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While we have the tools to achieve this goal, the persistent barriers to healthcare services experienced by too many individuals will need to be addressed to make significant progress and improve the health and quality of life of all people with human immunodeficiency virus (HIV). The necessary structural changes require actions by federal, state, and local policymakers and range from ensuring universal access to healthcare services to optimizing care delivery to ensuring a robust and diverse infectious diseases and HIV workforce. In this article, we outlines 10 key principles for policy reforms that, if advanced, would make ending the HIV epidemic in the United States possible and could have much more far-reaching effects in improving the health of our nation. [ABSTRACT FROM AUTHOR]

Globally, the nursing profession constitutes the largest proportion of the health workforce; however, it is challenged by widespread workforce shortages relative to need. Strategies to promote recruitment of the nursing workforce are well-established, with a lesser focus on strategies to alleviate the burden on the existing workforce. This burden may be exacerbated by the impact of low-value health care, characterised as health care that provides little or no benefit for patients, or has the potential to cause harm. Low-value health care is a global problem, a major contributor to the waste of healthcare resources, and a key focus of health system reform. Evidence of variation in low-value health care has been identified across countries and system levels. Research on low-value health care has largely focused on the medical profession, with a paucity of research examining either low-value health care or the de-implementation of low-value health care from a nursing perspective. The objective of this paper is to provide a scholarly discussion of the literature around low-value health care and de-implementation, with the purpose of identifying implications for nursing research. With increasing pressures on the global nursing workforce, research identifying low-value health care and developing approaches to de-implement this care, is crucial. [ABSTRACT FROM AUTHOR]

An editorial is presented the importance of health as a central policy issue in the 2024 US election and the need for rigorous research to inform health care and public health policies. Topics include various health-related challenges, such as health disparities, immigration policies, LGBTQ rights, firearm regulations, and the impact of the economy on mental health and access to essential needs.

The process of deinstitutionalisation gained momentum in the late 20th century, driven by disability rights movements and increased awareness of the harms of institutionalisation. This paper provides an overview of deinstitutionalisation in South Korea, focusing on the transformation of large disability residential facilities since the 1970s, with efforts towards promoting independent living. Current debates highlight conflicting perspectives among stakeholders. Advocates, primarily disabled individuals, support accelerated deinstitutionalisation for its benefits in autonomy, social integration, and improved quality of life. However, oppositions from families and service providers express concerns about care gaps and the need for specialized support for people with higher support needs. The paper underscores the importance of establishing a consensus on deinstitutionalisation objectives and proposes multidimensional alternatives, including legislative reforms, expanded community services, and improved facilities. Fostering social agreement is identified as pivotal for successful deinstitutionalisation and the well-being of disabled individuals. [ABSTRACT FROM AUTHOR]

Introduction: The requirement for medical services fluctuates. This study was carried out in order to attempt to extrapolate the service requirements for various cardiology services at Mater Dei Hospital, Malta over the coming five years, based on service demands from previous years.Methods: Past annual data was obtained from hospital records for various services (to 2017). Linear regression was carried out using a bespoke Excel™ spreadsheet in order to extrapolate possible services requirements up to 2022.Results: All services are expected to increase, with forecasts ranging between 41 and 354%, depending on services being considered.Discussion: It is easy to "get on with it" and perform the work required at the workplace but this study has shown that it is equally important to anticipate demands lest lack of planning leads to long and important waiting lists for critical diagnostics and treatments. Health care provision requirements are increasing worldwide. Even using conservative estimates and in the absence of the creation of new services, the demands for extant services are likely to continue to grow. Unless medium term plans are made for hardware, software, physical space and staffing, and the funding thereof, waiting lists for investigations in this speciality are bound to rise. This may be mitigated by novel treatments but since these cannot be predicted, it would be safer and wiser to plan ahead lest we are overwhelmed. This paper has also shown how WASP (Write a Scientific Paper) precepts can be applied to elegantly study a problem and write up a paper. [ABSTRACT FROM AUTHOR]

Introduction: Allied health has a valuable role in providing services to people living in residential aged care. The recent Royal Commission into Aged Care Quality and Safety included several important recommendations relating to the nursing, personal care, and allied health workforce and the care that they provide. The purpose of this paper is to review these recommendations and the Australian Government's policy responses and explore the emerging changes in allied health service provision in residential aged care. Methods: Data from the four available Quarterly Financial Reports from the 2022–2023 financial year were extracted and analysed in relation to staff costs and time per person per day across personal care, nursing, and allied health workers. Supplementary data sources including the 2020 Aged Care Workforce Census were accessed to provide contextual data relating to individual allied health professions, including occupational therapy. Results: The analysis shows a modest increase in median registered nurse minutes per person per day, and cost per person per day, from the first to second quarter, and again in the third and fourth. By contrast, median time and cost for allied health declined. From 5.6 minutes per person per day in the first quarter, reported allied health minutes fell to 4.6 minutes per person per day in the second quarter, an 18% decrease, and by the fourth quarter was 4.3 minutes per person per day. This is just over half the Australian average of 8 minutes reported to the RCACQS in 2019. Conclusion: Under recent residential aged care reforms, aged care providers have regulatory incentives to concentrate their financial resources on meeting the mandated care hours for registered nurses, enrolled nurses, personal care workers, and assistants in nursing. These same reforms do not mandate minutes of allied health services. Although providers of residential aged care in Australia continue to employ and value allied health, we argue that mandating care minutes for personal and nursing care without mandating the provision of allied health creates a perverse incentive whereby access to allied health services is unintentionally reduced. PLAIN LANGUAGE SUMMARY: Allied health has a valuable role in providing services to people living in residential aged care. The recent Royal Commission into Aged Care Quality and Safety included several important recommendations relating to the nursing, personal care, and allied health workforce and the care that they provide. In this paper, we argue that despite the positive intentions of some of the reforms following the Royal Commission, there have been unintended consequences that have reduced the spending on allied health in residential aged care and reduced the minutes residents receive of allied health. Consideration to mandating allied health care minutes in residential aged care should be considered. [ABSTRACT FROM AUTHOR]

What is known about the topic? Little is known about the state of mental health reform in Australia. This article describes the struggle to develop the systems of accountability necessary to assess national progress. What does this paper add? We provide some historical context regarding mental health reform and consider recent efforts in particular, before then describing current key opportunities. What are the implications for practitioners? Many people working in mental health are struggling to deliver quality services to Australians. This paper considers the broad policy issues which have led to this situation. This is useful for practitioners who can then better respond and participate in processes of systemic reform. Opportunities to engage now in key policy formulation are identified in the article. [ABSTRACT FROM AUTHOR]

Path-dependency theory says that complex systems, such as health systems, are shaped by prior conditions and decisions, and are resistant to change. As a result, major policy changes, such as health system reform, are often only possible in policy windows—moments of transition or contextual crisis that re-balance social power dynamics and enable the consideration of new policy ideas. However, even in policy windows there can be resistance to change. In this paper, we consider the role of ideas in constraining change. We draw on political science theory on the dynamic relationship between foreground ideas (policy programmes and frames) and background ideas (deeply held collective cognitive and normative beliefs) to better understand how ideas exert influence independently of the contextual conditions that give rise to them or the actors that espouse them. To do so, we examine two apparent policy windows in the South African National Health Insurance policy process. The analysis reveals how ideas can become institutionalised in organisations and procedures (such as policy instruments or provider networks), and in intangible cultural norms—becoming hegemonic and uncontested ideas that shape the attitudes and perspectives of policy actors. In this way, ideas operate as independent variables, constraining change across policy windows. While health policy analysts increasingly recognise the influence of ideational variables in policy processes, they tend to conceptualise ideas as tools actors wield to drive change. This analysis reveals the importance of considering ideas (values, norms, and beliefs) as persistent features of the policy-making context that constrain actors. [ABSTRACT FROM AUTHOR]

Background: Kerala has initiated many Universal Health Coverage (UHC) reforms in the last decade. The Aardram Mission launched in 2017 stands out owing to its scope, objectives, and commitments for strengthening Primary Health Care (PHC) in the State. The current study proposes to explore access and financial protection through the lens of equity in Kerala especially in the context of major UHC reforms carried out during the last decade. This paper will also highlight the key lessons from Kerala's approach towards UHC and health systems strengthening through a political economy approach. Methods: Data from the Kerala state sample of 75th Round (2017-18) National Sample Survey is used for this study. Comparison is also drawn from the 71st Round Sample Survey, 2014, to measure the state's progress in terms of access and financial protection. Logistic regression was used for the calculation. The findings were further explored through a political economy approach. Results: The share of public facilities for outpatient care is 47.5%, which is a significant increase from 34.0% (in 2014) in the state. The share of public sector for out-patient care has increased for the lower socio-economic population in the state. The share of public sector for in-patient care has also increased to 37.3% in 2017-18 from 33.9% in 2014, but not to the extent as the increase shown in outpatient care. The average out-of-pocket-expenditure during hospitalization has increased more in private facilities as compared to public for both outpatient care and hospitalization. Conclusions: Overall increase in the share of public facilities for both outpatient care and hospitalization is indicative of the enhanced trust among the people at large of the public healthcare delivery system in Kerala, post the launch of UHC reforms in the State. The insurance linked UHC reforms would be insufficient for the State to progress further towards UHC. Kerala with a long and successful history in 'public provisioning' should focus more on strengthening PHC through Aardram Mission in its journey towards pursuit of UHC. [ABSTRACT FROM AUTHOR]

Background: Hospitalisation resulting from complications of systemic therapy and radiotherapy places a substantial burden on the patient, society, and healthcare system. To formulate preventive strategies and enhance patient care, it is crucial to understand the connection between complications and the need for subsequent hospitalisation. This review aimed to assess the existing literature on complications related to systemic and radiotherapy treatments for cancer, and their impact on hospitalisation rates. Methods: Data was obtained via electronic searches of the PubMed, Scopus, Embase and Google Scholar online databases to select relevant peer-reviewed papers for studies published between January 1, 2000, and August 30, 2023. We searched for a combination of keywords in electronic databases and used a standard form to extract data from each article. The initial specific interest was to categorise the articles based on the aspects explored, especially complications due to systemic and radiotherapy and their impact on hospitalisation. The second interest was to examine the methodological quality of studies to accommodate the inherent heterogeneity. The study protocol was registered with PROSPERO (CRD42023462532). Findings: Of 3289 potential articles 25 were selected for inclusion with ~ 34 million patients. Among the selected articles 21 were cohort studies, three were randomised control trials (RCTs) and one study was cross-sectional design. Out of the 25 studies, 6 studies reported ≥ 10 complications, while 7 studies reported complications ranging from 6 to 10. Three studies reported on a single complication, 5 studies reported at least two complications but fewer than six, and 3 studies reported higher numbers of complications (≥ 15) compared with other selected studies. Among the reported complications, neutropenia, cardiac complications, vomiting, fever, and kidney/renal injury were the top-most. The severity of post-therapy complications varied depending on the type of therapy. Studies indicated that patients treated with combination therapy had a higher number of post-therapy complications across the selected studies. Twenty studies (80%) reported the overall rate of hospitalisation among patients. Seven studies revealed a hospitalisation rate of over 50% among cancer patients who had at least one complication. Furthermore, two studies reported a high hospitalisation rate (> 90%) attributed to therapy-repeated complications. Conclusion: The burden of post-therapy complications is emerging across treatment modalities. Combination therapy is particularly associated with a higher number of post-therapy complications. Ongoing research and treatment strategies are imperative for mitigating the complications of cancer therapies and treatment procedures. Concurrently, healthcare reforms and enhancement are essential to address the elevated hospitalisation rates resulting from treatment-related complications in cancer patients. [ABSTRACT FROM AUTHOR]

Purpose: The author, who is Chair of Norfolk's Safeguarding Adults' Board (SAB) reflects on the impact of a Safeguarding Adults Review (SAR) and the actions that resulted. The purpose of the paper is to provide an insight into a significant SAR and the resulting actions desinged to change practice. Design/methodology/approach: The actions illuminate the power of hospitals and politicians over people's lives. It took the deaths of three young adults with learning disabilities, in a hospital, to move beyond the status quo and organise some very different service responses. Findings: "Progress summits" have considered local and national actions. There have been important gains and setbacks, including the delayed reform of the Mental Health Act. Despite uncertainties, SAB can be detonators to listening and taking action. Originality/value: This is a unique insight into the impact of a Safeguarding Adults Review and the actions that resulted from this. [ABSTRACT FROM AUTHOR]

Aim A discussion on how informatics knowledge and competencies can enable nursing to instantiate transition to integrated models of care. Background Costs of traditional models of care are no longer sustainable consequent to the spiralling incidence and costs of chronic illness. The international community looks towards technology-enabled solutions to support a shift towards integrated patient-centred models of care. Design Discussion paper. Data sources A search of the literature was performed dating from 2000-2015 and a purposeful data sample based on relevance to building the discussion was included. Discussion The holistic perspective of nursing knowledge can support and advance integrated healthcare models. Informatics skills are key for the profession to play a leadership role in design, implementation and operation of next generation health care. However, evidence suggests that nursing engagement with informatics strategic development for healthcare provision is currently variable. Implications for nursing A statistically significant need exists to progress health care towards integrated models of care. Strategic and tactical plans that are robustly pragmatic with nursing insights and expertise are an essential component to achieve effective healthcare provision. To avoid exclusion in the discourse dominated by management and technology experts, nursing leaders must develop and actively promote the advancement of nursing informatics skills. For knowledge in nursing practice to flourish in contemporary health care, nurse leaders will need to incorporate informatics for optimal translation and interpretation. Conclusion Defined nursing leadership roles informed by informatics are essential to generate concrete solutions sustaining nursing practice in integrated care models. [ABSTRACT FROM AUTHOR]

This paper studies the creation of organisations via people processing (Prottas 1979), taking as its case study a new and developing family centre that aims to offer various social and health services under the same roof. The study draws on ethnomethodology, meaning that organisations are herein understood as being created and continuously produced in and through interaction. The data consist of 11 audio-recorded meetings from the centre's steering group, which includes managers from different service fields and welfare agencies. In analysing the creation of the centre through people processing, this paper scrutinises how the meeting participants orient themselves toward and produce the centre's client categories, what characteristics they connect to these categories, and how they do boundary work regarding which categories belong or not to the centre's target groups. The meeting participants produce three different family based client categories. The first category is ordinary families, those without any special problems who just pop into the centre to see other people. These families are distinguished from the second category, best matching families, who are defined as having problems that would benefit from the integrated, multi-professional work conducted at the centre. The third category, families with too specific needs, refers to client groups whose service needs are at least partly beyond the centre's expertise and resources. The centre needs these people-processing activities to make sense of its mission, clients and co-partners; this ongoing reasoning process allows the emerging centre to exist and find its place in the local service system. [ABSTRACT FROM AUTHOR]

Self-determination informed policies are key to improved outcomes for Aboriginal health. Aboriginal leadership must be reflected throughout any public health reform process that affects Aboriginal communities. This paper presents a body of oral health policy work, undertaken under Loddon Mallee Aboriginal Reference Group's (LMARG's) leadership, as an exemplar of a self-determination informed change, that led to an amendment of an Australian state (Victoria) regulation – The Drugs, Poisons and Controlled Substances Amendment (Registered Aboriginal and Torres Strait Islander Health Practitioners [AHPs]) Regulations 2022. A summary of activities undertaken by LMARG, from advocacy to leading the submission, to amend the regulation, is provided. The amendment, now in place, authorises registered AHPs to obtain, possess, and administer fluoride varnish (FV) as a part of health services they provide. FV is a concentrated form of fluoride applied to tooth surfaces to prevent tooth decay. The practical implication of this amendment is delivery of a culturally appropriate integrated oral health promotion FV model that addresses mainstream dental access barriers commonly experienced by Aboriginal people. The model aims at upskilling an Aboriginal workforce to facilitate timely FV application to Aboriginal children. Self-determination informed policies are key to improved outcomes for Aboriginal health. The paper presents work on an oral health policy, undertaken under Loddon Mallee Aboriginal Reference Group's leadership on an Australian state (Victoria) regulation – The Drugs, Poisons and Controlled Substances Amendment (Registered Aboriginal and Torres Strait Islander Health Practitioners) Regulations 2022, as an exemplar of a self-determination informed change. The amendment translates to a culturally appropriate integrated oral health promotion model that addresses dental access barriers experienced by Aboriginal people. This article belongs to the Collection Access to Primary Health Care. [ABSTRACT FROM AUTHOR]

The paper focused on the assessment of secondary healthcare administration in Lagos with respect to examined the administrative structure put in place in secondary healthcare facilities and evaluated the effects of administrative structure on secondary healthcare service in Lagos as well as analysed the challenges confronting the administration of secondary healthcare service in Lagos. The paper employed descriptive research design and quantitative research approach. The data were gathered through administration of structured questionnaire. The paper used 20% of the study population 1341, making 268 sample size for questionnaire which consisted of both medical and non-medical staff of three selected General Hospital in Lagos i.e. one from each senatorial district in Lagos State. Data collected were analysed using frequency distribution, percentages, tables, and t-test. The study revealed that sustainability of administrative structure put in place in Lagos State to manage the secondary healthcare service are impactful and has significant effects on the services rendered. Therefore, the paper recommended that hospital administration should provide up to date medical technology and infrastructure need to easy the work of health workers and promote service delivery and that government should be an increase in the financial commitment and budget allocation of the government to the health care sector to address the existing financial challenges. The paper concluded that sustainability of administrative structure has direct effect on secondary healthcare on service delivery in Lagos, Nigeria. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to apply critical legal analysis to laws, policies and reforms focused on special educational needs (SEN) and equality in England and to suggest a Neurodiversity spectrum statement. Design/methodology/approach – The paper reviews current legal and policy initiatives in SEN, together with recent reforms in equality law. Findings – While past and current policies may have laudable aims, tensions such as a lack of integration of education, health and social services have had prejudicial outcomes for children with SEN, their families/carers, and the professionals involved. Originality/value – Legal reforms promise to remedy some problems, but must be underpinned by adequate resourcing, appeal procedures, and remedies which foster the enforcement of legal duties. Some resources for families with children with SEN are noted. [ABSTRACT FROM AUTHOR]

What is known about the topic ? Governments acknowledge that current health arrangements are unsustainable, and a better resourced, integrated, and connected primary care system is central to the future. What does this paper add ? This paper calls out the most significant barriers to implementing the required national reform and poses potential solutions in addressing them. What are the implications for practitioners ? Without action, we will see increased system cost, and decreased service access and quality for Australian communities. [ABSTRACT FROM AUTHOR]

This article uses the problems associated with citizenship verification in U.S. government health insurance programs to argue that paper needs to be analyzed as a media technology. To examine paper as a media technology is to ask, “How does paper work?” and “What are the rules and habits that enable paper to be used in paperwork?” To consider paper as a media technology, this article makes 2 arguments. First, it argues that there is a set of skills and knowledge associated with paper documents that need to be recognized as a distinct form of literacy. Second, this article argues that the relation between paper and identity is an argument about the materiality of information. In focusing on how paper facilitates the materialization of information, this case study illustrates how distinct practices of use create specific relationships between technology and information that give information a distinct functional presence. [ABSTRACT FROM PUBLISHER]

Aging is a challenging process for people with gender nonconformity. Indeed, the older transgender population faces several disparities in accessing and using health care and social support services. Furthermore, the clinical management of gender transition in later life is empirical since clear research evidence is lacking. This paper aimed to present the problems encountered by older transgender adults in their access to social support and health care and to propose insightful solutions to address them both from a social and medical/nursing perspective. Trans elders face profound disparities in health and social care due to factors associated with limited accessibility to health services, social restrictions, administrative failures, and physical vulnerabilities. The medical treatment of older transgender adults also needs a careful approach to achieve satisfying gender affirmation without clinically significant risks. The potential induction of hormone-sensitive malignancies and the provocation of major adverse vascular events are the main concerns. Gender transition in older adults without a prior history of following gender-affirming therapy is challenging due to biological factors related to advanced age. Caring for elderly trans people unfolds at multiple levels. International organizations and governmental bodies should address the underprivileged status of elderly transgender people by creating and implementing inclusive policies. Safe and respectful clinical and residential environments and the formation of clearer medical guidelines could meet the unique needs of older trans adults. Care providers must advocate for their patients and be equipped to provide safe and effective services. [ABSTRACT FROM AUTHOR]

Several shifts in physiotherapy treatment of patients with rheumatoid arthritis (RA) have occurred over time. This paper aims to identify shifts in physiotherapy practice for patients with RA based on the author's work experiences from the 1980s until today at two Norwegian rheumatism hospitals, and to explore why shifts may have happened. A narrative was developed by describing events making a difference, categorizing, and ordering them with the help of narrative analysis and a sensitizing analytic lens on discourses. The storyline from the 1980s to approximately the turn of the millennium is called 'Shifts determined mainly by clinical context-driven events' which occurred in response to medical advances and physiotherapists' clinical experiences. These shifts were later justified by physiotherapists' research in the clinical context. The other storyline covers mainly the 2000s and is called 'Shifts increasingly determined by events beyond clinical physiotherapy context.' They include adjustments to further medical advances and implementation of biopsychosocial understanding of disease at the hospital, and to external research-based recommendations, health reforms, and economy. These processes have moved physiotherapy practice at the hospital from mainly providing individualized remedial and rehabilitative physiotherapy for the purpose to normalize physical function to an increasing focus on generic health measures for the purposes of health promotion and cardiovascular disease prevention. However, this shift may not fully match the complex needs presented by patients in disease remission with unrelenting fatigue and work inability and those who have multiple functional challenges and comorbidities. [ABSTRACT FROM AUTHOR]

In 2023, the UK Government published its long-awaited reform strategy for England's children's social care system. Whilst the strategy set out planned reforms for several aspects of the wider system, an area requiring particular 'priority' was the purported workforce instability seen within child protection social work. However, the strategy has subsequently faced criticism on the basis that the suggested reforms were not satisfactorily informed by the testimonies of practicing social workers. This paper draws from a mixed-method study to report on the lived experiences of a sample of 201 child protection social workers practicing across England, in the context of better understanding the factors which they believed were impacting on workforce stability within England's child protection system. Implications that emerge are the need for an increase in the monetary commitment offered by the UK Government (especially in the context of tackling high caseloads, and improving local authority pay scales to reduce the allure of agency work); a targeted emphasis on challenging local cultures preoccupied with evidencing compliance over time spent with children; and the Government taking a more assertive role in tackling the often-counterproductive commentary perpetuated by politicians and media. [ABSTRACT FROM AUTHOR]

Background: Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies – Pakistan, Brazil and Portugal. Main body: This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes. Conclusion: Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning. [ABSTRACT FROM AUTHOR]

The purpose of this case study is to explain the development of Queensland's strategic approach to health system reform, which promotes partnership across the health system to better deliver integrated and value-based health care across the continuum of care. The new health system vision was informed by undertaking literature searches on national and international health system approaches to reform and supported by extensive consultation across Queensland with more than 1100 stakeholders. Thematic analysis was undertaken to identify key themes that were translated into a high-level vision document that communicated Queensland's renewed focus on wellness and delivering more care in the community. This was circulated to stakeholders for iterative and collaborative refinement before final approvals. Collaboratively and iteratively developing the new health system vision for Queensland with key stakeholders has contributed to a shared understanding and ownership of a vision that is committed to system reform, focused on delivering high-value care that reflects what is important to consumers and health system stakeholders. What is known about the topic? Vision statements for organisations including health are common. However, there is little information available in the literature regarding approaches to developing a vision for a health system. What does this paper add? An overview of an approach to developing a new health system vision through comprehensive consultation that engages stakeholders broadly to develop an informed vision that has support from all levels of the health system. What are the implications for practitioners? The method used to develop this vision could be replicated across any large-scale organisation. Although time consuming, the outcome is a vision that is widely supported and sets the organisation up for success for implementation. This article belongs to the Special Issue: Value-based Healthcare. [ABSTRACT FROM AUTHOR]

People with innate variations of sex characteristics (also known as intersex traits or disorders or differences of sex development) have any of a wide range of innate physical traits that differ from medical and social norms for female and male bodies. Responses to these physical differences create experiences and risks of stigmatisation, discrimination, violence, and harmful medical practices intended to promote social and familial integration and conformity with gender stereotypes. As is evident globally, the Australian policy response to the existence and needs of people with innate variations of sex characteristics has been largely incoherent, variously framing the population as having disordered sex development in need of "fixing", and a third sex/gender identity group in need of recognition, with only recent engagement by intersex community-controlled civil society organisations. This paper presents an overview of the context and goals of the intersex human rights movement in Australia. Australian intersex community organisations have sought to apply human rights norms and develop new infrastructure to address key health and human rights issues, and necessitating new ways of resolving policy incoherence. Together with human rights, mental health, and public health institutions, they have called for significant changes to medical models of care and reform to research and classification systems. Intersex community organising and resourcing have made a tangible difference. The Australian Capital Territory is the first jurisdiction in the country to move ahead with reforms to clinical practice, including a legislative prohibition of certain practices without personal informed consent, oversight of clinical decision-making, and investment in psychosocial support. A national community-controlled psychosocial support service has also commenced. [ABSTRACT FROM AUTHOR]

Background: With the increasing number of people affected by multiple chronic conditions, it is essential for public-health professionals to promote strategies addressing patient needs for coordinated care. We aim to explore preference heterogeneity for better-coordinated care delivery models in Swiss older adults, and identify profiles of individuals more open to healthcare reforms. Methods: A DCE (discrete choice experiment) survey was developed online and on paper for the Swiss adults aged 50þ, following best practice. To elicit preferences, we estimated a latent class model allowing grouping individuals with similar preferences into distinct classes, and examined what background characteristics contributed to specific class membership. Results: The optimal model identified three classes with different openness to reforms. Class 1 (49%) members were concerned with premium increases and were in favour of integrated care structures with care managed by interprofessional teams. Individuals in class 2 (19%) were younger, open to reforms, and expressed the needs for radical changes within the Swiss healthcare system. Class 3 respondents (32%) were strongly reluctant to changes. Conclusions: Our study goes beyond average preferences and identifies three distinct population profiles, a majority open to reforms on specific aspects of care delivery, a smallest group in favour radical changes, and a third strongly against changes. Therefore, tailored approaches around healthcare reforms are needed, e.g. explaining the role of interprofessional teams in coordinating care, electronic health records and insurance premium variation. [ABSTRACT FROM AUTHOR]

Objective: The aim was to identify healthcare payment and financing reforms to promote health equity and ways that the Agency for Healthcare Research and Quality (AHRQ) may promote those reforms. Data Sources and Study Setting: AHRQ convened a payment and financing workgroup–the authors of this paper–as part of its Health Equity Summit held in July 2022. This workgroup drew from its collective experience with healthcare payment and financing reform, as well as feedback from participants in a session at the Health Equity Summit, to identify the evidence base and promising paths for reforms to promote health equity. Study Design: The payment and financing workgroup developed an outline of reforms to promote health equity, presented the outline to participants in the payment and financing session of the July 2022 AHRQ Health Equity Summit, and integrated feedback from the participants. Data Collection/Extraction Methods: This paper did not require novel data collection; the authors collected the data from the existing evidence base. Principal Findings: The paper outlines root causes of health inequity and corresponding potential reforms in five domains: (1) the differential distribution of resources between healthcare providers serving different communities, (2) scarcity of financing for populations most in need, (3) lack of integration/accountability, (4) patient cost barriers to care, and (5) bias in provider behavior and diagnostic tools. Conclusions: Additional research is necessary to determine whether the proposed reforms are effective in promoting health equity. [ABSTRACT FROM AUTHOR]

With the deepening reform of the medical and health system, China's community health services are also continuously improving. As the "gatekeeper" of community residents' health, community medical and health services provide basic health protection for community residents. In the final analysis, community medical and health service is a kind of service. In today's era where everyone pursues experience, improving service experience has become an important goal of modern health services. The community medical and health services evaluation is a multi-attribute group decision making (MAGDM) issue. The fuzzy number intuitionistic fuzzy sets (FNIFSs) are used as a tool for characterizing uncertain information during the community medical and health services evaluation. In this paper, a novel MAGDM is built on given CoCoSo method under FNIFSs for community medical and health services evaluation. First of all, this paper extends the CoCoSo to FNIFSs environment to build the fuzzy number intuitionistic fuzzy CoCoSo (FNIF-CoCoSo) method. Secondly, a new MAGDM model for community medical and health services evaluation based on CoCoSo algorithm is built. Finally, the practical example for community medical and health services evaluation to show the practicability and some comparisons are supplied to prove the effectiveness of the decision algorithm. [ABSTRACT FROM AUTHOR]

Background The Tea Party, which gained prominence in the USA in 2009, advocates limited government and low taxes. Tea Party organisations, particularly Americans for Prosperity and FreedomWorks, oppose smoke-free laws and tobacco taxes. Methods We used the Legacy Tobacco Documents Library, the Wayback Machine, Google, LexisNexis, the Center for Media and Democracy and the Center for Responsive Politics (opensecrets.org) to examine the tobacco companies' connections to the Tea Party. Results Starting in the 1980s, tobacco companies worked to create the appearance of broad opposition to tobacco control policies by attempting to create a grassroots smokers' rights movement. Simultaneously, they funded and worked through third-party groups, such as Citizens for a Sound Economy, the predecessor of AFP and FreedomWorks, to accomplish their economic and political agenda. There has been continuity of some key players, strategies and messages from these groups to Tea Party organisations. As of 2012, the Tea Party was beginning to spread internationally. Conclusions Rather than being a purely grassroots movement that spontaneously developed in 2009, the Tea Party has developed over time, in part through decades of work by the tobacco industry and other corporate interests. It is important for tobacco control advocates in the USA and internationally, to anticipate and counter Tea Party opposition to tobacco control policies and ensure that policymakers, the media and the public understand the longstanding connection between the tobacco industry, the Tea Party and its associated organisations. [ABSTRACT FROM AUTHOR]

The authors sought to explore the implications of the Patient Protection and Affordable Care Act's establishment of Accountable Care Organizations (ACO). Summit participants, who discussed best practices and issues to be addressed when designing and implementing ACOs. Healthcare leaders from across the country in charge of running, developing, and/or implementing ACOs for health systems. Participants were asked to consider the challenges, benefits, and strategies to ACO implementation. [ABSTRACT FROM AUTHOR]

Objective: The objective of the paper is to describe the impact of Spanish psychiatric reform on the organization and functioning of mental health services. Method: This paper is based on official administrative reports and on relevant related publications. Results: The most significant achievements of Spanish psychiatric reform have been: (i) the development of a new organization of mental health care, decentralized in character and territorially based; (ii) the integration of psychiatric patients in general health care; (iii) the creation of an extensive community network of health centres; and (iv) the development of more positive attitudes towards mental illness. However, our analysis also reveals the existence of significant deficiencies. Conclusion: Analysis of the Spanish experience shows that the process of psychiatric reform depends basically on long-term commitments, which in a system such as Spain's must come from central administration and also from the autonomous communities. [ABSTRACT FROM AUTHOR]

Describes the contribution of a series of focus groups and a revised discussion paper to the evolution of health care reform in South Australia. Impact of health care reform on health care agencies; Reasons for the struggles of evaluators to evaluate health care reform programs; Relationships between bureaucracy and health care service providers.

Objective: The authors present an account of the current state of sectorization in France and its development over the last decade. Method: The paper is based on statistics collected by the French Health Ministry and on relevant laws and regulations. Comments by patients, families and professionals are presented. Results: The supply of mental health care is usually satisfactory, and there is a tendency for in-patient units to be converted into day hospitals. There is a large disparity between regions, especially in child and adolescent psychiatry. The 1838 law governing compulsory admissions was revised in 1990, and this revision was the object of a commission of inquiry in 1995. Psychiatric units work on the borders between health and social services and are forging new links between the two. Conclusion: Psychiatric care requires an integrated health and social perspective. In the field of mental health legislation European recommendations are called for. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Principles for Ending Human Immunodeficiency Virus (HIV) as an Epidemic in the United States: A Policy Paper of the Infectious Diseases Society of America and the HIV Medicine Association" which appeared in the August 15, 2022 issue.

Mental health care reform is a long-term process and a key aspect of the development and progress of society as a whole. This paper aims to present an overview and analysis of mental health care services intended for adults within the public and civil sectors in the Republic of Serbia. The main method applied in this study is content analysis. The results show that certain services and measures to improve mental health care have been created and implemented, but many goals have not yet been achieved. The biggest challenges facing the provision of mental health care services - alongside a lack of financial resources - are discrepancies in regulations, the dominance of tertiary health services in providing treatment to people with mental health, a lack of services in the community, insufficient involvement of the civil sector, and weak intersectoral cooperation between different systems. Due to the lack of data transparency and comprehensive service registries, this paper presents a large - although not comprehensive - number of public, civil, and private sector mental health care services. Mental health care in the Republic of Serbia should in the future aim to overcome the gap between mental health policy and practice, promote deinstitutionalization, establish health and social services and support systems in the community, and search for protection models that will enable better social inclusion for people with mental health problems and the fulfillment of their social, economic, and all other human rights. [ABSTRACT FROM AUTHOR]

Purpose: This paper aims to explore the lived experiences of key stakeholders working with homeless people during the implementation of universal credit during the austerity years. Design/methodology/approach: The literature on austerity reveals welfare reforms' impact on support services staff. Service providers' perceptions of the impact of austerity-led policies and welfare reform via nine interviews with people working in homelessness organisations in Brighton and Hove in the UK. Service providers see the situation for their service users has gotten worse and that the policies make it more difficult to extricate themselves from their current situation. Three central themes relating to the impact of austerity-led welfare reforms were, namely, Universal Credit: the imposition of a precarious livelihood on welfare claimants; a double-edged sword: "If people are sanctioned: people can't pay"; and "Hard to maintain my own mental equilibrium". Findings: More precisely, this paper captures service providers' perceptions and experiences of the impact of austerity-led policies on their services and how they believe this, in turn, impacts their clients and their own lives. Research limitations/implications: The dimension cuts across service provision to vulnerable people and is intertwined with health and well-being outcomes. Austerity is detrimental to the health of service users and their clients. It is known that when it comes to the health and well-being of the most vulnerable, who have suffered most from the impacts of austerity policies. However, in times of open austerity, it falls also on those trying to ease their suffering. Originality/value: The data suggest that policies were developed and accentuated by austerity, which led to the stripping of welfare support from vulnerable people. This process has impacted the people who rely on welfare and service providers. [ABSTRACT FROM AUTHOR]

Healthcare reforms that demand quantitative outcomes and technical innovations have emphasized the use of Disability and Functional Outcome Measurements (DFOMs) to spinal conditions and interventions. Virtual healthcare has become increasingly important following the COVID-19 pandemic and wearable medical devices have proven to be a useful adjunct. Thus, given the advancement of wearable technology, broad adoption of commercial devices (ie, smartwatches, phone applications, and wearable monitors) by the general public, and the growing demand from consumers to take control of their health, the medical industry is now primed to formally incorporate evidence-based wearable device-mediated telehealth into standards of care. To (1) identify all wearable devices in the peer-reviewed literature that were used to assess DFOMs in Spine, (2) analyze clinical studies implementing such devices in spine care, and (3) provide clinical commentary on how such devices might be integrated into standards of care. A systematic review. A comprehensive systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA) across the following databases: PubMed; MEDLINE; EMBASE (Elsevier); and Scopus. Articles related to wearables systems in spine healthcare were selected. Extracted data was collected as per a predetermined checklist including wearable device type, study design, and clinical indices studied. Of the 2,646 publications that were initially screened, 55 were extensively analyzed and selected for retrieval. Ultimately 39 publications were identified as being suitable for inclusion based on the relevance of their content to the core objectives of this systematic review. The most relevant studies were included, with a focus on wearables technologies that can be used in patients' home environments. Wearable technologies mentioned in this paper have the potential to revolutionize spine healthcare through their ability to collect data continuously and in any environment. In this paper, the vast majority of wearable spine devices rely exclusively on accelerometers. Thus, these metrics provide information about general health rather than specific impairments caused by spinal conditions. As wearable technology becomes more prevalent in orthopedics, healthcare costs may be reduced and patient outcomes will improve. A combination of DFOMs gathered using a wearable device in conjunction with patient-reported outcomes and radiographic measurements will provide a comprehensive evaluation of a spine patient's health and assist the physician with patient-specific treatment decision-making. Establishing these ubiquitous diagnostic capabilities will allow improvement in patient monitoring and help us learn about postoperative recovery and the impact of our interventions. [ABSTRACT FROM AUTHOR]

BACKGROUND: At a time when welfare contracts are in crisis, it is timely to discuss different forms of disruptive innovation and responses of medical finance and economic systems, especially adjusting with new instruments for recovery and innovative solutions for health reforms. OBJECTIVE: The objective of this paper is to propose some ways to develop a framework for policy changes affecting life science sectors and healthcare. It aims to analyze the types of relationships between health or medical systems and the economic systems. METHOD: Medical systems used to be generally closed systems, but the new forms of delivery, especially with increase of telehealth and Mobile health (Mhealth) solutions (boosted by the COVID-19 pandemic, such as online consultations), have open traditional boundaries and generate more interactions with economic systems. It also led to new institutional arrangements at federal, national, or local levels, with different power games according to the history of institutions and cultural differences between countries. RESULTS: Which system dynamics prevail will also depend on the political systems in place, for instance very innovative open innovation systems dominated by private players such as the USA empower individuals and favor intuitive and entrepreneurial states. On the other hand, systems historically dominated by socialized insurance or former communist countries, have investigated "attunements" or adaptation mechanisms in system intelligence. However, systemic changes are not only implemented by traditional rulers (government agencies, federal reserve banks) but also face the emergence of systemic platforms dominated by Big Tech players. The new agendas expressed for instance in the United Nation (UN) framework and the set of Sustainable Development Goals (SDGs) for climate change and sustainable growth, also require global adjustment of supply and demand, in a context where the traditional drug/vaccine split is challenged by the new technologies (e.g., mRNA technologies). Investment for drug research led to the development of COVID-19 vaccines, but also potential cancer vaccines. Finally, welfare economics is increasingly criticized among economist circles; it requires new design for global value assessment framework, facing growing inequalities and inter-generational challenges in aging populations. CONCLUSION: This paper contributes to new models of developments and different frameworks for multiple stakeholders with major technological changes. [ABSTRACT FROM AUTHOR]

The article presents a summary of a report by the Texas Association of Local Health Officials (TALHO) on the future of public health in Texas. It tackles on the potential role of health care reform in the development of a strong health care system in the state. It cites that the Texas Department of State Health Services (DSHS) plays an important role in securing funding for state level and local public health programs and priorities.

Policy PointsThe implementation of large‐scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge.Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture.Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. Context: Large‐scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large‐scale transformation in health care systems. Methods: A realist study of the implementation of a value‐based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context‐mechanism‐outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. Findings: Forty‐two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large‐system transformation that illustrates when, for whom, and in what circumstances large‐system transformation worked well or worked poorly. Conclusions: System enablers offer nuanced guidance for the implementation of large‐scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large‐system value‐based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care. [ABSTRACT FROM AUTHOR]

This review aims to identify healthcare providers' (HCPs) experiences with issues related to the quality use of medicines among culturally and linguistically diverse (CALD) patients, the underlying factors, and the enablers of and barriers to providing culturally safe care to promote quality use of medicines. The searched databases were Scopus, Web of Science, Academic search complete, CINHAL-Plus, Google Scholar and PubMed/Medline. The initial search returned 643 articles, of which 14 papers were included. HCPs reported that CALD patients were more likely to face challenges in accessing treatment and sufficient information about treatment. According to the theoretical domains framework, determinants such as social influences due to cultural and religious factors, lack of appropriate resources about health information and cultural needs, lack of physical and psychological capabilities such as lack of knowledge and skills, and lack of motivation could impede HCPs' abilities to provide culturally safe care. Future interventions should deploy multilevel interventions, such as education, training, and organisation structural reforms. [ABSTRACT FROM AUTHOR]

In 2016, as a trainee doctor, I wrote a paper on changing the culture of medicine. I felt the medical system was broken back then, and it seems even less functional now, with higher rates of burnout, dropout and staff shortages nationally. As a result of a lack of resources, it feels impossible to provide the care to our communities expected of us, making our work challenging and disheartening. Until all stakeholders acknowledge the systemic issues faced by our workforce, service outcomes and physician well‐being may not improve. We need to collaborate and innovate to reform the healthcare system taking a multifaceted, evidence‐based approach, implementing an appropriate balance of systemic change and interventions to support individual well‐being. As we collectively work towards these changes, tragic optimism may spur physicians to develop meaning and purpose despite the inevitable challenges. This may serve as the motivation and fuel required to survive and sustain our practice but also thrive working in careers of value. [ABSTRACT FROM AUTHOR]

India’s experience with the National Rural Health Mission (NRHM) is notable on account of nationally formalising – at scale – community action in service delivery,monitoring, and planning of health services. A study was undertaken to document and create a historical record of NRHM’s ‘communitization’ processes. The oral history method of the Witness Seminar was adopted and two virtual seminars with five and nine participants, respectively, were conducted, and supplemented with 4 in depth interviews. Analysis of transcripts was done using ATLAS.ti 22 with the broad themes of emergence, evolution, and evaluation and impact of ‘communitization’ under NRHM. This paper engages with the theme of ‘emergence’ and adopts the Multiple Streams Framework (MSF) conceptualised by John Kingdon for analysis. Key findings include the pioneering role of boundary spanning decision makers and the Jan Swasthya Abhiyan (JSA) in advocacy and design of ‘communitization’ structures, and the legacy of rights based social mobilizations and state-civil society partnerships in health during the 1990s influencing the ethos underlying ‘communitization’. Democracy, leadership from the civil society in policy design and implementation, and state-civil society partnerships are linked to the positive results witnessed as part of ‘communitization’ in NRHM. [ABSTRACT FROM AUTHOR]

In this perspective paper we use publicly-available data to show that, despite much positive rhetoric in support of reforms in Scotland to integrate health and social care, these reforms, in their current state, have failed to meet their stated objectives. Rather than regress to the previous system, we propose continued evaluation of even more radical forms of such integration. This analysis, and set of future proposals, are timely given current considerations with respect to a National Care Service in Scotland and recent similar reforms in England and in other countries. [ABSTRACT FROM AUTHOR]

Objective: To provide a framework of mental health care reform across Europe. Method: On the basis of summary quantitative indices and expert ratings of broad aspects of mental health care structure, the process and outcome of psychiatric reform common trends and differences are outlined. Results: There has been a broad trend away from an institutional model of care with the mental hospital as the dominant institution, and community- and general hospital-based mental health services of varying comprehensiveness are in place in most countries. The social and broad community aspects of psychiatric reform have generally been somewhat less successful than changes in service set-up. Assessment of reform outcomes proves particularly difficult. Conclusion: Psychiatric reform processes have achieved some of their aims, and there are broadly similar trends. Regional variation is substantial and may be as important as cross-national differences. Mental health care reform is ongoing across the European region. [ABSTRACT FROM AUTHOR]

Objective: To describe the mental health care system in Russia against the background of rapid social, economic and political change since the late 1980s. Method: Indicators of social stress and deteriorating population mental health and official data on service provision are presented. Results: In the current system of psychiatric care dispensaries take a central position. Key issues of the discussion on mental health care include ways of coping with social stress disorders, strategies to redefine psychiatric rehabilitation in a changed social-economic context and steps towards strengthening social support networks for people with mental illness. Following political abuse of psychiatry, professionals have had to face justified and unjustified accusations, and been faced with a general challenge to their role. Conclusion: Tackling problems of social stress, the integration of mental health care in the general medical care system and the building-up of general hospital in-patient psychiatric units are of strategic importance. [ABSTRACT FROM AUTHOR]

Objective: To assess the mental health care system in Germany from the point of view of the federal association of family carers of people with mental illness. Method: Family carer involvement and perspective are discussed on the basis of available literature, questionnaire surveys and documents of carer organizations. Results: At the beginning of the reform movement the views of informal carers were not discussed. Since 1985 family carers have joined forces to express their views on needs of the severely mentally ill and their carers. Their aim is to point out deficits of the care system and to work towards improved care for their relatives with mental illness and changes in the mental health care system. Conclusion: In the reform process informal carers should receive support and be respected as experts and partners. [ABSTRACT FROM AUTHOR]

Objective: To describe the major changes in mental health care for adults in the Netherlands during the past 25 years. Method: Scientific literature and official documents. Results: Phases of the reform process are the integration of ambulatory services in the early 1980s and the following implementation of community mental health centres (RIAGGs); the differentiation and extramuralization of mental hospitals; the differentiation within the field of living accommodations; and the final fusion process between these three into integrated regional mental health care organizations. Current issues in the development of services are, e.g. the ever growing demand for mental health care, special programmes for defined target populations, legislation and patient rights, rehabilitation and empowerment. Conclusion: The Dutch mental health care system has a low threshold and a comparatively good quality. There is a long-lasting and strong influence of user and family organizations on the content and quality of services. Recently important organizational changes are taking place. [ABSTRACT FROM AUTHOR]

Objective: To describe the content of the Community Mental Health Care reform in Sweden, in effect from 1995 and directed to severely mentally ill people (SMI). Method: Evaluating changes, at local and national level, in living conditions among SMI and resources of services directed to them, by using registers, questionnaires, interviews and case studies. Results: A survey, covering 93% of the population, identified 43 000 SMI (prevalence of 0.63%); 4000 long-stay patients and 400 rehabilitation programmes were transferred from psychiatric services to social services (15% of the budget of psychiatric services). Employment and rehabilitation projects, family support and user programmes and educational projects for social services staff, were launched (funded by state subsidies). Conclusion: SMI still have difficulties in obtaining adequate support on the basis of disability laws and there continue to be barriers between social services and psychiatric services. [ABSTRACT FROM AUTHOR]

Objective: To describe the ongoing process of German psychiatric reform and the structure and functioning of mental health services. Method: Information sources used include official reports describing mental health services, relevant publications related to organization and functioning of services. Results: There has been far-reaching change in mental health care since the late 1960s: psychiatric hospitals have lost about 50% of their beds and one psychiatric hospital has been closed. One hundred and sixty-five general hospital psychiatric units have been built up. Out-patient, community and residential services have been developed. There is a lack of diversified residential and rehabilitation services, particularly for the most severely ill. Co-ordination of care is not always ensured, transfer of patients to remote nursing homes has occurred in some places. Carers and service users articulate their views to an increasing degree. Conclusion: Political and professional enthusiasm have been important in implementation of the German reform. Evolving it further will require major efforts. [ABSTRACT FROM AUTHOR]

Objective: To describe the background in general culture, public and professional discourse against which mental health care reform initiatives in Eastern Europe need to be seen. Method: An account of some key aspects of sociopolitical and cultural transition in Eastern European countries is given, and core results of a research project on attitudes and needs assessment in psychiatry in six Eastern European countries are reported. Results: In post-totalitarian cultures mental health reforms impinge on imagination in ways which are not easy to predict. Some of the reasons for this are traced to the psychiatric practices under the system of total control, e.g. dispensary care, political abuse, reification of classificatory terms. Data on a study of attitudes suggest that institutions had replaced community life in those parts of Europe. Conclusion: It is predicted that with time trust in the capacity of community to contain mental illness will be regained. [ABSTRACT FROM AUTHOR]