). The study period was 6th January to 5th July 2020. Results: Comparison between time periods pre- and post-onset of the COVID-19 pandemic within 2020 showed there were 81,712 fewer Emergency Department (ED) presentations (-18.8%), 19,692 fewer admissions from ED (-17.4%) and 210,357 fewer non-COVID-19 hospital admissions (-35.0%) than expected based on pre-COVID-19 activity. Reductions were greatest at the peak of population-level restrictions, at extremes of age and for elective admissions. In the period immediately following the first wave, acute hospital healthcare utilisation remained below pre-COVID-19 levels, however, there were increases in emergency alcohol-related admissions (Rate Ratio 1.22, 95% CI 1.03, 1.43, p-value 0.016), admissions with self-harm (Rate Ratio 1.39, 95% CI 1.01, 1.91, p-value 0.043) and mental health admissions (Rate Ratio 1.28, 95% CI 1.03, 1.60, p-value 0.028). Discussion: While public health implications of delayed and lost care will only become fully apparent over time, recovery planning must begin immediately. In the short-term, backlogs in care need to be managed and population health impacts of COVID-19 and associated restrictions, particularly in relation to mental health and alcohol, need to be addressed through strong public health and health system responses. In the long-term, COVID-19 highlights health system weakness and is an opportunity to progress health system reform to deliver a universal, high-quality, sustainable and resilient health system, capable of meeting population health needs and responding to future pandemics.

Beyond financial constraints: The politics of Irish health system reform in the aftermath of the great recession

AbstractThis article investigates the main factors influencing the success of welfare reforms in the context of crises. It focuses on the healthcare reform plan proposed in Ireland in the aftermath of the Great Recession, which aimed at the establishment of a universal health system but was only very partially implemented. As the plan would have required an increase in public expenditure, it may be expected that cost concerns explain the overall reform outcome in the context of an economic crisis. However, analysis of the process leading to the abandonment of a central element of the plan and the partial introduction of another component shows that, apart from financial concerns, the outcome is explained by three politico‐institutional factors: the political orientation of the parties in government; electoral (dis)incentives in pursuing different elements of the reform; and the extent of institutional change associated with them.

Lipodystrophy related to HIV—The Brazilian Public Health approach

Lipodystrophy associated with the human immunodeficiency virus (HIV) is an unpleasant disorder found in 6%-80% of patients infected with HIV. Brazil has a universal public health system, an effective program for patients diagnosed with HIV, providing lipodystrophy treatment since 2004. The objective of this article is to describe the Brazilian approach to this complication. A search in the Brazilian Health Care Legislation and the Brazilian Health System database was conducted to identify all the inclusion criteria and surgical treatment offered to HIV patients with lipodystrophy, identify all the facilities that offer this, and describe their geographic distribution. In addition, the number of procedures performed was obtained. The inclusion criteria were the following:1 diagnosis of HIV/AIDS and lipodystrophy due to the use of antiretroviral drugs for at least 12 months;2 no response or the impossibility of changing ART;3 clinical stability for six months without clinical manifestations suggestive of immunodeficiency in the last 6 months;4 laboratory results showing CD4 cell count >250 cells/mm3 and viral load <10,000 copies/ml in the last 6 months; and5 stable clinical and laboratory parameters. A total of 4,760 procedures were performed, with the most common procedure being facial filler with polymethylmethacrylate. Eleven hospitals were registered to offer this treatment. The Brazilian Health Care System approach to lipodystrophy has an organized plan with universal and integral coverage. All the procedures offered were safe and well-tolerated, according to the literature. However, regional distribution is the main issue and needs to be improved.

Kolkata-Coventry comparative registry study of acute heart failure: an insight into the impact of public, private and universal health systems on patient outcomes in low–middle income cities (KOLCOV HF Study)

IntroductionSurvival gaps in acute heart failure (AHF) continue to expand globally. Multinational heart failure (HF) registries have highlighted variations between countries. Whether discrepancies in HF practice and outcomes occur across...

Immigrant women’s experiences with Norwegian maternal health services: implications for policy and practice

ABSTRACT Purpose Navigating a health system which differs considerably from one’s own can be a challenging process. Navigating this in seeking maternal health care can be additionally daunting. This article explores how immigrant women from diverse countries and ethnic backgrounds experienced and navigated the Norwegian maternal health service during pregnancy and childbirth. Method Eleven semi-structured interviews collected between 2019 to 2020 and analysed thematically informed this analysis. Findings Principles of universalism underpinning all social and health policy in Norway, expect equality of service provision and access. These principles result in less individual choice. The women in this study found these contrary to their expectations of care but responded differently, with some experiencing the health provision as liberating while others distrusted that they were receiving the best care. A focus of concern was the expectation of more medicalized services. While some of these women used their own resources to circumvent the Norwegian health provisions, the implications for the health system extend beyond these women’s experiences. Conclusions The analysis suggests a need to encourage those whose expectations of care differ to build trust in institutions providing care. This article contributes to knowledge on the implications of diversity on Norway’s universal health system.

Regulatory intelligence of health technologies in Greece

Greece has a public universal health system, the National Health System (ESY) – with mandatory insurance coverage (IKA) for all working people (either employees or self-employed). On top of that, people can voluntarily have private insurance. EOPYY (National Organisation for Healthcare Provision) is the only responsible party for purchasing health services funded by public resources based on the National Social Security Fund (EFKA) contributions and state budget. There is only a limited number of drugs being exclusively provided by the public health care system, for free (EOPYY pharmacies) like the high-cost medications. Other than these, patients can buy any drug they want. National Organization for Medicines (EOF) is the regulatory authority and also responsible for pharmacovigilance of medicines, medical products, of beauty and veterinary drugs. In 2011, the pricing and reimbursement processes were separated, with pricing taking place after marketing authorization; subsequently, analysis for reimbursement by the social health insurance is allowed with inclusion in a positive list. New pharmaceutical products follow an external reference pricing system, in which the maximum ex-factory price for medicines under patent is defined by the mean of the three lowest prices for the same drug in European Union (EU) countries, this same rule being applied to biological and biosimilar medicines. Generic drugs are priced either by the mean of the three lowest prices charged in the EU or by a 50% price reduction in relation to the period in which the medication was under patent; thus, the maximum prices of the generic drugs are set at 65% of the price of the respective reference product. In 2018, the Health Technology Assessment (HTA) was introduced in the country to evaluate medications and to issue recommendations to the Ministry of Health on the inclusion or removal of products from the Positive List. As the HTA process is still being reformed in Greece, it is believed that, in the coming years, the country will have the opportunity to improve the implementation, having the linking of the HTA results with the clinical guidelines as one of the major challenges.

Physician Health Care Visits for Mental Health and Substance Use During the COVID-19 Pandemic in Ontario, Canada

Physicians self-report high levels of symptoms of anxiety and depression, and surveys suggest these symptoms have been exacerbated by the COVID-19 pandemic. However, it is not known whether pandemic-related stressors have led to increases in health care visits related to mental health or substance use among physicians. To evaluate the association between the COVID-19 pandemic and changes in outpatient health care visits by physicians related to mental health and substance use and explore differences across physician subgroups of interest. A population-based cohort study was conducted using health administrative data collected from the universal health system (Ontario Health Insurance Plan) of Ontario, Canada, from March 1, 2017, to March 10, 2021. Participants included 34 055 physicians, residents, and fellows who registered with the College of Physicians and Surgeons of Ontario between 1990 and 2018 and were eligible for the Ontario Health Insurance Plan during the study period. Autoregressive integrated moving average models and generalized estimating equations were used in analyses. The period during the COVID-19 pandemic (March 11, 2020, to March 10, 2021) compared with the period before the pandemic. The primary outcome was in-person, telemedicine, and virtual care outpatient visits to a psychiatrist or family medicine and general practice clinicians related to mental health and substance use. In the 34 055 practicing physicians (mean [SD] age, 41.7 [10.0] years, 17 918 [52.6%] male), the annual crude number of visits per 1000 physicians increased by 27%, from 816.8 before the COVID-19 pandemic to 1037.5 during the pandemic (adjusted incident rate ratio per physician, 1.13; 95% CI, 1.07-1.19). The absolute proportion of physicians with 1 or more mental health and substance use visits within a year increased from 12.3% before to 13.4% during the pandemic (adjusted odds ratio, 1.08; 95% CI, 1.03-1.14). The relative increase was significantly greater in physicians without a prior mental health and substance use history (adjusted incident rate ratio, 1.72; 95% CI, 1.60-1.85) than in physicians with a prior mental health and substance use history. In this study, the COVID-19 pandemic was associated with a substantial increase in mental health and substance use visits among physicians. Physician mental health may have worsened during the pandemic, highlighting a potential greater requirement for access to mental health services and system level change.

Socialism Against the Siege

Despite Cuba's advantages—due to its free, universal public health system and its capacity for rapid scientific development, which put us at the forefront in research and vaccine production globally—we were unable to escape the pandemic's blows.

Vaccination hesitation and refusal in countries with universal health systems: an integrative review about their effects

RESUMO O número de indivíduos que recusam ou hesitam a vacinação vem crescendo nos últimos anos em diversos países, e isso tem sido notado com a diminuição da cobertura vacinal. Diante desse cenário, faz-se necessário conhecer quais os efeitos que esses fenômenos têm trazido para os sistemas universais de saúde. O estudo objetivou revisar os efeitos da recusa/hesitação vacinal para a população de países com sistemas universais de saúde, na produção científica da área da saúde. Realizou-se uma revisão integrativa nas bases de dados Lilacs, SciELO, PubMed/Medline, Scopus e Embase. Identificou-se o total de 318 publicações, realizou-se revisão sistematizada e ordenada, permanecendo para leitura completa 12 artigos científicos. Verificaram-se sete categorias de abordagem do tema: 1) políticas públicas para imunização da população; 2) fatores da hesitação da vacinação contra gripe; 3) hesitação entre profissionais de saúde; 4) fatores importantes para a decisão dos pais de vacinarem; 5) segurança das vacinas; 6) determinantes sociais, demográficos e econômicos para hesitação/recusa; e 7) projeção de cobertura vacinal para o futuro e política de vacinação. Os artigos científicos estudados permitiram entender como se dá a recusa e a hesitação vacinal em diferentes cenários, os seus efeitos e como esses motivos estão interligados entre si.