The mental health needs of healthcare workers: When evidence does not guide policy. A comparative assessment of selected European countries

BACKGROUND

The healthcare workforce (HCWF) globally is facing high stress levels and deteriorating mental health due to workplace, labour market and policy deficiencies that further exacerbate the existing crisis. However, comprehensive and effective action is missing.

AIMS

We adopt a health system and governance perspective to address the mental health needs of healthcare workers (HCWs), considering the nature of interventions and the levels and actors involved in governance. The aim is to move the debate forward by identifying governance gaps hampering the implementation of health workforce policies and exploring strategies to effectively increase mental health support.

MATERIAL AND METHODS

A qualitative comparative methodology is applied based on a case study design utilising a multi-level intersectoral governance matrix. We conducted a rapid assessment of HCWF developments in the European context (Germany, Portugal, Romania, Switzerland and the United Kingdom), drawing on secondary sources and country experts.

RESULTS AND DISCUSSION

Awareness of mental health threats among HCWs increased, but policy discourse is driven by service delivery and labour market demands. The attention to HCWs' needs is stronger on the international level and weakest at national/regional levels. Although organisations and professions demonstrate varying degrees of activity, their efforts are scattered and lack sustainability. Similar challenges were identified across healthcare systems, including limited action, disconnected actors, missing coordination, and a lack of attention to governance gaps and system weaknesses.

CONCLUSION

Adopting a health system approach is important but not sufficient. Successful mental health policy implementation needs multi-level governance and coherent coordination mechanisms.

The workforce crisis in healthcare: Moving the debate to bridge evidence and policy

This Special Issue aims to advance the healthcare workforce (HCWF) debate by directing its attention to the implementation of policy recommendations and identifying weaknesses. The selection of articles highlights a wide range of HCWF policies and interventions across various countries. The challenges faced often stem from policy failures and governance gaps at the macro-, meso- and micro-levels of health systems. Recommendations to mitigate the HCWF crisis include interconnected strategies, multi-/transsectoral policies, solidarity-based efforts, collaboration, skill-mix reforms, equity measures, global approaches, and crucially, strong political will. In addition, specific policy solutions are explored, such as community-centred action and employment of community health workers, mental health support initiatives, inclusion of refugees and displaced healthcare workers into the labour market, and preparing the HCWF for the impact of climate change. This Special Issue calls for transformative HCWF policies and multi-level transsectoral governance as essential components needed to effectively address the crisis. This will only be possible, if HCWF policy moves higher up in the public policy arena leading, among other things, to the establishment of HCWF research as a distinct academic field.

Professionalization of the public health workforce: scoping review and call to action

BACKGROUND

The 'WHO-ASPHER Roadmap to Professionalizing the Public Health Workforce in the European Region' provides recommendations for strategic and systematic workforce planning around professionalization levers including: (i) competencies, (ii) training and education, (iii) formal organization, (iv) professional credentialing and (v) code of ethics and professional conduct as well as taxonomy and enumeration. It was based on a literature review till 2016. This scoping review aims to explore how the professionalization was documented in the literature between 2016 and 2022.

METHODS

Following the Joanna Briggs Institute guidelines, we searched Medline via PubMed, Web of Science, ERIC via EBSCO and Google Scholar and included studies on professionalization levers. Four critical appraisal tools were used to assess qualitative, quantitative, mixed methods studies and grey literature. The PRISMA Extension for Scoping Reviews (PRISMA-ScR) was used for reporting.

RESULTS

Eleven articles included in this review spanned 61 countries, targeting undergraduate, master's, doctoral degrees and continuing professional development. Most of these documents were reviews. About half provided a definition of the public health workforce; more than half covered the taxonomy and included information about competences, but the use of frameworks was sporadic and inconsistent. Formal organization and the necessity of a code of conduct for the public health workforce were acknowledged in only two studies.

CONCLUSIONS

In spite of some efforts to professionalize the public health workforce, this process is fragmented and not fully recognized and supported. There is an urgent need to engage policymakers and stakeholders to prioritize investments in strengthening the public health workforce worldwide.

Post-COVID health policy responses to healthcare workforce capacities: A comparative analysis of health system resilience in six European countries

A cross countries in Europe, health policy is seeking to adapt to the post-pandemic 'permacrisis', where high demands on the healthcare workforce and shortages continue and combine with climate change, and war. The success of these efforts depends on the capacities of the healthcare workforce. This study aims to compare health policy responses to strengthen the capacities of the healthcare workforce and to explore the underpinning dynamics between health systems, policy actors and health policies. The study draws on a qualitative, comparative analysis of Austria, the Czech Republic, Denmark, Germany, Italy and the Netherlands. The findings suggest that policy responses at the national level focused on hospitals and absorptive capacities, while policy responses at local/regional levels also included general practice and adaptive capacities. There were only few examples of policies directed at transformative capacities. The underling dynamics were shaped by health systems, where individual parts are closely connected, by embeddedness in specific service delivery and areas, and by power dynamics. In conclusion, sub-national health policy responses emerge as key to effective responses to the post-pandemic permacrisis, where health professions are central policy actors. Sub-national health policy responses build on existing power relations, but also have the potential to transcend these power relations.

Defining medical deserts-an international consensus-building exercise

BACKGROUND

Medical deserts represent a pressing public health and health systems challenge. The COVID-19 pandemic further exacerbated the gap between people and health services, yet a commonly agreed definition of medical deserts was lacking. This study aims to define medical deserts through a consensus-building exercise, explaining the phenomenon to its full extent, in a manner that can apply to countries and health systems across the globe.

METHODS

We used a standard Delphi exercise for the consensus-building process. The first phase consisted of one round of individual online meetings with selected key informants; the second phase comprised two rounds of surveys when a consensus was reached in January 2023. The first phase-the in-depth individual meetings-was organized online. The dimensions to include in the definition of medical deserts were identified, ranked and selected based on their recurrence and importance. The second phase-the surveys-was organized online. Finally, external validation was obtained from stakeholders via email.

RESULTS

The agreed definition highlight five major dimensions: 'Medical deserts are areas where population healthcare needs are unmet partially or totally due to lack of adequate access or improper quality of healthcare services caused by (i) insufficient human resources in health or (ii) facilities, (iii) long waiting times, (iv) disproportionate high costs of services or (v) other socio-cultural barriers'.

CONCLUSIONS

The five dimensions of access to healthcare: (i) insufficient human resources in health or (ii) facilities, (iii) long waiting times, (iv) disproportionate high costs of services and (v) other socio-cultural barriers-ought to be addressed to mitigate medical deserts.

Comparative health policy goes qualitative: Broadening the focus of research after COVID-19

The COVID-19 pandemic has pushed health policy frontstage and exposed the stark differences in government capacities to respond to the crisis. This has created new demands for comparative heath policy to support knowledge creation on a large scale. However, comparative health policy has not necessarily been well prepared; studies have focused on health systems and used typologies together with descriptive, quantitative methods. This makes it difficult to capture the multi-level nature of health policy, the diverse actors involved and the many societal facets of governance performance. We argue for broadening the perspective to include health policy as a bottom-up process with diverse interests. This calls for expanding the methodology of comparative health policy by also using approaches that make greater use of explorative, qualitative research. We introduce possible developmental pathways to illustrate what this may look like. The Pan-European Commission shows how to broaden the definition of comparative health policy, notably as transnational and planetary. The gender analysis matrix illustrates how comparative health policy can strengthen its assessment of performance by focussing on gender equity. The street-level bureaucrat framework highlights how analysing frontline work can help conduct small-scale bottom-up comparisons of health policy. Together, these developmental pathways demonstrate the potential to broaden comparative health policy towards greater responsiveness to the societal performance of governments, such as social inequalities created by the COVID-19 pandemic. This also opens opportunities for strengthening the global outlook of comparative health policy.

Migrant healthcare workers during COVID-19: bringing an intersectional health system-related approach into pandemic protection. A German case study

Introduction

Migrant healthcare workers played an important role during the COVID-19 pandemic, but data are lacking especially for high-resourced European healthcare systems. This study aims to research migrant healthcare workers through an intersectional health system-related approach, using Germany as a case study.

Methods

An intersectional research framework was created and a rapid scoping study performed. Secondary analysis of selected items taken from two COVID-19 surveys was undertaken to compare perceptions of national and foreign-born healthcare workers, using descriptive statistics.

Results

Available research is focused on worst-case pandemic scenarios of Brazil and the United Kingdom, highlighting racialised discrimination and higher risks of migrant healthcare workers. The German data did not reveal significant differences between national-born and foreign-born healthcare workers for items related to health status including SARS-CoV-2 infection and vaccination, and perception of infection risk, protective workplace measures, and government measures, but items related to social participation and work conditions with higher infection risk indicate a higher burden of migrant healthcare workers.

Conclusions

COVID-19 pandemic policy must include migrant healthcare workers, but simply adding the migration status is not enough. We introduce an intersectional health systems-related approach to understand how pandemic policies create social inequalities and how the protection of migrant healthcare workers may be improved.

Violence against healthcare workers in the middle of a global health crisis: what is it about policy and what to learn from international comparison?

Introduction

Violence against healthcare workers is a global health problem threatening healthcare workforce retention and health system resilience in a fragile post-COVID 'normalisation' period. In this perspective article, we argue that violence against healthcare workers must be made a greater priority. Our novel contribution to the debate is a comparative health system and policy approach.

Methods

We have chosen a most different systems comparative approach concerning the epidemiological, political, and geographic contexts. Brazil (under the Bolsonaro government) and the United Kingdom (under the Johnson government) serve as examples of countries that were strongly hit by the pandemic in epidemiological terms while also displaying policy failures. New Zealand and Germany represent the opposite. A rapid assessment was undertaken based on secondary sources and country expertise.

Results

We found similar problems across countries. A global crisis makes healthcare workers vulnerable to violence. Furthermore, insufficient data and monitoring hamper effective prevention, and lack of attention may threaten women, the nursing profession, and migrant/minority groups the most. There were also relevant differences. No clear health system pattern can be identified. At the same time, professional associations and partly the media are strong policy actors against violence.

Conclusion

In all countries, muchmore involvement from political leadership is needed. In addition, attention to the political dimension and all forms of violence are essential.

Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation

BACKGROUND

The health workforce is central to healthcare systems and population health, but marginal in comparative health policy. This study aims to highlight the crucial relevance of the health workforce and contribute comparative evidence to help improve the protection of healthcare workers and prevention of inequalities during a major public health crisis.

METHODS

Our integrated governance framework considers system, sector, organizational and socio-cultural dimensions of health workforce policy. The COVID-19 pandemic serves as the policy field and Brazil, Canada, Italy, and Germany as illustrative cases. We draw on secondary sources (literature, document analysis, public statistics, reports) and country expert information with a focus on the first COVID-19 waves until the summer of 2021.

RESULTS

Our comparative investigation illustrates the benefits of a multi-level governance approach beyond health system typologies. In the selected countries, we found similar problems and governance gaps concerning increased workplace stress, lack of mental health support, and gender and racial inequalities. Health policy across countries failed to adequately respond to the needs of HCWs, thus exacerbating inequalities during a major global health crisis.

CONCLUSIONS

Comparative health workforce policy research may contribute new knowledge to improve health system resilience and population health during a crisis.

SDG5 "Gender Equality" and the COVID-19 pandemic: A rapid assessment of health system responses in selected upper-middle and high-income countries

Introduction

The COVID-19 pandemic disrupted healthcare and societies, exacerbating existing inequalities for women and girls across every sphere. Our study explores health system responses to gender equality goals during the COVID-19 pandemic and inclusion in future policies.

Methods

We apply a qualitative comparative approach, drawing on secondary sources and expert information; the data was collected from March-July 2022. Australia, Brazil, Germany, the United Kingdom, and the USA were selected, reflecting upper-middle and high-income countries with established public health and gender policies but different types of healthcare systems and epidemiological and geo-political conditions. Three sub-goals of SDG5 were analyzed: maternity care/reproductive health, gender-based violence, and gender equality/women's leadership.

Results

We found similar trends across countries. Pandemic policies strongly cut into women's health, constrained prevention and support services, and weakened reproductive rights, while essential maternity care services were kept open. Intersecting gender inequalities were reinforced, sexual violence increased and women's leadership was weak. All healthcare systems failed to protect women's health and essential public health targets. Yet there were relevant differences in the responses to increased violence and reproductive rights, ranging from some support measures in Australia to an abortion ban in the US.

Conclusions

Our study highlights a need for revising pandemic policies through a feminist lens.

[Health workforce development in rheumatology : A mapping exercise and wake-up call for health policy]

BACKGROUND AND OBJECTIVE

Health workforce shortage in German rheumatology has been identified as a healthcare service and delivery problem. Health policy has increased staffing targets, yet effective intervention strategies are lacking. This research aimed to systematically map the rheumatology workforce to improve the evidence for interventions and explore possibilities for more effective health workforce management.

METHODS

The WHO National Health Workforce Accounts provided a conceptual framework for the mapping exercise. Four major sets of indicators were selected, comprising staffing levels, health labor market flows, composition and education/training. A comparison of age groups and time series was applied to explore trends. Public statistics and other secondary sources served our analysis using descriptive methodology.

RESULTS

In Germany there are 1076 physicians specialized in internal medical rheumatology. Absolute numbers have nearly doubled (91%) since 2000 but with a strong demographic bias. Between 2000 and 2019 numbers markedly increased in the group aged 50 years and older but only by 9% in the younger group under 50 years; since 2010 the group aged 40-50 years even faces a decrease. In 2019, the absolute numbers of rheumatologists in retirement age exceeded those aged 40 years and under. Since 2015 an expanding workforce trend has overall flattened but this was strongest in the hospital sector; the numbers in resident training did not show any relevant growth.

CONCLUSION

Health workforce trends reveal that an available number of rheumatologists cannot meet new health policy planning targets. There is a need for effective health workforce management, focusing on innovation in resident training, improved task delegation and gender equality.

Health workforce needs of small medical specialties: findings from rheumatology in Germany

Background

Small medical specialties may be more vulnerable to workforce shortage and the COVID-19 pandemic and this may directly impact in the provision of care for chronically-ill patients. This study aims to explore health workforce development and new needs, using rheumatology in Germany as a case study.

Methods

An explorative multi-methods approach was applied, combining health labour market assessment of rheumatology physicians (public statistics 2000-2019) and a questionnaire-based online survey conducted in early 2021 (n = 101 respondents; rheumatology physicians and residents). Main selected topics: work hours, workload, mental health issues, discrimination and sexual harassment experiences, impact of COVID-19. Descriptive statistical analysis was performed and qualitative content analysis for free-text information.

Results

Health labour market analysis showed that the numbers of rheumatologists increased markedly between 2000 and 2019 in the groups aged +50 years, but only 9% in younger groups under 50 years; since 2010 the group 40-50 years showed decreases. In 2019, the absolute number of rheumatologists working in healthcare after retirement-age exceeded those aged 40 and under. Survey data revealed a strong mismatch between actual and desired work hours for women and men. 81% rated their workload as high or very high; every sixth rheumatologist has suffered from stress or burnout syndromes at least once in the past. Experiences of gender discrimination and sexual harassment/violence were frequently reported, mostly by women. COVID-19 was an amplifier of stress with major stressors being digitalisation and increased demand for communication and patient education.

Conclusions

Decreasing health workforce capacities in German rheumatology combine with negative perceptions of work and workplace conditions, threatening both retention and service delivery.

Key messages

• Small medical specialties, like rheumatology, face severe shortage that threaten healthcare for chronically-ill patients and need greater attention.

• COVID-19 has reinforced rheumatologists’ workload and stressors, thus worsing mental health and retention.

Health workforce needs and health policy responses to COVID-19: a European comparative assessment

Background

The COVID-19 pandemic revealed the importance of the health workforce for health system resilience. This study aims to explore whether and how healthcare system in Europe have responded to new emergent needs and transformed their health workforce policies.

Methods

A qualitative comparative approach is applied, based on multi-level governance theory and a rapid assessment of three areas of health workforce policy: mental health, gender equality, and public health competencies. We consider two years of the pandemic with a focus on recent waves, October 2021-January 2022. Denmark, Germany, Portugal, Romania and Switzerland are selected for comparison, representing different health systems, health workforce conditions and COVID-19 indicators in the European Union and European Economic Area.

Results

Across countries the pandemic has highlighted mental health needs, persisting gender inequalities and demand for public health competencies. Our comparison reveals similar weaknesses and governance gaps. (1) Mental health needs of healthcare workers are increasingly recognised (more strongly in Denmark and less in Romania with the other countries clustering in-between); however, health workers’ perceptions are not used as guidance and effective programmes are lacking. (2) The situation is worst in relation to gender equality goals that are largely ignored in pandemic policy and recovery plans. (3) Public health competences are more advanced and integrated in the NHS systems in Denmark and Portugal, but no country has taken action to innovate health workforce education and strengthen public health.

Conclusions

The comparative assessment highlights that health systems failed to adequately respond to health workforce needs and the COVID-19 challenges. Action has to be taken to implement participatory governance and step up efforts towards more responsive and resilient health workforce policy.

Health workers’ perception vs medically approved COVID-19 infection risk: the risk communication gap

Background

This study analyses how healthcare workers (HCWs) perceived risks, protection and preventive measures during the COVID-19 pandemic in relation to medically approved risks and organisational measures. We aim to explore ‘blind spots’ of pandemic protection and identify mental health needs.

Methods

A German multi-method hospital study at Hannover Medical School serves as an ‘optimal-case’ scenario of a high-income country, well-resourced hospital sector and an organisation with low HCW infection rate serves to explore governance gaps in HCW protection. Document analysis, expert information and survey data (n = 1163) were collected as part of a clinical study into SARS-CoV-2 serology testing during the second wave of the pandemic (November 2020-February 2021). Selected survey items included perceptions of risks, protection and preventive measures. Descriptive statistical analysis and regression were undertaken for gender, profession and COVID-19 patient care.

Results

Our study reveals a low risk of 1% medically approved infections among participants, but a much higher mean personal risk estimate of 15%. The majority (68.4%) expressed ‘some’ to ‘very strong’ fear of acquiring infection at the workplace. Individual protective behaviour and compliance with protective workplace measures were estimated as very high. Yet only about half of the respondents felt strongly protected by the employer; 12% even perceived ‘no’ or ‘little’ protection. Gender and contact with COVID-19 patients had no significant effect on the estimations of infection risks and protective workplace behaviour, but nursing was correlated with higher levels of personal risk estimations and fear of infection.

Conclusions

A strong mismatch between low medically approved risk and personal risk perceptions of HCWs brings stressors and threats into view, that may be preventable through improved information, risk communication and inclusion of mental health support in pandemic preparedness.

Key messages

• Healthcare workers’ perceptions of COVID-19 infection risks are much higher than medically approved infection risk.

• Pandemic preparedness and protection plans must pay greater attention to information, risk communication and mental health needs.

SDG5 Gender Equality during the COVID-19 pandemic: an international comparative policy assessment

Background

The COVID-19 pandemic caused severe disruptions in healthcare systems and societies and exacerbated existing inequalities for women and girls across every sphere. Our study explores health systems responses to gender equality goals during the COVID-19 pandemic and which role these goals play in pandemic recovery policies.

Methods

We apply a qualitative comparative approach. Country case studies (expert information, secondary sources) were collected in March/April 2022. The sample comprised Australia, Brazil, Germany, United Kingdom and USA, reflecting conditions of high to upper-middle income countries with established public health systems, democratic political institutions and gender equality policies. Selected topics: maternity care/reproductive services, violence against women, and gender equality/female leadership.

Results

All countries tried to keep essential maternity and reproductive services open, but strong limitations applied especially for prevention and counselling services; at the same time, digitalisation/telemedicine supported service expansion. Violence against women and children strongly increased during the pandemic. Routine services were partly kept open and new helplines occasionally established, but no action was taken to scale-up mental health support and respond to new demand. A push-back of gender equality was observed across countries in all areas of health and social care, often coupled with strong increase in intersecting social inequalities; participation of women in decision-making bodies was generally weak and not monitored.

Conclusions

Across countries, gender equality policies cracked under the pressure of the COVID-19 pandemic; this is true for countries with male and female political leaders, and for different areas of SDG5 and health. There is an urgent need for more effective intersectional gender equality policies and improved participation of women in global health and in health system recovery plans.

Key messages

• Health systems failed to take action to protect SDG5 goals; gender and intersecting inequalities strongly increased during the pandemic.

• Building back better after COVID-19 will only be possible with an intersectional gender equality programme and feminist policy approaches.

“A sorrow shared …”: a qualitative content analysis of what couples with recurrent miscarriages expect from one another and their families and friends

STUDY QUESTION

When couples have to face recurrent pregnancy loss (RPL), what are the partners’ wishes and needs and what is their perception of helpful and unhelpful factors with regard to their own, their partners’ and their families’ and friends’ ways of dealing with the problem?

SUMMARY ANSWER

Women and men with repeated miscarriages want open communication about their losses, but expect a sensitive and empathetic attitude from others, not pity or trivialization.

WHAT IS KNOWN ALREADY

RPL not only causes the women affected and their partners considerable emotional distress; it also has an impact on the couples’ relationships and the way they relate to their families and friends. Studies suggest that women have a greater need than their male partners to talk about their losses and that these differences may lead to dissatisfaction and cause relational tension. In addition, men often assume a ‘mainstay’ role, supporting their partners and displaying fortitude in the face of distress. As yet, however, little research has been conducted so far on the question of what the members of couples with RPL expect from one another and from their families and friends.

STUDY DESIGN, SIZE, DURATION

The study sample consisted of 147 couples and 17 women with at least 2 miscarriages attending the special unit for RPL at the University Women’s Hospital in Heidelberg (Germany) for the first time between September 2018 and October 2020 (response rate: 82.7%). The patients were asked to participate in this combined qualitative and questionnaire study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In order to explore the wishes and needs of those affected in more detail, the free text responses obtained were examined in this study by using qualitative content analysis. Categories and subcategories were created inductively to summarize and systematize content.

MAIN RESULTS AND THE ROLE OF CHANCE

Patients affected by RPL want their partners and their families and friends to deal with the topic openly and empathically. In the partnership itself, acceptance of individual grieving modes and sharing a common goal are important factors. Men, in particular, want their partners to be optimistic in facing up to the situation. Regarding communication with family and friends, it transpired that ‘good advice’, playing the matter down, inquiries about family planning, pity and special treatment are explicitly not appreciated.

LIMITATIONS, REASONS FOR CAUTION

The sample was a convenience sample, so self-selection effects cannot be excluded. In addition, the level of education in the sample was above average. Accordingly, the sample cannot be regarded as representative. The results of the content analysis are based on the respondents’ written answers to open-ended questions in the questionnaire. Unlike qualitative interview studies, further questioning was not possible in the case of ambiguities or to request more details.

WIDER IMPLICATIONS OF THE FINDINGS

Frank and sincere communication about miscarriages and about one’s own emotions and needs should be promoted both in the partnership and among family members and friends in order to strengthen the potential of social support as a resource. Open communication about the different needs of both partners is necessary to create mutual understanding. The results show the importance not only of empathy and consideration for the couples concerned but also their desire not to be pitied. Striking a fine balance between fellow-feeling and pity may also lead to tension, and this potential dilemma should be addressed in psychosocial counselling. Overall, the study contributes to a better understanding of what couples want from their families and friends when they are attempting to come to terms with RPL and highlights potential challenges in the interaction between affected couples and their families and friends.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study. None of the authors declared any conflicts of interest.

TRIAL REGISTRATION NUMBER

DRKS00014965.

Healthcare Workers' Perceptions and Medically Approved COVID-19 Infection Risk: Understanding the Mental Health Dimension of the Pandemic. A German Hospital Case Study

Introduction

This study analyses how healthcare workers (HCWs) perceived risks, protection and preventive measures during the COVID-19 pandemic in relation to medically approved risks and organizational measures. The aim is to explore “blind spots” of pandemic protection and make mental health needs of HCWs visible.

Methods

We have chosen an “optimal-case” scenario of a high-income country with a well-resourced hospital sector and low HCW infection rate at the organizational level to explore governance gaps in HCW protection. A German multi-method hospital study at Hannover Medical School served as empirical case; document analysis, expert information and survey data (n = 1,163) were collected as part of a clinical study into SARS-CoV-2 serology testing during the second wave of the pandemic (November 2020-February 2021). Selected survey items included perceptions of risks, protection and preventive measures. Descriptive statistical analysis and regression were undertaken for gender, profession and COVID-19 patient care.

Results

The results reveal a low risk of 1% medically approved infections among participants, but a much higher mean personal risk estimate of 15%. The majority (68.4%) expressed “some” to “very strong” fear of acquiring infection at the workplace. Individual protective behavior and compliance with protective workplace measures were estimated as very high. Yet only about half of the respondents felt strongly protected by the employer; 12% even perceived “no” or “little” protection. Gender and contact with COVID-19 patients had no significant effect on the estimations of infection risks and protective workplace behavior, but nursing was correlated with higher levels of personal risk estimations and fear of infection.

Conclusions

A strong mismatch between low medically approved risk and personal risk perceptions of HCWs brings stressors and threats into view, that may be preventable through better information, training/education and risk communication and through investment in mental health and inclusion in pandemic preparedness plans.

Health system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries

BACKGROUND

The health workforce is a key component of any health system and the present crisis offers a unique opportunity to better understand its specific contribution to health system resilience. The literature acknowledges the importance of the health workforce, but there is little systematic knowledge about how the health workforce matters across different countries.

AIMS

We aim to analyse the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe (January-May/June 2020), and to assess how health systems prerequisites influence these capacities.

MATERIALS AND METHODS

We selected countries according to different types of health systems and pandemic burdens. The analysis is based on short, descriptive country case studies, using written secondary and primary sources and expert information.

RESULTS AND DISCUSSION

Our analysis shows that in our countries, the health workforce drew on a wide range of capacities during the first wave of the pandemic. However, health systems prerequisites seemed to have little influence on the health workforce's specific combinations of capacities.

CONCLUSION

This calls for a reconceptualisation of the institutional perquisites of health system resilience to fully grasp the health workforce contribution. Here, strengthening governance emerges as key to effective health system responses to the COVID-19 crisis, as it integrates health professions as frontline workers and collective actors.

The contribution of professions to the governance of integrated care: Towards a conceptual framework based on case studies from Denmark

OBJECTIVE

Good governance of integrated care is key to better health care, but we know little about how professions can help make this happen. Our aim is to introduce a conceptual framework to analyse how professions contribute to the governance of integrated care, and to apply the framework to a secondary analysis of selected case studies from Denmark.

METHODS

We developed a framework, which identified the what, how and why of the contribution professions make to the governance of integrated care. We included five qualitative Danish studies, using coordination as an indicator of integrated care. We adopted a thematic approach in our analysis, combining deductive and inductive elements.

RESULTS

Health professions engage in highly diverse activities, which fall into closely connected clusters of more formal or more informal coordination. Professions apply many different adaptive mechanisms at different levels to fit coordination into local contexts. Professions are driven by interlocking rationales, where a common focus on patients connects organizational and professional concerns.

CONCLUSIONS

Our analytical framework emerges as a useful tool for analysis. The contribution of professions to the governance of integrated care needs greater attention in health policy implementation as it can promote more effective governance of integrated care.

Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems

This article is dedicated to the WHO International Year of Health and Care Workers in 2021 in recognition of their commitment during the COVID-19 pandemic. The study aims to strengthen health workforce preparedness, protection and ultimately resilience during a pandemic. We argue for a health system approach and introduce a tool for rapid comparative assessment based on integrated multi-level governance. We draw on secondary sources and expert information, including material from Denmark, Germany, Portugal and Romania. The results reveal similar developments across countries: action has been taken to improve physical protection, digitalization and prioritization of healthcare worker vaccination, whereas social and mental health support programmes were weak or missing. Developments were more diverse in relation to occupational and organizational preparedness: some ad-hoc transformations of work routines and tasks were observed in all countries, yet skill-mix innovation and collaboration were strongest in Demark and weak in Portugal and Romania. Major governance gaps exist in relation to education and health integration, surveillance, social and mental health support programmes, gendered issues of health workforce capacity and integration of migrant healthcare workers (HCW). There is a need to step up efforts and make health systems more accountable to the needs of HCW during global public health emergencies.

Increasing planning targets is not enough: health workforce management in rheumatology in Germany

Background

Health workforce shortage in German rheumatology and its negative impact in healthcare are increasingly recognised. Health policy has increased staffing targets, but effective intervention strategies are lacking. This paper aims to systematically map the rheumatology workforce and to explore opportunities for intervention, thus contributing to better health workforce management.

Methods

The WHO National Health Workforce Accounts (NHWA) provided a conceptual framework for the mapping exercise. Four major sets of indicators were selected, comprising staffing levels, health labour market flows, skill-mix and education/training. Comparison of age-groups and time series was applied to explore trends. Public statistics and other secondary sources served the analysis, using descriptive methodology.

Results

Rheumatologists nearly doubled in absolute numbers since 2000, but this trend shows a problematic demographic bias. Between 2000 and 2019 numbers increased markedly in the groups aged +50 years, but only about 9% in younger groups under 50 years. Most alarming, since 2010 the group 40 to 50 years showed a reverse trend and strong decreases. In 2019, absolute numbers of rheumatologists working in healthcare after retirement-age exceeded those aged 40 and under. Since 2015 an expanding workforce trend overall flattened, but strongest in the hospital sector; annual inflows do not show relevant growths.

Conclusions

Health workforce assessment reveals negative demographic trends and decreasing appeal of the specialty especially to men, thus highlighting a need for more effective health workforce management. Intervention strategies should target innovation in resident training and task shifting and improve gender equality.

Key messages

Health workforce trends indicate that new health policy planning targets cannot be met with an available stock of rheumatologist. The WHO NHWA provide a useful toolbox to map health workforce trends and identify weaknesses and gaps.

Health workforce protection and preparedness during COVID-19: a rapid assessment of EU countries

Background

Healthcare workers face high pressures and new threats during the COVID-19 pandemic, and health systems and governance are key to improve preparedness and protection. This study aims to introduce a tool for rapid assessment based on an integrated multi-level governance approach and to empirically explore preparedness and protection.

Methods

The study is explorative in nature and applies a comparative approach. The assessment tool comprises four major dimensions of governance: system, sector, occupational and sociocultural issues (focus on gender issues and migrant healthcare workers) of protection and preparedness. Secondary sources and expert information serve the empirical exercise, using material from Denmark, Germany, Portugal and Romania.

Results

We revealed similar developments across countries: action has been taken to improve physical protection, vaccination of healthcare workers and digitalisation, while social and mental health support programmes were poor or lacking. Developments were more diverse in relation to occupational/ organisational preparedness: some ad-hoc transformations of work routines and tasks were observed in all countries, yet skill-mix innovation and collaboration were strong in Demark and weak in Portugal and Romania. We are able to identify major governance gaps in relation to integration of education and health systems, social and mental health support programmes, gendered issues of health workforce capacity, integration of migrant healthcare workers, and comprehensive surveillance and monitoring.

Conclusions

There is a need to step up efforts and make health systems more accountable to the needs of healthcare workers during global public health emergencies.

Health system resilience and health workforce capacities: health system responses during COVID-19

Background

The present crisis offers a unique opportunity to better understanding the specific contribution of the health workforce to health system resilience, and more specifically to the adaptive, absorptive and transformative capacities that influence how health systems respond to the COVID-19 pandemic.

Methods

The study examined different capacities in the context of the health system as the central prerequisite of health system resilience. We compared health policies and services responses in Austria, Denmark, Germany, Italy, the Netherlands and the UK. The selection is based on differences in types of health care systems and pandemic burdens in the first wave. Country experts complied descriptive case studies using written secondary and primary sources.

Results

During the first wave of the pandemic, the contribution of the health workforce rested on a broad range of capacities. The absorptive capacity concerned the freeing up capacities for newly established Covid-19 wards in hospitals. The adaptive capacity focused on increasing health workers. The transformative capacity concerned new service offerings. The influence of health systems was most visible in relation to the substantive areas of health care delivery at play, and less so in relation to the specific range of capacities of the health workforce. The lack of distinct patterns was striking, considering the inclusion of health systems, which differ on many counts.

Conclusions

The study calls for a reconceptualization of the institutional perquisites of health system resilience to grasp more fully the manifold and unique health workforce contribution. Governance is the key to effective health system responses to the COVID-19 crisis, and health professions are part and parcel of governance as frontline workers and collective actors. This requires improving health workforce capacities and strengthening the integration of health professions in health governance.

Managing protection and surveillance of health workers during COVID-19: German multi-centre survey

Background

Health workers face a higher risk of infection during the COVID-19 pandemic than the average population, yet we know very little on how protection is managed in daily practice. The aim of this study is to contribute new empirical data on the management of protection in clinical settings with a focus on surveillance, using Germany as case study.

Methods

We draw on material gathered in multi-centre hospital surveillance online surveys in Germany, which are part of a national COVID-19 University Research Network (project B-FAST). Selected indicators include tools, strategies and access to protection, with a focus on the composition of new surveillance teams; n = 100 responses, comprising n = 33/92% of all university medical centres; n = 67/18% of participating hospitals in two German Federal States in March 2021.

Results

Three major strategies of protection were identified: expanding services, information and access for all health workers in the clinical setting; establishing novel surveillance teams to protect hospital employees comprising hotline, testing and tracing teams; creating large-scale in-house vaccination programs in accordance with national vaccination prioritisation policy of health workers. The composition of the surveillance teams showed high variation in relation to professional groups/skills and status. In particular, hospital hygienists (often with a professional background in nursing) were included in all teams, but their share varied from only 24% in testing to 60% in hotline and even 95% in tracing teams.

Conclusions

German hospitals have stepped up efforts to protect health workers primarily through comprehensive surveillance and personal protection including vaccination. Our findings reveal capacity for innovation in the management of protection especially in two areas: improving the skill-mix and leadership of surveillance teams, and strengthening the role of hospital hygienists in surveillance.

Key messages

The building of interdisciplinary hospital surveillance teams plays an important role in innovating surveillance and strengthening protection. The skill-mix and leadership of the surveillance teams need further research and policy investigation to improve efficiency.

Work situation of rheumatologists and residents in times of COVID-19 : Findings from a survey in Germany

Background and objective

The work situation is an important dimension of professional life and wellbeing, and a policy lever to strengthen recruitment and retention. This study aims to explore the work situation of physicians and residents in internal medical rheumatology, considering the impact of the coronavirus pandemic COVID-19.

Methods

A questionnaire-based online survey was conducted in early 2021 at the Hannover Medical School, supported by the German Society of Rheumatology. Target groups were all rheumatology physicians and residents in Germany. The main areas of investigation included work hours, task delegation, and collaboration; workload and mental health issues; discrimination and sexual harassment experiences; and the impact of COVID-19. Descriptive statistical analysis was performed for the standardized items and qualitative content analysis for the free-text information.

Results

The respondents (n = 101) expressed positive attitudes towards cooperation and task delegation to medical assistants, especially those specialized in rheumatology, while attitudes towards cooperation with GPs pointed to blockades. There was a strong mismatch between actual and desired work hours both in the group of women and in the group of men. 81% rated their workload as high or very high; every sixth rheumatologist has suffered from stress or burnout syndromes at least once in the past. Experiences of gender discrimination and sexual harassment/violence were frequently reported, mostly by women. COVID-19 was an amplifier of stress, with major stressors being digitalization and increased demand for communication and patient education.

Conclusion

There is an urgent need to improve the work situation of rheumatologists and reduce stress and mental health risks.

Supplementary Information

The online version of this article (10.1007/s00393-021-01081-5) includes the survey questionnaire in German.

P-490 Recurrent pregnancy loss acts as a posttraumatic stress event in both women and men

Study question

What are the psychological impacts of recurrent pregnancy loss (RPL) on men and women and their interdependencies?

Summary answer

Women show higher psychological risks than men, except for lack of social support. Avoidance behaviour of men correlates with higher posttraumatic stress of their partner.

What is known already

About 1-3% of all couples trying to conceive are affected by RPL. The loss of the unborn child can be the most traumatic experience in a woman’s life and is associated with significant psychological distress besides the instant grief. RPL can also be stressful for the partner, even though being at a lower risk for psychiatric morbidities. The man’s gender role expects him to support and not to show weakness which may result in a suppression of his feelings and a disenfranchised grief.

Study design, size, duration

Cross-sectional study. All women and men referred to the special unit for RPL between March 2019 and October 2020 were asked to participate voluntarily with a total sample size of 105 couples and 17 women. Exclusion criteria were less than two pregnancy losses, inadequate knowledge of the German language and incomplete data.

Participants/materials, setting, methods

Couples were invited to fill out a questionnaire package estimating their psychological risks (e.g. posttraumatic stress disorder, anxiety, depression, perceived social support) and coping strategies with established instruments. Clinical history was obtained from medical records. Couple data were analysed with the Actor Partner Interdependence Model, taking the couple as the unit of analysis.

Main results and the role of chance

The response rate was 82.3%. The following psychological risks were measured among women versus men: posttraumatic stress disorder (PTSD): 13.7% versus 3.9% (p = 0.017); anxiety: 50.4% versus 17.3% (p < 0.001), depression: 48.1% versus 14.4% (p < 0.001), lack of social support: 32.5% versus 32.7% (N.S.). A risk in at least one category showed 68.9% of women versus 44.8% of men (p < 0.001), with those at higher risk indicating a lower satisfaction with their partnership (p < 0.001) and higher impairment of their sexual life (p < 0.001). Neither total number of pregnancy losses nor time gap since last pregnancy loss showed relevant correlations with psychological risks. For women, number of curettages, controlled for the number of pregnancy losses, correlates with the severity of posttraumatic stress (p < 0.05). Higher levels of anxiety, depression and a lack of social support in women correlated positively with posttraumatic stress in their partners. The coping strategy “trivialization and wishful thinking” as well as the subscale “avoidance” of the Impact-of-Event-Scale (self-report questionnaire measuring posttraumatic stress) of men was correlated with more severe posttraumatic stress in their female partners (both p < 0.05).

Limitations, reasons for caution

The data show only correlations between the measured variables, as cross-sectional studies are not suitable to analyse causal relationships. The sample was obtained in a special unit for RPL at a university hospital, so the findings may not be generalizable to all couples with RPL.

Wider implications of the findings

Screening psychological risks in couples with RPL may be reasonable considering the high risks in both sexes and the extent of PTSD diagnoses in women, their interdependencies and the potential risk of chronification. Professionals should encourage affected couples to support each other and provide targeted information on mental health services.

Trial registration number

DRKS 00014965

P–490 Recurrent pregnancy loss acts as a posttraumatic stress event in both women and men

Study question

What are the psychological impacts of recurrent pregnancy loss (RPL) on men and women and their interdependencies?

Summary answer

Women show higher psychological risks than men, except for lack of social support. Avoidance behaviour of men correlates with higher posttraumatic stress of their partner.

What is known already

About 1–3% of all couples trying to conceive are affected by RPL. The loss of the unborn child can be the most traumatic experience in a woman’s life and is associated with significant psychological distress besides the instant grief. RPL can also be stressful for the partner, even though being at a lower risk for psychiatric morbidities. The man’s gender role expects him to support and not to show weakness which may result in a suppression of his feelings and a disenfranchised grief.

Study design, size, duration

Cross-sectional study. All women and men referred to the special unit for RPL between March 2019 and October 2020 were asked to participate voluntarily with a total sample size of 105 couples and 17 women. Exclusion criteria were less than two pregnancy losses, inadequate knowledge of the German language and incomplete data.

Participants/materials, setting, methods

Couples were invited to fill out a questionnaire package estimating their psychological risks (e.g. posttraumatic stress disorder, anxiety, depression, perceived social support) and coping strategies with established instruments. Clinical history was obtained from medical records. Couple data were analysed with the Actor Partner Interdependence Model, taking the couple as the unit of analysis.

Main results and the role of chance

The response rate was 82.3%. The following psychological risks were measured among women versus men: posttraumatic stress disorder (PTSD): 13.7% versus 3.9% (p = 0.017); anxiety: 50.4% versus 17.3% (p < 0.001), depression: 48.1% versus 14.4% (p < 0.001), lack of social support: 32.5% versus 32.7% (N.S.). A risk in at least one category showed 68.9% of women versus 44.8% of men (p < 0.001), with those at higher risk indicating a lower satisfaction with their partnership (p < 0.001) and higher impairment of their sexual life (p < 0.001). Neither total number of pregnancy losses nor time gap since last pregnancy loss showed relevant correlations with psychological risks. For women, number of curettages, controlled for the number of pregnancy losses, correlates with the severity of posttraumatic stress (p < 0.05). Higher levels of anxiety, depression and a lack of social support in women correlated positively with posttraumatic stress in their partners. The coping strategy “trivialization and wishful thinking” as well as the subscale “avoidance” of the Impact-of-Event-Scale (self-report questionnaire measuring posttraumatic stress) of men was correlated with more severe posttraumatic stress in their female partners (both p < 0.05).

Limitations, reasons for caution

The data show only correlations between the measured variables, as cross-sectional studies are not suitable to analyse causal relationships. The sample was obtained in a special unit for RPL at a university hospital, so the findings may not be generalizable to all couples with RPL.

Wider implications of the findings: Screening psychological risks in couples with RPL may be reasonable considering the high risks in both sexes and the extent of PTSD diagnoses in women, their interdependencies and the potential risk of chronification. Professionals should encourage affected couples to support each other and provide targeted information on mental health services.

Trial registration number

DRKS 00014965

Global health and health workforce development: what to learn from COVID-19 on health workforce preparedness and resilience

This Special Issue is dedicated to the healthcare workers across the globe. It draws together studies from different disciplines and regions to identify important lessons learned on weaknesses as well as on opportunities for health workforce innovation through a global health lens. Beginning with strategic reflections on the role of the health workforce and public health competences in responding to the COVID-19 pandemic crisis, major themes include the protection and experiences of frontline healthcare workers, the role of health systems and policy, planning and management issues, and education and health labour markets. Developed in collaboration with European Public Health Association 'Health Workforce Research' section, the Special Issue contributes to the WHO International Year of Health and Care Workers (YHCW) in 2021 in recognition of their dedication to providing care during the COVID-19 pandemic, even risking their own health and life.

Support for global health and pandemic preparedness in medical education in Germany: Students as change agents

The COVID‐19 pandemic has reinforced Germany's role as global health player, but the education system is lagging behind and does not adequately prepare health professionals for the new challenges. This study aims to strengthen global health in undergraduate medical education in Germany. Major objectives include: to review the current situation, explore changing demand for global health and introduce innovative teaching models and the drivers for change. Mixed methods and an explorative approach were applied, comprising a scoping review, online surveys carried out at Hanover Medical School, March/April 2020. Target groups were undergraduate medical students (n = 384) and additionally lecturers (n = 172), and finally new multiprofessional teaching courses initiated by students and developed collaboratively. The results reveal only slow pace of change on the level of the education system, while demand for global health education has increased markedly in all actor groups, but strongest in the group of students in the preclinical phase. Implementation of global health programmes illustrates how students can become change agents and enhance institutional innovation bottom‐up. However, in order to achieve wider transformative potential, these efforts must be flanked by macro‐level policy changes and integrated in future pandemic preparedness strategies.

Public health competences through the lens of the COVID-19 pandemic: what matters for health workforce preparedness for global health emergencies

The COVID‐19 pandemic is raising new questions on public health competences and leadership and on health workforce preparedness for global public health emergencies. The present commentary aims to highlight demand and opportunities for innovation through the disruptions caused by the COVID‐19 crisis. We review the public health competency framework recently launched by WHO and ASPHER through the lens of COVID‐19. The framework provides guidance for aligning public health and global health competences across sectors and professional groups. Five critical competency areas can be identified in relation to public health emergencies: (1) flexibility, adaptation, motivation, communication, (2) research, analytical sensitivity, ethics, diversity, (3) epidemiology, (4) preparedness and (5) employability. However, this may not be enough. New models of public health leadership and changes in the health workforce are needed, which transform the silos of professions and policy. Such transformations would include learning, working, leading and governing differently and must stretch far beyond the public health workforce. To achieve transformative capacity, critical public health competences must be considered for all healthcare workers on all levels of policymaking, thus becoming the ‘heart’ of health workforce resilience and pandemic preparedness.

When informal work and poor work conditions backfire and fuel the COVID-19 pandemic: Why we should listen to the lessons from Latin America

Latin America is among the regions with the highest incidence of COVID-19 where the pandemic is creating a humanitarian crisis. In this Commentary we aim to reveal underlying problems of this crisis, that may be an underestimated global driver of the pandemic and a serious risk to health and healthcare systems. We set the focus on informal work and related poorly regulated sub-contracting which create poor work conditions as one dimension of the social determinants of health. We use the examples of Germany and Brazil, as opposite sides geographically and concerning the pandemic, to highlight a need for greater attention to these risks and for systematic inclusion in health systems resilience. In both countries, informal work may turn into hot spots of COVID-19, thus reinforcing social inequalities on a grand scale both nationally and globally. Our two contrasting country cases thus reveal a global threat that should be treated as such. There is much to learn for Europe and the world from Brazil and Latin America on what happens when informal labour and poor work environments backfire during the COVID-19 pandemic. We should listen carefully to these lessons.

Digital health in a social health insurance system: new emergent market powers in Germany

Background

This presentation analyses the dynamics of digital health from a governance perspective. It aims to explore the driving forces for the implementation of digital health in Germany. Germany is chosen as a case study of a social health insurance system, which is based on joint self-governance of sickness funds and providers, and strong corporatist power of the medical profession.

Methods

A qualitative explorative approach is applied, drawing on document analysis and other secondary sources. The research is based on a governance approach adapted from Glassman and Buse's model of public health policy reform.

Results

The WHO Global Strategy for Digital Health 2020-2024 serves as a key international policy framework. However, the analysis reveals firstly that implementation is shaped by national healthcare systems and may create different results; secondly, the global strategy provides only a weak guidance on the national level. In Germany, strong corporatism and weak state intervention is supporting market forces and private actors. Poorly developed digital health governance has opened a window of opportunity for market powers as driving forces for digital health, thus creating new risks of social inequalities. There is an urgent need for public health to step up advocacy for health literacy to improve the accessibility to digital health for all citizens.

Conclusions

National healthcare systems strongly shape the implementation of international digital health frameworks, which makes digital health an issue of governance. Stronger public health orientation and a people-centred approach are needed to counteract new emergent social inequalities created by market power.

Key messages

Market power and private actors are important drivers of digital health in the German healthcare system. Social health insurance systems may be vulnerable to market powers and new digital health inequalities.

Migrant carers in Europe: double jeopardy of labour market exploitation and hostile environments

Background

Many health systems have responded to growing population needs and expanded long-term care services for older people (LTC). However, no country managed to adequately increase the human resources for health. A large group of transnationally mobile migrant carers fill the gaps and mitigate policy failure. This study aims to explore the connections between health labour markets, migrant care workers and populism and to reveal blind spots in the governance of the LTC workforce.

Methods

An explorative comparative approach was applied, which draws on a rapid review of the literature, public statistics and document analysis. A novel analytical framework was developed, which is informed by transsectoral governance and combines four major dimensions: LTC system (e.g. cash benefits, public responsibility), health labour market situation (supply-demand) in the LTC sector, labour migration policies relevant for LTC, and the role of populist parties. Five EU countries were selected which represent different conditions in LTC: Austria, Denmark, Germany, Italy and Poland.

Results

Typologies of sending and receiving countries are no longer sustainable, but transnational mobility flows still impact differently in healthcare systems and national labour markets. Undersupply coupled with cash-benefits and a culture of family responsibility are predicting high inflows of migrant carers, who are channelled in low-level positions or in the informal care sector. These conditions can often be observed in countries with strong populist movements.

Conclusions

Health labour markets, LTC systems, culture and political factors combine to create a double jeopardy for migrant carers, exploited as labour market subjects and exposed to hostile social environments as individual citizens. Action has to be taken to improve public health advocacy for migrant carers and to establish effective European health labour market regulation and transnational health workforce governance.

Migrant carers in Europe in times of COVID-19: a call to action for European health workforce governance and a public health approach

The present study explores the situation of migrant carers in long-term care (LTC) in European Union Member States and the disruptions caused by the COVID-19 pandemic from a public health perspective. The aim is to bring LTC migrant carers into health workforce research and highlight a need for trans-sectoral and European heath workforce governance. We apply an exploratory approach based on secondary sources, document analysis and expert information. A framework comprising four major dimensions was developed for data collection and analysis: LTC system, LTC health labour market, LTC labour migration policies and specific LTC migrant carer policies during the COVID-19 crisis March to May 2020. Material from Austria, Italy, Germany, Poland and Romania was included in the study. Results suggest that undersupply of carers coupled with cash benefits and a culture of family responsibility may result in high inflows of migrant carers, who are channelled in low-level positions or the informal care sector. COVID-19 made the fragile labour market arrangements of migrant carers visible, which may create new health risks for both the individual carer and the population. Two important policy recommendations are emerging: to include LTC migrant carers more systematically in public health and health workforce research and to develop European health workforce governance which connects health system needs, health labour markets and the individual migrant carers.

The specialised health workforce matters: how to adapt the WHO National Health Workforce Accounts

Background

The importance of a sustainable health workforce is increasingly recognised. However, the specialised heath workforce remains marginal in health workforce planning, policy and research. This paper aims to improve the integration of small specialised professional groups in health workforce governance and to critically assess existing tools, using Germany and rheumatology physicians as a case study.

Methods

A qualitative explorative approach was applied, which draws on a scoping review of the literature, public statistics and expert information. The National Health Workforce Accounts (NHWA) and the WHO 'AAAQ' framework served as guidance to assess workforce development in rheumatology in Germany.

Results

On average physician density is high in Germany, yet access to specialised care may be seriously delayed and services may not be accessible to all patients; e.g. currently only half of the patients with spondyloarthritis are treated by a rheumatologist which impacts quality of care. An estimated 850 to 1000 additional rheumatologists are needed to ensure early diagnoses and treatment and prevent long-term health damage. However, shortage will even reinforce in future: annual inflow of newly registered rheumatologists over recent years did not exceed 30 to 50 physicians and young rheumatologists more often prefer part-time work.

Conclusions

Specialised health professions with small numbers and long duration of training face specific challenges to create a sustainable workforce. This calls for (1) greater investment in education and training, (2) greater attention to qualitative indicators, such as assess and prevention measurements like early diagnosis, and (3) a dynamic health workforce approach to respond to both new technologies/ treatments and changing preferences of the health professionals, like part-time work.

Key messages

Integrating the specialised health workforce in health workforce governance is important to improve prevention, quality and access to care. NHWA may be aligned to qualitative indicators and prevention policies to respond more effectively to future population needs.

Nurse density matters: a 30-country observational study of antimicrobial resistance priority type

Background

Although the warming climate and antimicrobial use were associated with antimicrobial resistance (AMR), they showed poorer explanatory strength in southern and eastern European countries, characterized with higher levels of nurse emigration. The present study investigated the contribution of nurse density to AMR variance explanation in the EU/EEA region for “Priority 1” AMR types (WHO).

Methods

A 30-country observational study was conducted. Combined species six-year prevalence of carbapenem resistant gram-negative bacteria (Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae and Acinetobacter spp.; CRGN) were determined using public ECDC data of clinical isolates, which were subjected to statistical analysis.

Results

Countries with low nurse density (< median) displayed a 10-fold higher median CRGN prevalence compared to those with high density (p < 0.001). Furthermore, proportions of reported isolates for all species (standardized by the total number of reported isolates per country) negatively correlated with nurse density with the exception of Ecoli, which showed a positive correlation (rs = 0.73, p < 0.001). In multivariate analysis, nurse but not physician density significantly explained total log_CRGN variance (R2=83%). Notably, nurse density had a higher contribution to variance explanation than outpatient antimicrobial use. However, this observation could be retained only for countries without a gate-keeping role of GPs.

Conclusions

This study contributes novel data by identifying a potential association between nurse density and CRGN. Statistical observation might be supported by survey data on health workers' attitudes, which identified nurses and associates as the professionals most likely to perform hand hygiene.

Key messages

Including nurses in future AMR policies may help to tackle the spread of critical AMR types, such as CRGN. Strengthening the role of nurses in fighting AMR may be most beneficial in countries without a gatekeeping system.

How professions make intersectoral governance happen in the context of Denmark

Background

Intersectoral governance is recognised as key to achieving better healthcare, but our understanding of how to make this happen is limited. Earlier studies on individual professionals fail to acknowledge the resources of health professions as collective actors and pay very little attention to professional agency to support intersectoral governance. The aim is to add new knowledge on how professions contribute to intersectoral governance in healthcare.

Methods

The study develops a novel conceptual framework, distinguishing between the what, the how and the why of professional agency. The study is based on a secondary analysis of five qualitative case studies of coordination in Denmark, conducted 2011-8 and with a total of 89 hours observations, 18 focus groups, 36 interviews. The case selection identified studies from different organisational settings. Coordination was the key indicator of intersectoral governance and used for coding and for drawing up a data display for more systematic analysis.

Results

Health professions engage in a wide range of coordination activities; this includes documenting, monitoring, meeting, giving practical support and teaching. Health professions employ diverse mechanisms to adapt coordination activities to local contexts; this is about flexibility and combining mechanisms in a highly tailored way. When they engage in coordination activities, health professions draw on two different rationales: one relates to better healthcare services for patients, the other to professional interests, including work conditions.

Conclusions

Health professions engage in coordination that spans sectors, organisations and/or professional groups; thus professions are key to making intersectoral governance happen.

Key messages

Health professions have many resources highly relevant for coordination. Policy and administrative decision makers need to better support health professions to strengthen intersectoral governance.

The migrant health workforce in European countries: does anybody care?

Background

Data and knowledge on the migrant health workforce are poorly developed, and we do not understand which institutional contexts may foster responsible governance. This introduction seeks to set the scene for critical debate by placing the structure and composition of the migrant health workforce in the context of health systems and policy. The aim is to confront growing nationalism and populism with the important contribution of migrant carers to health system performance and the health of the population.

Methods

A comparative approach was applied and a rapid review of available data and research undertaken. Five EU countries were selected which represent different healthcare systems, health workforce patterns and political contexts in high-income countries, comprising Austria, Denmark, Germany, Italy, UK.

Results

The migrant workforce pattern show high variation. The number of physicians is highest (around 28%) in the UK, and low in Austria, Denmark and Italy (below 5%) while Germany is in a middle position (around 10%). The picture turns when looking at nurses and carers, where Italy and Germany for instance are placed in higher ranks. The results suggest three things: no coherent patterns of health system types and composition of the migrant care workforce can be identified. There is also no clear connection between the size of the migrant health workforce and the relevance of populist movements. And finally, the migrant carers remain largely absent in the policy debates; none of the health systems has develop a comprehensive governance model that ‘cares’ for the migrant carers and that could help to highlight their contribution against the threats of growing nationalism and populism.

Conclusions

There is a need for comprehensive European monitoring and research to develop more inclusive health workforce governance and to identify institutional conditions that improve capacity and capability for ‘care’ ‘of the migrant health workforce.

Researching the health workforce: a framework for action

Background

The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains challenging. There is a need to improve research and education to address these questions effectively and build capacity for public health approaches in health workforce policy. This paper introduces an agenda for health workforce research.

Methods

The research agenda has been developed through bringing together expertise and knowledge from a wide range of authors and leading organisations involved in health workforce research and policy. It takes a health system approach and focuses on Europe.

Results

Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. The research highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policymakers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation.

Conclusions

There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. Action has to be taken to establish new training courses and Master programmes to create competences for leadership in health workforce research.

An international perspective on organisational strategies to foster skill-mix changes in healthcare

Background

The implementation of skill-mix innovations in healthcare organisations is a complex process which many factors affect, positively or negatively. Facilitators are factors which stimulate or expand skill-mix change, whereas barriers are factors that limit or restrict skill-mix change. This study provides an overview of the most common facilitators and barriers.

Methods

An overview of systematic reviews was conducted as part of a larger project studying skill-mix innovations. 20 reviews on organisational-level factors related to the implementation of skill-mix innovations were included. The evidence from the reviews was supplemented with country case studies.

Results

Organisational factors, such as physical proximity of services involved in the skill-mix or well-functioning information systems, are often discussed in the literature on skill-mix implementation at organisational level. The same applies to individual factors, such as required knowledge levels or (lack of) trust. Process factors and characteristics of the skill-mix intervention seem to play a less important role, even though coaching and support for professionals seem to facilitate the implementation process. The institutional environment mainly seems to have a hampering effect, especially related to a lack of financing, reimbursement issues or perceived fears of liability. Often, the implementation of skill-mix interventions at organisational level is approached by focusing on specific facilitators and barriers, yet little attention is paid to structural approaches.

Conclusions

There is no single appropriate strategy for implementing skill-innovations that will fit all organisations. Managers must adopt an optimal strategy when implementing skill-mix, usually involving a combination of approaches best suited to local factors, to their specific organisational context and to the individuals involved.

Thinking outside the box: Association of antimicrobial resistance with climate warming in Europe - A 30 country observational study

The association of antimicrobial resistance (AMR) with climatic factors gained higher attention since resistance increased with increasing local temperatures in the USA. We aimed to investigate whether the explanatory strength of climatic factors holds true in a region encompassing diverse healthcare systems, like Europe. In particular, we determined whether exposure to temporal climate warming is associated with an increase in AMR prevalence for clinically relevant pathogens. A 30-country cross-sectional study was conducted. The six-year prevalence of carbapenem-resistant Pseudomonas aeruginosa (CRPA), Klebsiella pneumoniae (CRKP), Multiresistant Escherichia coli (MREC), and Methicillin-resistant Staphylococcus aureus (MRSA) was determined based on > 900 k clinical isolates. Bi- and multivariate analysis were performed to identify associations with climatic variables using healthcare and socio-economic confounders. CRPA was significantly associated with the warm-season change in temperature, which, alongside corruption perception, explained 78% of total CRPA variance. Accordingly, a 0.5 °C increase of year-wise temperature change (exposition) resulted in a 1.02-fold increase (p = 0.035) in CRPA prevalence (outcome). For a given country, exposition status doubled the odds of outcome attainment compared to non-exposition (OR = 2.03, 95%-CI [1.03-3.99]). Moreover, we found significant associations of CRKP, MREC, and MRSA with the warm-season mean temperature, which had a higher contribution to MRSA variance explanation than outpatient antimicrobial drug use. We identified a novel association between AMR and climatic factors in Europe, which reveals two aspects: climatic factors significantly contribute to the explanation of AMR in different types of healthcare systems, while climate change (i.e. warming) might increase AMR transmission, in particular CRPA.

New public management, physicians and populism: Turkey's experience with health reforms

Recent debates on the rise of right-wing or neoliberal populism globally have prompted public health and health systems researchers to explore its implications in the healthcare systems. This case study of Turkey's recent health reform initiative, the Health Transformation Program, aims to contribute to this debate by examining the nexus among populism, professionalism and the contemporary market and managerial reforms, often described as New Public Management (NPM). Building on document analysis and secondary sources, this article introduces a framework to explore whether and how populist agendas grow up in the shadow of NPM policies. We aim to deepen our understanding of the governance settings that might be used in different ways by right-wing populist leaders to advance their agendas. Our research reveals that the NPM reforms in Turkey have opened a 'backdoor' through which right-wing populist agendas were supported and the position of the medical profession as an important stakeholder in the institutional settings was weakened. However, what mattered most in the reform process was not the policies themselves but the ways new managerialist policies were implemented. Our analysis makes blind spots of the NPM reforms and healthcare governance research visible and calls for greater attention to implementation processes.

Understanding the role of physicians within the managerial structure of Russian hospitals

This article examines the role of physicians within the managerial structure of Russian hospitals. A comparative qualitative methodology with a structured assessment framework is used to conduct case studies that allow for international comparison. The research is exploratory in nature and comprises 63 individual interviews and 49 focus groups with key informants in 15 hospitals, complemented by document analysis. The material was collected between February and April 2017 in five different regions of the Russian Federation. The results reveal three major problems of hospital management in the Russian Federation. First, hospitals exhibit a leaky system of coordination with a lack of structures for horizontal exchange of information within the hospitals (meso-level). Second, at the macro-level, the governance system includes implementation gaps, lacking mechanisms for coordination between hospitals that may reinforce existing inequalities in service provision. Third, there is little evidence of a learning culture, and consequently, a risk that the same mistakes could be made repeatedly. We argue for a new approach to governing hospitals that can guide implementation of structures and processes that allow systematic and coherent coordination within and among Russian hospitals, based on modern approaches to accountability and organisational learning.