Bickenbach et al. in their paper propose the transformation of the Learning Health System paradigm into a Learning Rehabilitation System. The shift towards Rehabilitation, as opposed to the traditional anatomical-physiological approach, holds paramount importance in healthcare since Rehabilitation, as defined by the World Health Organization, centers on the individual, emphasizing the optimization of functioning and reduction of disability. In this commentary we would like to add some concepts to the discussion. When establishing an Individual Rehabilitation Project, the environment in which patients live and healthcare workers operate should be considered, since the broad context could be very different. We believe that a smooth and successful transition through a Learning Rehabilitation System needs an ethical and not moralistic educational system, solid international political stability and an active prevention perspective by health organizations. A new "health pyramid" grounded in the concept of human functioning of the single individual, should be the compass guiding future health interventions.

In hospitals, decisions are often made under time pressure. There is, however, little evidence on how time pressure affects the quality of treatment and the documentation behaviour of physicians.

Launched in 2021, the Recovery Support Programme (RSP) provides mandated intensive improvement support to NHS healthcare providers and systems in England experiencing significant financial, quality or safety failings. The aim is to prevent further deterioration, embed improvement and to enable sustained stabilisation. We conducted a rapid multi-method study to evaluate the early implementation of the RSP to understand initial impact and identify further developments which could improve its delivery. We found that whilst the RSP is generally perceived as more supportive and less punitive than the special measures regime it replaced, there are areas where its delivery could be enhanced. There is variation in how the programme is delivered across regions and several core processes could be standardised to enable more structured assessment of system capability and development of capacity to support change. The presence of cross system collective leadership and external facilitation may be the core-enabling features necessary to embed improvement and enable sustained stabilisation in NHS organisations.

In this paper, we examine trends in provider fees charged, government expenditure on private out-of-hospital medical services, and out of pocket costs following policy changes intended to reduce government expenditure. We examine the experience of a high-need patient group: people diagnosed with cancer. The Australian system for these services is predominantly publicly funded under fee for service; with no government control on the fees charged by providers. We calculate out of pocket costs for patients in the 12 months following a cancer diagnosis and find a large variation in these costs according to the type of treatment received as well as the place of residence and presence of additional government protection. We find that volumes of services, provider fees, and out of pocket costs rose over time. These findings are especially important for a high-need patient group as out of pocket costs are considered a barrier to access to healthcare. Governments may respond to the long-term fiscal challenges by attempting to constrain benefits it pays; our results demonstrate that careful consideration of the full impact of such policies is needed.

Self-medication is prevalent in European countries, where health systems are committed to providing universal and equitable access to medicines and health services. This study aims to explore the relationship between the use of over-the-counter (OTC) and prescribed drugs, as well as between OTC drug use and healthcare service utilization. Data from the European Health Interview Survey, wave 2019, were analyzed using logistic regressions on a sample of employed individuals from 26 countries. The main findings point to complementary and triangular relationships between the consumption of over-the-counter and prescribed drugs, and the use of health care consultations. Additionally, it was confirmed that the consumption of over-the-counter drugs is more likely when people are absent from work for health reasons. Finally, the study recommends fostering collaboration between pharmacists and healthcare providers to create comprehensive medication profiles for patients.

Diagnostic services played a key role in government responses to the COVID-19 pandemic. In our work to support diagnostics in over 20 countries of the Global South, with a focus on Latin America, we observed common problems in resource-limited settings. We identify common constraints of (i) affordability of reagents, (ii) access to reagents, (iii) poor infrastructure, and (iv) limited human resources. Enhancing diagnostic services in resource-limited settings cannot be sustained only by international cooperation and philanthropic missions. Success depends on domestic leadership and regional cooperation of which the existent influenza or dengue networks in Latin America are prime examples. A Latin American Center for Disease Control and Prevention (CDC), as proposed by some, can only be successful if reliable funding and a clear mandate are secured. A stronger inclusion of diagnostic tool development and data sharing will be imperative for dealing with emerging pathogens.

Utilizing data from a randomized controlled trial conducted in France and Italy, we propose a seven-category classification system for vaccine behaviors to better investigate the instability of individual preferences in response to two different information framings of the adverse event of vaccine-related death in different languages-one more scientific and abstract, and the other more anecdotal and concrete. We find that loss-framed messages increase vaccine hesitancy in both France and Italy, with abstract framing contributing to a greater extent than concrete framing. The results also highlight significant gender effects. Contrary to previous studies, women exhibit less hesitancy than men. Furthermore, gender differences in reactions to the framing of the loss are revealed: reading the concrete framing, men become less willing to be vaccinated, whereas women become more hesitant with the abstract framing. To enhance vaccine acceptance, effective communication should consider how different loss-framed messages impact vaccine decision-making differently based on gender.

Our review examines the operational dynamics and effectiveness of integrated healthcare models in Australia, focusing on their relevance for older rural adults with preventable chronic diseases. Using Whittemore and Knafl's (2005) systematic integrative review methods, we conducted a search across five databases, including Medline-EBSCO, PubMed, CINAHL, EMBASE, and SCOPUS. The Sustainable Integrated Chronic Care Models for Multimorbidity (SELFIE) framework, established by Leijten et al. (2018), was used for reflexive thematic synthesis. A two-stage screening process identified 15 integrated healthcare models, with five RCTs evaluating their effects on chronic conditions. The analysis revealed two key themes: aspects of care integration (service delivery, leadership, workforce, technology, and finance) and changes in patient and healthcare outcomes. Care coordination and multidisciplinary team care were common features, bridging gaps between health and social services for older patients. Despite challenges such as irregular funding and underutilisation of technology, several models demonstrated positive patient and healthcare outcomes. Virtual care platforms and remote monitoring systems have shown promise in improving patient engagement and enabling real-time care adjustments, particularly in rural areas with limited healthcare access. Our review highlights the need for integrated healthcare for older rural Australians with preventable chronic conditions, revealing the complexity of service models. Policy shifts towards coordinated services and changes in leadership and healthcare practices are essential to ensure this demographic receives integrated care that meets their needs.

The specialization of Health Human Resources (HHR) is increasingly recognized as essential for addressing evolving healthcare demands. This paper presents a comprehensive policy framework for assisting with the implementation of Clinical Nurse Specialist (CNS) roles at the national or regional level, integrating key dimensions including barriers and enablers, regulation and governance, education and training requirements, career development, workforce planning, and economic analysis. The framework was applied to the implementation of CNS roles in Portugal, resulting in the issuance of a decree-law by the government. Our findings demonstrate that the economic analysis step was critical in addressing concerns from government authorities and health system funders regarding the potential budgetary impact of CNS implementation. By providing evidence-based projections of costs and benefits, the economic analysis facilitated smoother negotiations and consensus-building among stakeholders, including nursing unions. Furthermore, the integration of workforce planning ensured the alignment of educational capacity with workforce needs, thus avoiding potential implementation bottlenecks. The application of the framework also revealed important feedback relationships between its dimensions, highlighting the interdependent nature of the implementation process. This dynamic approach, which adapts to real-time feedback and stakeholder input, underscores the necessity of a holistic and iterative strategy for successful CNS role integration. The insights gained from the Portuguese case underscore the utility of this policy framework in guiding the implementation of advanced nursing roles in diverse healthcare contexts.

The Flemish government implemented a cash-for-care scheme in 2017, allocating a personal budget (PB) as a voucher or cash budget to persons with physical and intellectual disabilities to increase budget holders' empowerment. However, the literature shows that personal (inherent to budget holders) and contextual factors (inherent to cash-for-care schemes) potentially have an impact. This study, therefore, reports on Flemish budget holders' empowerment and its associated factors. A survey was developed, examining personal and contextual factors related to empowerment. A convenience sample with multiple recruitment sources (via policy, user-, and care organization support) was used to recruit participants. Data collection took place from April 4, 2022, to October 31, 2022, and data were analyzed using bivariate and linear regression analyses. The survey was completed by 224 budget holders. The complexity of administrative procedures, educational level, private financial resources, and presence of an (in)formal care network were not associated with Flemish budget holders' empowerment. However, the regression analyses showed that knowledge of the care and well-being sector, PB allocation type (cash and combination versus vouchers), and respondent type (proxies representing the budget holder versus people with disabilities as respondents) predicted empowerment. Knowledge and flexibility in PB use are significantly associated with higher empowerment scores. Enhancing knowledge about the (disability) care sector is thus a key objective when implementing a cash-for-care scheme.

This paper explores an Australian place-based collaboration of ten agencies to reform the delivery of integrated health and social care services to children and families with complex health and social challenges. Data comprises interview transcripts of semi-structured individual interviews with 17 employees across the six most-engaged agencies in late 2022. Employing thematic analysis, we found that whilst there was agreement on the vision of creative, trust-based collaboration to drive, implement and scale up service delivery reform, points of tension highlighted complexities that acted contrary to this vision. These tensions suggest the need to clarify the governance role of the collaboration, attend to project maturation processes, revise the strategic direction as collaborations evolve, maintain communication and agency involvement, and continue to listen to consumer and clinician voices. We conclude that, in a complex service system environment, it is crucial to maintain and review a shared vision, clear strategies and a healthy collaborative environment. These conclusions may inform other interagency collaborations and policies with the goal of integrating health and social care.

The global migration of the health and care workforce (HCWF) has intensified, leading to complex policy scenarios and diverse migration patterns. While the traditional narrative of individual health and care workers (HCWs) migrating from low- and middle-income countries to high-income countries in search of higher income, career prospects and working conditions remains relevant, it now coexists with many other drivers, incentives, and dynamics at individual and policy level. The evolving dynamics of HCW migration have profound implications extending far beyond health labour markets, influencing broader societal and political landscapes. Despite their significance, the qualitative shifts in HCWF migration patterns and the governance challenges they present are poorly understood and under-researched, and policies have thus been limited in their effectiveness. In this policy comment we argue for a global response and an enhanced focus on policy implementation, using selected case studies to illustrate the argument. The cases highlight complexities of HCW migration patterns and opportunities for strengthening implementation of the WHO Global Code of Practice to respond effectively to the diverse needs of health systems and individual HCWs.

Over the past two decades, private equity (PE) firms-private investors that use large pools of money to buy into and restructure companies-have become increasingly involved in U.S. healthcare ownership and management. PE's goal of acquiring quick financial gains is typically accomplished by assigning debt to the facilities and practices it buys, cutting labor costs, changing services to the most lucrative, upcoding diagnostic codes to raise prices, and merging, shutting down, or selling practices. This study shows that private equity has expanded into nearly every corner of U.S. healthcare, and in some sectors, such as hospitals, nursing homes and physician specialties, quite significantly. The PE business model is theorized to be incompatible with high quality, efficient, accessible healthcare. Empirical research supports this framework to some extent. Few studies find evidence for better healthcare quality/patient outcomes or lower expenditures. A few studies find better access in profitable areas for PE, and three find lower operating costs and/or higher operating margins, which may have negative impacts in other healthcare system outcomes. A few studies show no difference in various healthcare system outcomes. Otherwise, the preponderance of studies indicates worse or mixed (mostly worse) outcomes with PE ownership. PE involvement in healthcare is greater in the U.S. than Europe, but there is potential for it to reach similar levels in Europe. Federal and state policy initiatives to regulate PE in U.S. healthcare are in the incipient stage and would benefit greatly by more research on PE's impacts.

The growing number of well-established use (WEU) applications was reported by the Coordination Group for Mutual Recognition and Decentralised Procedures - Human (CMDh). The procedures from the CMDh annual statistics and products from the Mutual Recognition Information Product Index were analysed between 2006 and 2023. Drop-out and CMDh referral rates were determined, and the Anatomical Therapeutic Chemical codes for WEU products were subjected to trend analysis. The Summaries of Product Characteristics (SmPC) of active substances with a growing interest were scored to determine the level of disharmonisation in the most commonly authorised strength and pharmaceutical forms. The rise in the relative number of WEU applications has been confirmed. The reasons for heightened interest in WEU applications could be explained by (i) the reliable legal basis it has transformed into, (ii) the flexibility, (iii) the incentive system awarding protection. Products containing 3 mg melatonin and 25,000 IU colecaliferol in solid oral forms were the most sought-after products in recent years. An analysis of the SmPCs revealed a significant degree of disharmonisation in the clinical particulars, and it also shed light on intra- and inter- Reference Member State (RMS) variance in the decision making. The current European medicine approval system is not suited to effectively handle this ever-increasing use of one of the most resource intensive legal bases due to the high level of disharmonisation that has been overlooked for years. Consequently, a change in the current application compilation and assessment practices might be beneficial to ensure patient safety and therapy success.

Intimate partner violence (IPV) is a major global health issue, yet few studies explore its long-term public healthcare burden in countries with universal healthcare systems. This study analyzes this burden among Canadian women using data from the Neighborhood Effects on Health and Wellbeing survey and Ontario Health Insurance Plan (OHIP) records from 2009 to 2020. We employed inverse probability weighting with regression adjustment to estimate differences in cumulative costs and OHIP billings between those reporting exposure to IPV during the survey and those who did not. Our sample included 1,094 women, with 38.12 % reporting IPV exposure via the Hurt, Insult, Threaten, Scream scale. Findings show a significant public healthcare burden due to IPV: women reporting IPV in 2009 had an average of 17 % higher healthcare costs and 41 additional OHIP billings (0.1732;95 % CI: 0.0578-0.2886; 41.23;95 % CI: 12.63-69.82). Policies prioritizing primary prevention and integration of trauma-informed care among healthcare providers are vital to alleviate the long-term burden on public health systems.

The implementation of legally mandated staffing levels for nurses has complex and wide-ranging effects on the organizational environment in which they operate.

Germany serves as a pioneering example for the integration of digital health applications. Since October 2020, digital health applications that passed a benefit evaluation have been provisionally or permanently included in the benefit basket of the German statutory health insurance. However, free price setting by the manufacturers in the first year after the introduction in the benefit basket led to high prices. After several policy debates, maximum reimbursement prices were introduced. This article provides an overview of the changing reimbursement and pricing landscape after implementing maximum reimbursement prices. Processes of setting reimbursement prices are described, first results of maximum reimbursement prices are presented and critically reflected by views of stakeholders affected. Results of the first 1.5 years show that only four digital health applications were assigned a product-specific maximum price. For three of these digital health applications, the manufacturer's price is below the statutory health insurance's maximum reimbursement price. Although there is relatively minor impact on costs so far, this may change over the years with a growing number of digital health applications. Nevertheless, a systematic and transparent adjustment of the pricing mechanism after one year of inclusion in the benefit basket is necessary to strike a balance between the benefits of new digital health applications, statutory health insurance expenditures and the promotion of novel digital health applications.

Multiple job holding (MJH), historically referred to as moonlighting, is increasingly recognized among healthcare workers, yet it remains underexplored among nurses. This study investigates the prevalence and motivations for MJH among nurses in Belgium. Using a cross-sectional survey, data were collected in 924 nurses between November 2022 and March 2023. The aim was to identify key influencing factors driving nurses to consider or engage in MJH, with motivations categorized into "push" and "pull" factors. Results show that 38.3 % of nurses hold multiple jobs, with financial necessity and job dissatisfaction (push factors) as the dominant drivers. Younger nurses, men, and those without children were more likely to engage in MJH. Pull factors, such as professional growth and job autonomy, also played a role but were deemed less important. Financial insecurity, particularly the inability to live comfortably on a single income, emerged as a strong predictor of MJH. Additionally, nurses with master's degrees were more likely to take on secondary jobs, possibly due to career development motivations. Despite the growing trend of MJH, the study highlights concerns about nurses working outside their primary profession during a nursing shortage. These findings suggest a need for policy interventions to address inadequate financial compensation and improve job satisfaction within nursing roles to reduce the reliance on secondary employment.

Innovation in healthcare is highly supply-driven, leading to underinvestment in less profitable health areas, unmet needs and inefficient use of public resources. This study proposes a framework to structure the identification of health-related patient and societal needs across different health conditions, supporting the evolution towards needs-driven healthcare policy and innovation. The Needs Examination, Evaluation and Dissemination (NEED) assessment framework was based on the results of two systematic literature reviews and stakeholder and expert consultation. The first review concerned patient needs criteria and the second concerned societal needs criteria. Relevant publications in Ovid Medline® or Embase®, in English, French or Dutch were included. The NEED framework addresses patient, societal, and future needs across health, healthcare, and social domains. Patient-level needs encompass five criteria in the health domain (e.g., impact on quality of life), four in the healthcare domain (e.g., burden of treatment) and four in the social domain (e.g., impact on social life). Societal needs encompass four health needs criteria (e.g., transmissibility), two healthcare needs criteria (e.g., value for money) and two social needs criteria (e.g., productivity losses). Future needs criteria (2) consider future burden of disease and economic burden. Equity is recognised as a transverse dimension, requiring unmet needs data disaggregated by population sub-groups. Each criterion is associated with one or more measurable indicators. This framework represents an important first step towards a more needs-driven healthcare policy and innovation landscape.

Pharmacotherapies are common therapeutic interventions in patient care. Despite most medications being self-managed by patients at home, little attention has been paid to medication risks in the outpatient medication management process. As community pharmacies dispense medicines to outpatients, they are well-positioned to decrease preventable harm by implementing systemic medication risk management practices. This article is a mid-term review of a national development programme to enhance community pharmacies' involvement in outpatient medication risk management in Finland (Valo programme 2021-2026). The article comprises the programme description utilising the US Centers for Disease Control and Prevention's framework, and the programme's preliminary mid-term results. Through the programme: 1) the same patient safety incident reporting and learning system used by most Finnish health- and social care (HSC) organisations was implemented in community pharmacies, 2) medication safety culture was promoted by enhancing community pharmacists' competencies in medication safety, 3) regional collaboration between community pharmacies and HSC organisations was supported through networks, and 4) a national research strategy was created to support outpatient medication safety research. Involving community pharmacies in outpatient medication risk management supports HSC systems. This article introduces nationwide actions that could be utilised in other countries to enhance community pharmacies' involvement.

Integrated care attempts to address multiple care needs, but barriers to implementation remain. The service user perspective can guide policy and practice to advance implementation.