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Background Value-based healthcare (VBHC) is a conceptual framework to improve the value of healthcare by health, care-process and economic outcomes. Benchmarking should provide useful information to identify best practices and therefore a good instrument to improve quality across healthcare organizations. This paper aims to provide a proof-of-concept of the feasibility of an international VBHC benchmarking in breast cancer, with the ultimate aim of being used to share best practices with a data-driven approach among healthcare organizations from different health systems. Methods In the VOICE community—a European healthcare centre cluster intending to address VBHC from theory to practice—information on patient-reported, clinical-related, care-process-related and economic-related outcomes were collected. Patient archetypes were identified using clustering techniques and an indicator set following a modified Delphi was defined. Benchmarking was performed using regression models controlling for patient archetypes and socio-demographic characteristics. Results Six hundred and ninety patients from six healthcare centres were included. A set of 50 health, care-process and economic indicators was distilled for benchmarking. Statistically significant differences across sites have been found in most health outcomes, half of the care-process indicators, and all economic indicators, allowing for identifying the best and worst performers. Conclusions To the best of our knowledge, this is the first international experience providing evidence to be used with VBHC benchmarking intention. Differences in indicators across healthcare centres should be used to identify best practices and improve healthcare quality following further research. Applied methods might help to move forward with VBHC benchmarking in other medical conditions. [ABSTRACT FROM AUTHOR]

This paper aims to contribute to the growing literature on resilience by focusing on coping with hardship during the Great Recession, drawing upon primary data gathered through household and key informant interviews in nine European countries. As the resilience approach highlights agency, the paper examines the nature of household responses to hardship during this period on the basis of the 'structure-agency problem'. An important contribution of this paper is to identify different forms of agency and discuss their implications. More specifically, we conceptualise three different types of agency in coping with hardship: absorptive, adaptive and transformative. Analysis of the findings indicates that structural constraints remain prominent. Most coping mechanisms fall under the category of absorptive and adaptive agency characterised here as burden-bearing actions that 'conform' to changing circumstances rather than shaping those circumstances. [ABSTRACT FROM AUTHOR]

The Covid-19 pandemic has brought great financial problems to the whole world. The football industry also felt the negative effects. A two-month break from not playing football matches affected all football factors. The clubs lost income from various sources, among which they were most financially affected by the lack of fees for TV rights and the loss of earnings from the game itself. The Covid-19 pandemic caused problems even after the return of football competitions, among other things due to the ban on spectators coming to the stadiums. There was no income from nonfootball sources, such as concerts and other events held at football stadiums. Due to the firm connection between the media, the economy and football, the aim of this paper is to present, from an economic and media point of view, the situation in which the football industry in Europe finds itself under the influence of the Covid-19 pandemic. [ABSTRACT FROM AUTHOR]

This paper proposes an adaptive network fuzzy inference system (ANFIS) based decision support system that can provide European policy makers with systematic guidance in allocating and prioritizing scant public resources, whilst accomplishing the best growth performance at a regional level. We do so by taking the stance of the Smart Specialization Strategies, which aim at consolidating the regional strengths and make effective and efficient use of public investment in R&D. By applying the ANFIS method, we were able to understand how—and to what extent—the competitiveness drivers promoted technological development and how the latter contributes to the economic growth of European regions. We used socio–economic, spatial, and patent-based data to train, test, and validate the models. What emerges is that an increase of R&D investments enhances the regional employment rate and the number of patents per capita; in turn, by taking into account the several combinations of specialization and diversification indicators, this leads to an increase of the regional gross domestic product (GDP). [ABSTRACT FROM AUTHOR]

Professional football (soccer) in Europe has changed dramatically in the past two decades, largely due to the escalation of media rights deals. Many professional football clubs are now complex businesses, intrinsically concerned with financial matters. Within the rapidly changing business context of football, the aim of this research is to further understand the main issues that are related to a career as a manager. This paper has five sections: (1) we offer an appraisal of the general literature as it applies to professional football management; (2) we introduce the theoretical focus of the article with specific reference to the “career” and describe the context and background to the research; (3) we describe the research methodology and present and discuss the research results, which center on the career development of the manager; the position of a manager in organizational structures, and how the changing organization affects the role of manager; (4) we set out the conclusions and implications of our research; and (5) we offer our plans to progress this research, enabling a new body of knowledge to be developed on this specialized role. [ABSTRACT FROM AUTHOR]

This paper explores the recent resurgence in use of ecstasy/MDMA in Europe and highlights keys areas of continuity and divergence between the ecstasy market of the 1990s and the current MDMA market. Based on a scoping study involving a targeted multi-source data collection exercise on MDMA, it highlights nine areas that have undergone some level of change, linked with both supply and demand for the drug. Factors discussed include: innovation in production techniques; changes in precursor chemical availability; the role of online markets; competition with other stimulants and new psychoactive substances; the increased availability of high-strength MDMA; and the shift from subcultural towards more mainstream use of the drug. The paper proposes that the MDMA on Europe's contemporary market is in some respects a third generation product with a different consumer profile, with implications that responses developed at the time of the drug's earlier iteration, may be in need of a review and revamp. [ABSTRACT FROM AUTHOR]

Aim This study examined the outputs of research papers in diabetes from 31 European countries between 2002 and 2013, and their funding. Methods Diabetes research papers in the Web of Science were identified by means of a filter based on journals and title words. For 2009-2013 papers, the funders were coded to show their sector and nationality. Results Europe published 40 547 diabetes papers in the 12 years between 2002 and 2013. Denmark, Sweden and Finland published the most relative to their wealth, but the UK published the most absolutely despite an apparently low burden (as measured by disability-adjusted life years). The largest source of funding was government (30%), followed by the non-profit sector (18%) and industry (13%). The European Commission supported 2.7% of papers, but more in Latvia (33%) and Estonia (16%). Based on an estimated cost per paper of €260 000, the annual research expenditure in Europe was approximately €986 million in 2013. Conclusions The European diabetes burden in disability-adjusted life years increased by one third between 2002 and 2012, but its output of research papers has decreased from 44% to 36% of the world total. This decrease needs to be reviewed in the context of European non-communicable disease research policy. [ABSTRACT FROM AUTHOR]

Background: Randomised clinical trials are key to advancing medical knowledge and to enhancing patient care, but major barriers to their conduct exist. The present paper presents some of these barriers.Methods: We performed systematic literature searches and internal European Clinical Research Infrastructure Network (ECRIN) communications during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project.Results: The following barriers to randomised clinical trials were identified: inadequate knowledge of clinical research and trial methodology; lack of funding; excessive monitoring; restrictive privacy law and lack of transparency; complex regulatory requirements; and inadequate infrastructures. There is a need for more pragmatic randomised clinical trials conducted with low risks of systematic and random errors, and multinational cooperation is essential.Conclusions: The present paper presents major barriers to randomised clinical trials. It also underlines the value of using a pan-European-distributed infrastructure to help investigators overcome barriers for multi-country trials in any disease area. [ABSTRACT FROM AUTHOR]

Aims: This is the first part of a two-part paper that takes an explorative approach to assess crisis and austerity in European countries during the Great Recession. The ultimate aim of this two-part paper is to explore the “crisis–austerity” thesis by Stuckler and Basu and assess whether it is the interplay between austerity and crisis, rather than the current economic crisis per se, that can led to deterioration in population health. In Part I of this paper we offer one way of operationalizing crisis severity and austerity. We examine countries as specific configurations of crisis and policy responses and classify European countries into “ideal types.” Methods: Cases included were 29 countries participating in the European Union Statistics on Income and Living Conditions (EU-SILC) surveys. Based on fuzzy set methodology, we constructed two fuzzy sets, “austerity” and “severe crisis.” Austerity was measured by changes in welfare generosity; severe crisis was measured by changes in gross domestic product (GDP) per capita growth. Results: In the initial phase of the Great Recession, most countries faced severe crisis combined with no austerity. From 2010–2011 onward, there was a divide between countries. Some countries consistently showed signs of austerity policies (with or without severe crisis); others consistently did not. Conclusions: The fuzzy set ideal-type analysis shows that the European countries position themselves, by and large, in configurations of crisis and austerity in meaningful ways that allow us to explore the “crisis–austerity” thesis by Stuckler and Basu. This exploration is the undertaking of Part II of this paper. [ABSTRACT FROM AUTHOR]

This paper explores which demographic characteristics substantially bias self-reported physical and cognitive health status of older Europeans. The analysis utilises micro-data for 19 European countries from the Survey of Health, Ageing and Retirement in Europe to compare performance-tested outcomes of mobility and memory with their self-reported equivalents. Relative importance analysis based on multinomial logistic regressions shows that the bias in self-reported health is mostly due to reporting heterogeneities between countries and age groups, whereas gender contributes little to the discrepancy. Concordance of mobility and cognition measures is highly related; however, differences in reporting behaviour due to education and cultural background have a larger impact on self-assessed memory than on self-assessed mobility. Southern as well as Central and Eastern Europeans are much more likely to misreport their physical and cognitive abilities than Northern and Western Europeans. Overall, our results suggest that comparisons of self-reported health between countries and age groups are prone to significant biases, whereas comparisons between genders are credible for most European countries. These findings are crucial given that self-assessed data are often the only information available to researchers and policymakers when asking health-related questions. [ABSTRACT FROM AUTHOR]

The outcomes of bargaining over losses, the subject of this paper, have rarely been studied. But experimental studies of related situations, such as those involving bankruptcies or bequests in which the sum of the legal claims that can be made against a bank or firm or estate are greater than their values, have produced strong support for the proportionality principle. To test whether this principle would find support in other situations involving losses we designed an experimental game in which four players start out with differing initial endowments of real money. They are then informed that a certain amount of this resource has to be given back to the experimenter. How should the loss be shared among the agents? This game was run at different locations and under different treatments over a period of almost three years. We found that the proportionality principle was rarely proposed and even less frequently accepted as a solution to this problem. One of the main reasons for this result was that the two players with the smallest endowments opposed most of the proposals which asked them to contribute at least some positive amount of their own initial resource. [ABSTRACT FROM AUTHOR]

Rare diseases are an important public health issue with high unmet need. The introduction of the EU Regulation on orphan medicinal products (OMP) has been successful in stimulating investment in the research and development of OMPs. Despite this advancement, patients do not have universal access to these new medicines. There are many factors that affect OMP uptake, but one of the most important is the difficulty of making pricing and reimbursement (P&R) decisions in rare diseases. Until now, there has been little consensus on the most appropriate assessment criteria, perspective or appraisal process. This paper proposes nine principles to help improve the consistency of OMP P&R assessment in Europe and ensure that value assessment, pricing and funding processes reflect the specificities of rare diseases and contribute to both the sustainability of healthcare systems and the sustainability of innovation in this field. These recommendations are the output of the European Working Group for Value Assessment and Funding Processes in Rare Diseases (ORPH-VAL), a collaboration between rare disease experts, patient representatives, academics, health technology assessment (HTA) practitioners, politicians and industry representatives. ORPH-VAL reached its recommendations through careful consideration of existing OMP P&R literature and through a wide consultation with expert stakeholders, including payers, regulators and patients. The principles cover four areas: OMP decision criteria, OMP decision process, OMP sustainable funding systems and European co-ordination. This paper also presents a guide to the core elements of value relevant to OMPs that should be consistently considered in all OMP appraisals. The principles outlined in this paper may be helpful in drawing together an emerging consensus on this topic and identifying areas where consistency in payer approach could be achievable and beneficial. All stakeholders have an obligation to work together to ensure that the promise of OMP's is realised. [ABSTRACT FROM AUTHOR]

The first of this two-paper series addresses a practical day-ahead auction model, where generation revenue constraints are explicitly incorporated in the problem formulation, as routinely done in several national electricity markets across Europe. The revenue-constrained market-clearing procedure includes the effect of the transmission network, inter-temporal constraints associated with generation scheduling, demand-side bidding, and marginal pricing. This auction design is an instance of price-based market clearing which features two major complicating factors. First, locational marginal prices become decision variables of the optimization process. In addition, producer revenues are formulated as bilinear and highly nonconvex products of power outputs and market-clearing prices. The resulting problem is formulated as a mixed-integer nonlinear bilevel program with bilinear terms for which available solution techniques rely on heuristics, approximations, or modeling simplifications. This paper presents a novel and exact methodology whereby the original problem is recast as an equivalent single-level mixed-integer linear program. As a consequence, finite convergence to optimality is guaranteed and the use of standard commercial software is allowed. The proposed transformation is based on duality theory of linear programming, Karush-Kuhn-Tucker optimality conditions, and integer algebra results. In the second part of this two-paper series, numerical results from several case studies illustrate the effective performance of the proposed solution approach. [ABSTRACT FROM AUTHOR]

Countries all over the world face increasing flood risks because of urbanization and the effects of climate change. In Europe, flooding is the most common of all natural disasters and accounts for the largest number of casualties and highest amount of economic damage. The current scientific debate on how urban agglomerations can be made more resilient to these flood risks includes a discussion on how a diversification, coordination, and alignment of flood risk management strategies (FRMSs), including flood risk prevention through proactive spatial planning, flood defense, flood risk mitigation, flood preparation, and flood recovery, can contribute to flood resilience. Although effective implementation of FRMSs can be considered a necessary precondition for resilience, efficient and legitimate flood risk governance can enhance this societal resilience to flooding. Governance and legal research has the potential to provide crucial insights into the debate on how to improve resilience. Yet the social sciences have only looked into this issue in a fragmented manner, often without a comparative scope. This special feature addresses this knowledge gap by focusing on the scope and workings of FRMSs, but also on cross-cutting topics such as uncertainties, distributional effects, solidarity, knowledge management, and citizen participation. The papers included in this feature are written by both policy analysts and legal scholars. The above-mentioned issues are thus approached via a multidisciplinary perspective. All papers convincingly show that one-size-fits-all solutions for appropriate and resilient flood risk governance arrangements do not exist. Governance arrangements should be tailored to the existing physical, socio-cultural, and institutional context. This requires an open and transparent debate between scientists and practitioners on the normative starting point of flood risk governance, a clear division of responsibilities, the establishment of connectivity between actors, levels, and sectors through bridging mechanisms, and adequate knowledge infrastructures, both nationally and internationally. [ABSTRACT FROM AUTHOR]

This paper presents a meta-synthesis of the literature on community-based self-management to support experiences of people diagnosed with type 2 diabetes. The aim was to synthesise findings on both formal and informal self-management support with particular reference to the relevance and influence of the social context operating at different levels. The review forms part of EU- WISE, a project financed through EU's 7th Framework Programme. The review was performed by systematically searching MEDLINE, PubMed, EMBASE, CINAHL, Psyc INFO and Web of Science for English language publications between 2005 and 2014 presenting research conducted in Europe on the experiences and perspectives of self-management concerns of patients diagnosed with type 2 diabetes. The search yielded 587 abstracts, which were reduced through search strategy refinement and eligibility and quality criteria to 29 papers that were included in the review. This review highlights the relevance of contextual factors operating at micro- and macro-levels. The synthesis yielded six second-order thematic constructs relating to self-management: sense of agency and identity, the significance and meaning of social networks, minimal disruption of everyday life, economic hardship, the problem of assigning patients' responsibility and structural influences of primary care. Using a line of argument synthesis, these themes were revisited, and a third-order construct, connectivity emerged which refers to how links in daily life are interwoven with peoples' social networks, local communities, economic and ideological conditions in society in a way which support self-management activities. This meta-synthesis indicates a need to heed the notion of connectivity as a means of mobilising and supporting the self-management strategies of people with type 2 diabetes in everyday life. [ABSTRACT FROM AUTHOR]

This paper discusses the development of economic higher education in Czechoslovakia from 1945 to 1953, ie before the emergence of new economic universities with the same name: University of Economics (Vysoká škola ekonomická) in Prague and Bratislava. Its aim is to determine possible similarities and differences in economic education between the Czech lands and Slovakia. Although the paper embraces the issue comprehensively, the main focus is on the comparison of two of the most important colleges, the Commercial College in Prague and Slovak College of Commerce in Bratislava. It concludes and claims that despite the Czechoslovak uniform policy in tertiary education, there were undoubtedly some national differences. Essentially, they stemmed from different networks and the number of economic schools in the Czech lands and Slovakia and from different prior traditions. Overall, Slovaks endeavoured to continue with the preceding development more than Czechs. [ABSTRACT FROM AUTHOR]

The expansion of urban ecosystems and climate change, both outcomes of massive lifestyle changes, contribute to a series of side effects such as environmental deterioration, spread of diseases, increased greenhouse gas emissions and introduction of invasive species. In the case of the Athens metropolitan area, an invasive mosquito species—the Asian tiger mosquito (Aedes albopictus)–has spread widely in the last decade. This spread is favoured within urban environments and is also affected by changing climatic trends. The Asian tiger mosquito is accompanied by risks of mosquito-borne diseases, greater nuisance levels, and increased expenses incurring for its confrontation. The main aims of this paper are (i) to estimate the various costs associated with their control of this invasive species, as well as its health and nuisance impacts, (ii) to evaluate the level of citizens’ well-being from averting these impacts and (iii) to record citizens’ and experts’ perceptions regarding alternative control measures. Evidence shows that experts tend to place a high value on mosquito control when associated with serious health risks, while citizens are more sensitive and concerned about the environmental impacts of control methods. The synthesis of results produced by the current study could act as a preliminary guide for the estimation of societal welfare from the confrontation of similar problems in the context of a complex ecosystem. [ABSTRACT FROM AUTHOR]

Objective: The main aims of this paper are to analyse the monetary value of informal care time using different techniques and to identify significant variables associated with the number of caregiving hours. Data and methods: A multicentre study in two Spanish regions in adult caregivers was conducted. A total sample of 604 people was available. A multivariate analysis was performed to identify the variables associated with the number of hours of caregiving time. In the monetary valuation of informal care provided, three approaches were used: replacement cost method, opportunity cost and contingent valuation (willingness to pay and willingness to accept). Results: The main determinants of the amount of time of informal care provided were age, gender, the level of care receiver´s dependence and the professional care services received (at home and out of home). The value estimated for informal care time ranges from EUROS 80,247 (replacement cost method) to EUROS 14,325 (willingness to pay), with intermediate values of EUROS 27,140 and EUROS 29,343 (opportunity cost and willingness to accept, respectively). Several sensitivity analyses were performed over the base cases, confirming the previous results. Conclusions: Time of informal care represents a great social value, regardless of the applied technique. However, the results can differ strongly depending on the technique chosen. Therefore, the choice of technique of valuation is not neutral. Among the determinants of informal care time, the professional care received at home has a complementary character to informal care, while the formal care outside the home has a substitute character. [ABSTRACT FROM AUTHOR]

Background: Patient and public involvement (PPI) is a requirement for UK health and social care research funding. Evidence for how best to implement PPI in research programmes, such as National Institute for Health Research (NIHR) Collaborations for Applied Health Research and Care (CLAHRCs), remains limited. This paper reports findings from an action research (AR) project called IMPRESS, which aims to strengthen PPI within CLAHRC East of England (EoE). IMPRESS combines AR with Normalisation Process Theory (NPT) to explore PPI within diverse case study projects, identifying actions to implement, test and refine to further embed PPI. Methods: We purposively selected CLAHRC EoE case study projects for in-depth analysis of PPI using NPT. Data were generated from project PPI documentation, semi-structured qualitative interviews with researchers and PPI contributors and focus groups. Transcripts and documents were subjected to abductive thematic analysis and triangulation within case. Systematic across case comparison of themes was undertaken with findings and implications refined through stakeholder consultation. Results: We interviewed 24 researchers and 13 PPI contributors and analysed 28 documents from 10 case studies. Three focus groups were held: two with researchers (n = 4 and n = 6) and one with PPI contributors (n = 5). Findings detail to what extent projects made sense of PPI, bought in to PPI, operationalised PPI and appraised it, thus identifying barriers and enablers to fully embedded PPI. Conclusion: Combining NPT with AR allows us to assess the embeddedness of PPI within projects and programme, to inform specific local action and report broader conceptual lessons for PPI knowledge and practice informing the development of an action framework for embedding PPI in research programmes. To embed PPI within similar programmes teams, professionals, disciplines and institutions should be recognised as variably networked into existing PPI support. Further focus and research is needed on sharing PPI learning and supporting innovation in PPI. [ABSTRACT FROM AUTHOR]

Background: NEETs (young people not in employment, education or training) are at higher risk for poorer mental and physical health. In France, the Missions locales (MLs) are the only social structures dedicated to this population. We sought to determine whether the systematic offer of a social and preventive medicine consultation at a ML might increase NEET participants’ access to training in the 12 months following the intervention. Methods: This intervention research was a parallel randomised controlled interventional study conducted at five MLs in mainland France in 2011–2012. It included 976 NEETs aged 18 to 25 years who attended one of the five MLs. At inclusion, participants were randomly assigned (1:1:1) to three groups: those in the first group were invited to see a social worker (not studied in this paper), those in the second group were invited to see a doctor and a social worker (intervention group), and the third was a control group. The primary outcome was participation in at least one training session during the year following study inclusion. Results: Among the 976 participants, 504 were randomly assigned to the intervention group and 472 to the control group; 704 (72.1%) were included in the analyses. A significantly higher proportion of the participants in the intervention group participated in a training session in the 12 months following the intervention than of those in the control group (63.3% vs 55.6%; p = 0.04). This difference was significantly greater for women, those less than 21 years of age, those unstably housed and those with a lower level of education. Conclusions: Social and preventive medicine consultations that are fully integrated into the social services for NEETs have an impact on their access to training and contribute to changing some of their health-related behaviours. This may improve their access to the labour market. [ABSTRACT FROM AUTHOR]

Many studies have shown that childhood circumstances can have long term consequences that persist until old age. To better understand the transmission of early life circumstances, this paper analyses the effects of health and financial situation during childhood on quality of life after retirement as well as the mediating role of later life health, educational level, and income in this association. Moreover, this study is the first to compare these pathways across European regions. The analyses are based on data of 13,092 retirees aged ≥ 60 and ≤ 85 years from the fifth wave of the Survey of Health, Aging, and Retirement in Europe (SHARE) with full information on childhood and later life measures of health, educational level, financial situation, and quality of life as well as relevant covariates. Five European regions are studied: Central-Western Europe (Austria, Germany), Central-Eastern Europe (Czech Republic, Estonia, Slovenia), Northern Europe (Denmark, Sweden), Southern Europe (Italy, Spain), and Western Europe (Belgium, France, The Netherlands). Path analysis is used to identify the direct and indirect effects of childhood measures on quality of life. We find retirees’ quality of life to be associated with childhood finances and health in all five European regions. While both the direct and indirect effects of childhood health are rather moderate and homogeneous across regions, especially the direct effects of childhood finances on quality of life after retirement display a distinct North-South gradient being strongest in Southern Europe. Potential explanations for the regional variations are differences in the countries’ welfare systems. [ABSTRACT FROM AUTHOR]

In this article, guest writers from the Istituto Superiore di Sanità in Italy, the leading scientific technical body of the Italian National Health Service present a historic case study considering the role and evolution of the information specialists at their institution over a twenty year period. The paper places a particular emphasis on the initiatives undertaken in consumer health information and health literacy promotion, in order to improve public health in Italy. Areas covered include the development of online health information provision, early strategies to support the improvement of health literacy, and national projects and collaborations. H.S. [ABSTRACT FROM AUTHOR]

Background: This paper reports the methods and findings from a systematic review of economic evaluations conducted in the community aged care sector between 2000 and 2016.Methods: Online databases searched were PubMed, Medline, Scopus, and web of science, CINAHL and informit. Studies were included if they 1) were full economic evaluations that compared both the costs and outcomes of two or more interventions 2) in study population of people aged 65 years and over 3) dependent older people living in the community 4) alternatives being compared were care models or service delivery interventions in the community aged care sector (a group of programs that have been established as a support system to allow older people to remain living in their own homes for as long as possible, as an alternative to institutional or residential care) and 5) published in the English language between 2000 and November 2016.Results: Eleven studies reporting upon economic evaluations of service delivery interventions in community aged care were identified; the majority of which were undertaken in Europe. Critical appraisal of the identified studies highlighted the methodological rigour in these evaluations.Conclusion: This systematic review highlights the paucity of economic evaluation studies conducted to date in the community aged care sector. The findings highlight the importance of cost utility analysis methodology as it allows for a uniform outcome measure, that facilitates the comparison of different interventions. In addition, multi-attribute utility measures that represent those quality of life domains that are most important to older people should be used and attention must be paid to the inclusion of informal care costs and outcomes as this is a key resource in community aged care service delivery. [ABSTRACT FROM AUTHOR]

Background This paper provides the socio-economic context of the MIGHEAL study, the results of which are presented in this special issue. The aim of the MIGHEAL study was to compare the physical and mental health of the native and migrant populations of Greece in the wake of the economic crisis that commenced in 2008. Methods The background of the migrant population of Greece is described, drawing on population censuses of Greece and data on residence permits held by foreigners. Then the migrant and native populations are compared with respect to several socio-economic outcomes, using Eurostat data on unemployment and the risk of poverty. Results The settled migrant population of Greece is largely of Central and Eastern European origin, resulting from the massive migrant inflowsthat started at the beginning of the 1990s after the collapse of socialist regimes in the area. Before the economic crisis, migrant unemployment was lower than that of natives, but after its onset, the unemployment of migrants surpassed that of natives. Prior to the crisis, migrants were already subject to greater risk of poverty than natives, but the gap widened considerably subsequent to the crisis. Conclusion The Greek institutional framework has restricted access to citizenship for both first- and second-generation migrants while conditions for permit renewal are onerous, rendering citizenship an important factor differentiating socio-economic outcomes. The different outcomes observed among the native and migrant populations after the onset of the Greek economic crisis create concerns regarding health inequalities between the two populations. [ABSTRACT FROM AUTHOR]

Background: Many low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced social health insurance payroll taxes after the political transition in the late 1980s, combined with budget transfers to allow for exempting specific population groups from paying contributions, such as those outside formal sector work and in particular vulnerable groups. This paper assesses the institutional design aspects of such financing arrangements and their performance with respect to universal health coverage progress in LMIC of the European region. Methods: The study is based on a literature review and review of secondary databases for the performance assessment. Results: Such financing arrangements currently exist in 13 LMIC of that region, with strong commonalities in institutional design: This includes a wide range of different eligible population groups, mostly mandatory membership, integrated pools for both the exempted and contributors, and relatively comprehensive benefit packages. Performance is more varied. Enrolment rates range from about 65 % to above 95 %, and access to care and financial protection has improved in several countries. Yet, inequities between income quintiles persist. Conclusions: Budget transfers to health insurance arrangements have helped to deepen UHC or maintain achievements with respect to UHC in these European LMICs by covering those outside formal sector work, and in particular vulnerable population groups. However, challenges remain: a comprehensive benefit package on paper is not enough as long as supply side constraints and quality gaps as well as informal payments prevail. A key policy question is how to reach those so far uncovered. [ABSTRACT FROM AUTHOR]

In recent years, most European countries have experienced substantial demographic changes and rising cultural diversity. Understanding the social and economic impacts of these shifts is a major challenge for policymakers. Richard Florida’s ideas have provided a popular – and pervasive – framework for doing so. This paper assess Florida’s legacy and sets out a ‘post-Florida’ framework for ‘technology, talent and tolerance’ research. The paper first traces the development of Florida’s ideas. ‘Florida 1.0’, encapsulated by the Three Ts framework, has performed badly in practice. There are problems in bringing causality to the fundamental relationships, and in consistently replicating the results in other countries. ‘Florida 2.0’, though suggests that Creative Class metrics have value as alternative measures of human capital. This create space for a post-Florida agenda based on economic micro-foundations. I argue that the growing body of ‘economics of diversity’ research meets these conditions, and review theory and empirics. Urban ‘diversity shocks’ shift the size and composition of populations and workforces, with impacts operating via labour markets, and through wider production and consumption networks. While short-term labour market effects are small, over time low-value industrial sectors may become migrant-dependent. Diversity may help raise productivity and wages through innovation, entrepreneurship, market access and trade channels. Bigger, more diverse cities help generate hybridised goods and services, but may also raise local costs through crowding. All of this presents new challenges for policymakers, who need to manage diversity’s net effects, and address both economic costs and benefits. [ABSTRACT FROM AUTHOR]

There are few analyses available of the role played by finance and business consultancies in post-socialist economic geographies and even fewer on the internationalization of small and medium-sized enterprises (SMEs). Both issues are addressed in this paper with a focus on Italian banks and business services as well as their relationship to SME outsourcing in Central and Eastern Europe. The basic premise of this paper is that a relationship exists between the internationalization of banks, services, and SMEs when analyzed within the framework of the Uppsala Internationalization Process Model. Specifically, banks and services allow the mobilization of resources forming knowledge pipelines between Italian firms and Central and Eastern European regional economies. [ABSTRACT FROM AUTHOR]

As it stands there is no viable health care option for undocumented immigrants of low socioeconomic status. Even more worrisome is that Affordable Care Act simply does not address this issue with any direct plan. The US is in a very influential time period in terms of undocumented immigration and its relationship with health care. The purpose of this paper is to examine international examples of undocumented immigrant health care and their implications for the United States' undocumented immigrant health care. This study found that physicians in the US must work to prevent the initiation of policies which exclude undocumented immigrants from accessing health care. Exclusionary policies implemented in European nations have had disastrous effects on physicians and patients. This paper examines the implications which similar policies would have if implemented in the US. [ABSTRACT FROM AUTHOR]

The energy system is facing changes across Europe, motivated by CO 2 emission reduction targets and driven by the expansion of renewable energy sources (RES). Germany is carrying out efforts to reshape its future energy system to be mainly based on RES. Nonetheless, flexible generation capacities like natural gas (NG) power plants will still be needed in the coming decades. Recent developments in the NG market have been characterised by uncertainties on the supply side as plans have been put forth for new pipelines to facilitate Russian or Caspian NG towards Europe as well as increasing volumes of liquefied natural gas entering the market. This paper aims to show the interdependence between infrastructure developments and primary NG demand in the German energy system. The authors analyse impacts for the German ‘Energiewende’ on a time horizon from 2010 to 2050. Coupling a European NG model with a German energy system model, we develop six scenarios regarding climate policy in Germany and European diversification strategies in infrastructure expansion. The results show, that NG prices influence sectoral changes especially in the residential sector. Further strategies to reduce CO 2 emissions in the entire energy system should also consider NG as part of the solution. [ABSTRACT FROM AUTHOR]

Renewable energy is a focal point of discussion in the European Union, as clean production technologies contribute to all three aims of energy policy (security, competitiveness, and sustainability). This paper focuses on an empirical assessment of feed-in tariff and quota obligation policies, as well as their policy design elements, applied to solar photovoltaic energy in the European Union over the period 2000–2014. The results indicate that only feed-in tariff policy has significant impacts in terms of installed photovoltaic capacity. However, its main policy design elements (tariff size and contract duration) have a positive but not significant influence on the development of this clean production technology. Policy-makers should consider the importance of reducing regulatory uncertainty about these parameters. [ABSTRACT FROM AUTHOR]

Abstract: A quarter of the European population lives in ‘polycentric urban regions’ (PURs): clusters of historically and administratively distinct but proximate and well‐connected cities of relatively similar size. This paper explores whether tighter integration can increase agglomeration benefits at the PUR‐level. We provide the first comprehensive list of European PURs (117 in total), establish their level of functional, institutional and cultural integration and measure whether this affects their performance. ‘Performance’ is defined as the extent to which urbanisation economies have developed, proxied by the presence of metropolitan functions. In this first‐ever cross‐sectional analysis of PURs we find that while there is evidence for all dimensions of integration having a positive effect, particularly functional integration has great significance. Regarding institutional integration, it appears that having some form of metropolitan co‐operation is more important than its exact shape. Theoretically, our results substantiate the assumption that networks may substitute for proximity. [ABSTRACT FROM AUTHOR]

Recent research has shown that divorce reduces the likelihood of home-ownership. Even in later life, ever-divorced men and women display lower home-ownership rates than their married counterparts. There is, however, a lack of knowledge about the consequences of divorce for a majority of divorcees: those who remain in home-ownership or move back into home-ownership after an episode in rental housing. This paper investigates the economic costs of divorce by focusing on the housing wealth of ever-divorced home-owners in later life (age 50 and over), against the background of changing welfare and housing regimes. The empirical analysis is based on data from ten European countries that participated in the third and fourth waves of the Survey of Health, Ageing and Retirement in Europe (SHARE 2007/8 and 2011/2). Our analyses support an association between divorce experience and lower housing wealth holdings for men and women who remain in home-ownership after a divorce, or re-enter home-ownership after a spell in rental housing. This means that a divorce has negative housing consequences for a broader range of individuals than thus far assumed. In countries with a dynamic housing market and a deregulated housing finance system, ever-divorced home-owners are worse off than their married counterparts. In these countries, more elderly individuals with a weaker financial situation are able to remain in or regain access to (mortgaged) home-ownership, but at the cost of lower housing equity. Further research should focus on the implications (e.g. for wellbeing, economic position) of such cross-country variations. [ABSTRACT FROM AUTHOR]

Population ageing, together with the negative effects of the recent economic and financial crisis that some European countries are still facing, have threatened the sustainability of public pension systems. In this context, voluntary private pensions have emerged as the most feasible alternative to supplement the minimum provided by Social Security Systems; however, this financial product does not enjoy its expected popularity. A potential explanation of this reality might be due to the fact that European countries are far from being homogeneous, nor their pensions systems. Therefore, any policy geared toward improving financial retirement planning should take into account these potential differences. As a first approach to their analysis, this paper proposes the existence of four different ‘social models’ in Europe -namely, Continental, Mediterranean, Nordic and Transitional-. Overall, empirical evidence confirmed the significant influence of country’ ‘social model’ on the decision to invest in retirement accounts on a sample of 31,468 individuals in 2013. It was also proved that this decision is positively related to age, household income and wealth, higher levels of formal education, job situation, good health status, and long-term planning horizons; and negatively related to age squared, household size or financial risk aversion. In short, future policies and reforms regarding private pensions should not only take into account the existence of individual differences among Europeans, but also the existence of differences depending on institutional and cultural country factors. [ABSTRACT FROM AUTHOR]

Some southern countries in Europe, together with Ireland, were particularly affected by the sovereign debt crises in the Eurozone and were obliged to implement tough corrective measures which proved to be very recessive in nature. As a result, not only GDP declined but unemployment jumped to very high levels as well. This paper uses a modified version of k -means (restricted k -means) to analyze the clustering of the Eurozone countries during the recent sovereign debt crisis, combining monthly data on unemployment and government bond yield rates. Our method shows that the separation of southern Europe from the other Eurozone is not necessarily a good characterization of this area before the crisis but the group of externally assisted countries plus Italy gains consistence as the crisis evolved, although there is no perfect homogeneity in this group, since the problems they faced, the type of response requested, the speed of reaction to the crisis and the lasting effects were not the same for all these countries. [ABSTRACT FROM AUTHOR]

In a context where the economic strains are challenging European policies as well as the very fabric of governmental contributions to public life, innovation and efficacy of public policy in research are called upon to support growth in Europe and to sustain employment and entrepreneurial capacities. Governments need evidence that the investments in space, while providing strategic tools to implement sovereign policies, create jobs and build the competitive European economy of the future. This is particularly true when the decisions at stake have a potential bearing on the future of the European space sector for at least the next 30 years, as it has been the case for the ESA Council at ministerial level meeting in December 2014. On that occasion, Ministers took the decision to start the development of a new Ariane 6 launcher and Vega evolutions having a critical bearing on the Member States’ strategic industrial capabilities and on the sustainability of the European guaranteed access to space. Given the importance of the subject, and following similar studies undertaken in the past for e.g. the Ariane 1–4 programme, the Agency has requested an independent consulting team to perform a dedicated study to assess ex-post the direct, indirect and induced socio-economic impacts of the Ariane 5 programme (mid-term evaluation) and of the Vega programme (early evaluation) globally, at European level, and within the economies and industries of each ESA Member State. This paper presents the assessment of the socio-economic impacts allowing the evaluation of the return on public investments in launchers through ESA in a wider perspective, going beyond the purely economic terms. The scope of the assessment covered in total approximately 25 ESA programmatic and activity lines and 30,000 commitments from 1986 to end 2012. In the framework of the study, the economic impact of the European launcher programmes is measured through a GDP impact defined as the straight economic activity deriving from the injection of Participating States funding channelled through ESA into the space upstream (manufacturing) industry, and through a cumulative assessment of the enabled revenues (catalytic impacts) arising from Ariane 5 and Vega operations. [ABSTRACT FROM AUTHOR]

Aims: Based on the ideal type classification of European countries done in Part I of this paper, Part II explores whether the real ‘danger’ to public health is the interplay between austerity and crisis, rather than recession itself. Methods: We constructed two fuzzy sets of changes in population health based on a pooled file of European Union Statistics on Income and Living Conditions (EU-SILC) data (2008 and 2013) including 29 European countries. The linear probability analyses of ‘limiting long-standing illness’ and ‘less than good’ health were restricted to the age group 20–64 years. We performed fuzzy set qualitative comparative analysis (fsQCA) and studied whether configurations of ‘severe crisis’ and ‘austerity’ were linked to changes in population health. Results: Overall, the results of this fsQCA do not support the ‘crisis–austerity’ thesis. Results on ‘less than good’ health were highly inconsistent, while results on ‘limiting long-standing illness’, contrary to the thesis, showed a two-path model. Countries with either no severe crisis or no austerity were subsets of the set of countries that experienced deteriorated health. Results also show that several countries combined both paths. Conclusions: This fuzzy set analysis does not support Stuckler and Basu’s ‘crisis–austerity’ thesis, as those European countries that experienced recession and austerity were not consistently the countries with deteriorating health. There may be multiple reasons for this result, including analytical approach and operationalization of key concepts, but also resilient forces such as family support. We suggest more research on the topic based on more recent data and possibly other, or more, dimensions of austerity. [ABSTRACT FROM AUTHOR]

Education reforms come in two general types: access and quality reforms. Access reforms provide more educational opportunities, while quality reforms improve educational effectiveness. This paper investigates empirically the factors affecting the enactment of these two kinds of reforms in public primary and secondary education. By using a novel dataset of U.S. state legislation from 2008 to 2013, we find that both access and quality reforms are more likely in times of bad educational outcomes. Moreover, this is the first study documenting that teachers' union strength correlates positively with access reforms and negatively with quality reforms. Our results also shed light on the way teachers' unions promote their political interests: both lobbying and contributions are effective at opposing undesired reforms, but contributions have an extra effect of influencing the enactment of desired reforms. [ABSTRACT FROM AUTHOR]

Non-R&D innovation activities account for a significant portion of innovation efforts carried out across very heterogeneous economies in Europe. However, to incorporate them into economic models is not always straightforward. Moreover, relying only on R&D data does not capture well innovation in the services sector. To counter these problems, this paper builds an augmented macro-theoretical growth model where, besides R&D, non-R&D innovation activities play a key role as main drivers of TFP. The model is estimated for a sample of EU-26 countries over the period 2004–2008, showing that the distinction between R&D and non-R&D innovation activities is significant for a number of different issues. First, we find both R&D and non-R&D to be statistically significant and economic important in technological catch-up. Second, there is a differential sizable impact of R&D and non-R&D; the impact of R&D on TFP growth is found to be twice as big as that of non-R&D. And third, the two types of innovation cannot strictly been seen as complementary, at least for the case of countries with high R&D intensities or high non-R&D intensities. [ABSTRACT FROM AUTHOR]

Background: Financial difficulties in childhood may be associated with immediate and long-term consequences for mental health. The aim of the current paper is to investigate the association between childhood financial difficulties and adult depression, and assess the relative contribution of financial difficulties in childhood to symptoms of adult depression across different age groups. Methods: Using three age cohorts (25-40, 41-59, 60-75) from 19 countries in the European Social Survey Round 7 (N=18 401), multi-level and country-wise OLS regression analyses were used to investigate the association between financial difficulties in childhood and adult depression, while adjusting for age, education, gender, highest education in family, level of family conflict, number of social meetings and marital status. Results: Financial difficulties in childhood was found to be influential predictors of depression scores for 25-40 year olds in 10 out of 19 countries in fully adjusted models. In older participants, depression scores were mostly influenced by frequency of social meetings and marital status. There was great variation in the pattern of influential risk factors across countries, and the predicted effect childhood financial difficulties had on adult depression scores. Conclusion: Childhood financial difficulties as predictors of depression appear to, by themselves, exert the strongest influence in younger adults. There was, however, large variation between countries in the magnitude of associated risk, and in the pattern of risk factors contributing to adult depression, which underscores the need to account for country-level factors when aiming to gain knowledge about mental health. [ABSTRACT FROM AUTHOR]

There are widespread perceptions and countless documented cases of tight-knit networks of politicians and businessmen colluding in the allocation of public procurement contracts in return for political party donations. In the absence of systematic evidence, neither the magnitude of the problem nor the effectiveness of policies curbing such corruption is well-understood. In order to advance our understanding of these phenomena, this paper tests whether political financing regulations can contribute to controlling corruption in public procurement. We utilize aggregated official micro-level data on almost 3 million contracts awarded across twenty-nine European countries from 2009 to 2014 to measure the risk of high-level institutionalized corruption using novel proxy indicators. Legislation regulating political finances is directly measured by coding national laws from 2009 to 2014. In cross-country panel regression and difference-in-difference models, we find that introducing additional political financing restrictions does not have a measurable negative impact on public procurement corruption risks. In fact, the observed effect is positive in most models. The observed relationship remains the same for most constitutive components of political financing regulations. Several challenges remain for a conclusive judgement on political party financing regulations' effectiveness in curbing corruption, such as measuring implementation rather than legislation, allowing for a longer lead-time for regulatory impact, or considering institutional inter-dependencies. [ABSTRACT FROM AUTHOR]

Sustainable development has become one of the burning issues on a global, local and individual levels as a result of climate changes, pollution, rapid development and changes in the global information, economic, industrial and business sectors and value systems. In this sense, education for sustainable development, as part of lifelong learning, has become one of the most important strategic and educational policy issues in Serbia. The aim of this paper is to highlight the potential of geography as a school subject, with special reference to the role of the subject matter of geoheritage and geodiversity in education for sustainable development. The aim of pointing the benefits of integrated and out-of-classroom approaches in teaching geography, which favour an active, experiential and exploratory approach to learning about geodiversity and geoheritage, is that students can acquire competencies in sustainable development. As outcomes of geography classes, competencies also represent a basis for raising awareness and increasing accountability and responsibility in individuals for preserving geoheritage and geodiversity as part of the Serbian national treasure. [ABSTRACT FROM AUTHOR]

Creative industries are increasingly understood to contribute to localised innovation and dynamism. This paper provides a methodologically consistent comparison of creative industries across France, Great Britain, Italy and Spain. We map spatial agglomerations of creative activities showing evidence of urban concentration, which for Britain and France coincides with the dominance of capital cities, whilst for Spain and Italy, significant concentrations can also be found in secondary cities. The four countries also differ in the specialisation profiles and in the role played by policy makers. A lack of dove-tailing with the European Union smart agenda is argued to be a cause of concern. [ABSTRACT FROM AUTHOR]

Background: Research has shown that individual socio-economic circumstances throughout life affect health in older ages. However, little attention has been paid to the broad economic context affecting individual's life-chances. This paper examines whether economic downturns experienced during young and mid-adulthood have long-run effects on physical health. Methods: We exploit data on economic fluctuations in the period 1945-2010 in 11 European countries, linked to longitudinal data from three waves of the Survey of Health, Ageing and Retirement in Europe. We estimate a country fixed effect model assessing whether downturns experienced at 5-year intervals between ages 25 and 54 are associated with levels and onset of new limitations with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) in older age (55-80). Results: Experiencing an economic downturn at ages 45-59 is associated with increased risk of having at least one disability limitation in later-life (odds ratio [OR] for ADL = 1.66, 95% CI [Confidence Interval] 1.24, 2.22; OR for IADL = 1.46, 95% CI 1.10, 1.94). Economic downturns at ages 40-44 and 45-49 also increase the risk of a new functional limitation in later-life (OR for IADL ages 40-44 = 1.20, 95% CI 1.03, 1.40; OR for IADL ages 45-49 = 1.44, CI 1.10-1.88). Economic downturns experienced around these ages are also associated with significantly greater risks of smoking and excessive alcohol consumption as well as lower incomes in older age. Conclusions: Exposure to an economic downturn at ages 40-49 is associated with poorer health in older ages, possibly by increasing risk of unhealthy behaviours and low incomes persisting into older age. [ABSTRACT FROM AUTHOR]

Primary Health Care (PHC) in Greece lags behind over time in adopting the principle of Alma Ata. From the description of Introduction of PHC of Germany, Great Britain, Sweden and Nederland, we conclude several similarities and significant differences in the organization, providing, financing and compensation of medical staff depending on special feature of each health care system. On the other hand, PHC in Greece shows significant weaknesses -- fragmentation and lack of strategic planning, understaffing and underfunding, not highly qualified and goal-oriented staff in PHC, inequalities, discontinuity in care, low efficiency, absence of planning- which make it difficult and fragmented the operation of new outpatient clinics. The reforms of the health sector from 2009 until today, mainly with the law 3918/2011 and 4338/2014 for the establishment of E.O.P.Y.Y and P.E.D.Y, have focused on horizontal cuts and sharing the cost to the citizens. For the requirements of the review, research and review papers were searched within the PubMed, Scopus and Google Scholar database, while data were drawn upon O.E.C.D (Organization for Economic CO-operation and Development), ELSTAT (Hellenic Statistical Authority) and WHO (World Health Organization) about PHC in those countries from 2008 up to March 2016. [ABSTRACT FROM AUTHOR]

In this paper we address the academic discourse on food insecurity and food security in Europe as expressed in articles published in scientific journals in the period 1975 to 2013. The analysis indicates that little knowledge has been produced on this subject, and that the limited research that has been produced tends to focus on the production of food rather than on people's access to food. The lack of knowledge about European food insecurity is particularly alarming in these times, which are characterised by increasing social inequalities and poverty, as well as shifting policy regimes. More empirical, comparative and longitudinal research is needed to survey the extent of food security problems across European countries over time. There is also a need to identify groups at risk of food insecurity as well as legal, economic, practical, social, and psychological constraints hindering access to appropriate and sufficient food. [ABSTRACT FROM AUTHOR]

Background: The association between income inequality and societal performance has been intensely debated in recent decades. This paper reports how unmet need for medical care has changed in Europe during The Great Recession, and investigates whether countries with smaller income differences have been more successful than inegalitarian countries in protecting access to medical care during an economic crisis. Methods: Six waves of EU-SILC surveys (2008-2013) from 30 European countries were analyzed. Foregone medical care, defined as self-reported unmet need for medical care due to costs, waiting lists, or travel difficulties, was examined among respondents aged 30-59 years (N= 1.24 million). Countries' macro-economic situation was measured by Real Gross Domestic Product (GDP) per capita. The S80/S20 ratio indicated the country's level of income inequality. Equity issues were highlighted by separate analyses of disadvantaged respondents with limited economic resources and relatively poor health. Cross-tabulations and multilevel linear probability regression models were utilized. Results: Foregone medical care increased 2008-2013 in the majority of the 30 countries, especially among the disadvantaged parts of the population. For the disadvantaged, unmet need for medical care tended to be higher in countries with larger income inequalities, regardless of the average economic standard in terms of GDP per capita. Both for disadvantaged and for other parts of the samples, a decline in GDP had more severe effects on access in inegalitarian countries than in countries with less income inequality. Conclusions: During The Great Recession, unmet need for medical care increased in Europe, and social inequalities in foregone medical care widened. Overall, countries with a more egalitarian income distribution have been more able to protect their populations, and especially disadvantaged groups, against deteriorated access to medical care when the country is confronted with an economic crisis. [ABSTRACT FROM AUTHOR]

Article Processing Charges (APCs) have recently been studied as a means towards a sustainable Open Access (OA) environment for scholarly communications. However, APCs at any level represent a substantial economic barrier to the authors, institutions, funding agencies and governments that many of its advocates most wish to serve through OA initiatives. This paper claims that no business model based on APCs as a tool to facilitate the large-scale transition to OA can navigate the ethical dilemmas identified by political philosophers as appropriate for the kind of global environment in which scholarly publishing operates. [ABSTRACT FROM AUTHOR]

This paper develops an analytical approach to comparative political economy that focuses on the relative importance of different components of aggregate demand—in the first instance, exports and household consumption—and dynamic relations among the “demand drivers” of growth. We illustrate this approach by comparing patterns of economic growth in Germany, Italy, Sweden, and the United Kingdom over the period 1994–2007. Our discussion emphasizes that export-led growth and consumption-led growth have different implications for distributive conflict. [ABSTRACT FROM AUTHOR]

Objectives Given the impact of the global economic crisis, delivering better health care with limited finance grows more challenging. Through the lens of institutional theory, this paper explores pressures experienced by hospital leaders to improve quality and constrain spending, focusing on how they respond to these often competing demands. Methods An in-depth, multilevel analysis of health care quality policies and practices in five European countries including longitudinal case studies in a purposive sample of ten hospitals. Results How hospitals responded to the financial and quality challenges was dependent upon three factors: the coherence of demands from external institutions; managerial competence to align external demands with an overall quality improvement strategy, and managerial stability. Hospital leaders used diverse strategies and practices to manage conflicting external pressures. Conclusions The development of hospital leaders’ skills in translating external requirements into implementation plans with internal support is a complex, but crucial, task, if quality is to remain a priority during times of austerity. Increasing quality improvement skills within a hospital, developing a culture where quality improvement becomes embedded and linking cost reduction measures to improving care are all required. [ABSTRACT FROM AUTHOR]