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BackgroundData transparency has played a key role in this pandemic. The aim of this paper is to map COVID-19 data availability and accessibility, and to rate their transparency and credibility in selected countries, by the source of information. This is used to identify knowledge gaps, and to analyse policy implications.MethodsThe availability of a number of COVID-19 metrics (incidence, mortality, number of people tested, test positive rate, number of patients hospitalised, number of patients discharged, the proportion of population who received at least one vaccine, the proportion of population fully vaccinated) was ascertained from selected countries for the full population, and for few of stratification variables (age, sex, ethnicity, socio-economic status) and subgroups (residents in nursing homes, inmates, students, healthcare and social workers, and residents in refugee camps).ResultsNine countries were included: Bangladesh, Indonesia, Iran, Nigeria, Turkey, Panama, Greece, the UK, and the Netherlands. All countries reported periodically most of COVID-19 metrics on the total population. Data were more frequently broken down by age, sex, and region than by ethnic group or socio-economic status. Data on COVID-19 is partially available for special groups.ConclusionsThis exercise highlighted the importance of a transparent and detailed reporting of COVID-19 related variables. The more data is publicly available the more transparency, accountability, and democratisation of the research process is enabled, allowing a sound evidence-based analysis of the consequences of health policies.FundingThis study was conducted as part of the Summer School “Sustainable Health: designing a new, better normal after COVID-19”. It is a researchers/student collaboration.

Economic crises carry a substantial impact on population health and health systems, but little is known on how these transmit to health workers (HWs). Addressing such a gap is timely as HWs are pivotal resources, particularly during pandemics or the ensuing recessions. Drawing from the empirical literature, we aimed to provide a framework for understanding the impact of recessions on HWs and their reactions. We use a systematic review and best-fit framework synthesis approach to identify the relevant qualitative, quantitative and mixed-methods evidence, and refine an a priori, theory-based conceptual framework. Eight relevant databases were searched, and four reviewers employed to independently review full texts, extract data and appraise the quality of the evidence retrieved. A total of 57 peer-reviewed publications were included, referring to six economic recessions. The 2010–15 Great Recession in Europe was the subject of most (52%) of the papers. Our consolidated framework suggests that recessions transmit to HWs through three channels: (1) an increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.

Background: Fiscal decentralisation (FD) is a widely implemented decentralisation policy consisting of the allocation of pooling and spending responsibilities from the central government to lower levels of governance within a country. In 2001, The Italian National Health System (Servizio Sanitario Nazionale, SSN) has introduced a strong element of FD, making regions responsible for their own pooling of resources and for their budgets. Despite the relevance, only few studies exist on health sector-FD in Italy, mostly looking at the effects of FD on infant mortality. Methods: This study performs a fixed-effects panel data analysis of Italian Regions and Autonomous provinces between the years 2001 and 2017, to investigate the effects of health sector-FD on availability, accessibility, and utilisation of healthcare services in Italy. Results: FD decreases availability of staff and hospital beds, decreases utilisation of care, measured by hospitalisation rates, and increases interregional patients’ mobility for healthcare purposes, a finding suggesting increased disparities in access to healthcare. These effects seem to be stronger for public – rather than private – services, and are more prominent in poorer areas. Conclusion: This evidence suggest that FD has created a fragmented and unequal healthcare system, in which levels of availability, utilisation of, and accessibility to resources – as well as the extent of public sector’s retrenchment – coincide with the wealth of the area.

Background For 56,000 refugees and asylum seekers in Reception and Identification Centres (RICs) and Reception Sites (RS) in Greece, living in severely substandard living conditions, prevention measures have been severely limited. We assessed the impact of COVID-19 on migrants in these settings. Methods We did a retrospective analysis of policy documents and national surveillance data to identify COVID-19 outbreaks and estimate incidence among migrants residing in these camps (26th Feb - 15th Nov 2020). Incidence proportion (IP) of COVID-19 confirmed cases was calculated for three population groups (migrant populations in RICs, migrant populations in RSs, and the general population in Greece) during three time periods (first wave, second wave, and overall across the 9-month period). Results 25 outbreaks were identified in migrant reception facilities, with 6 (85.7%) of 7 RICs and 18 (56.3%) of 32 RSs reporting at least one outbreak during the study period. The overall 9-month COVID-19 IP among refugee and asylum seeker populations residing in RSs on the Greek mainland was 1,758 cases per 100,000 population; in RICs the incidence was 2,052 cases per 100,000 population. Compared to the general population the risk of COVID-19 infection among migrants in reception facilities was 2.5 to 3 times higher; the risk of acquiring COVID-19 infection was higher among migrant populations in RSs on the Greek mainland (IP ratio: 2.45; 95% CI: 2.25-2.68) but higher still among migrant populations in RICs in the Greek islands and the land border with Turkey (IP ratio: 2.86; 95% CI: 2.64-3.10), where living conditions are particularly poor. Conclusions We identified high levels of COVID-19 transmission among migrants in reception facilities in Greece, with immediate implications for policy and practice to ensure refugee and asylum seeker populations are included in national response plans to reduce transmission, alongside ensuring their inclusion in plans for COVID-19 vaccine roll out. Key messages Thousands of migrants in Greece live in severely substandard conditions and largely excluded from the COVID-19 response. We identified high levels of COVID-19 transmission among migrants in reception facilities in Greece, with immediate implications for policy and practice.

Ο εξευρωπαϊσμός, η διαδικασία δηλαδή διαμόρφωσης και μεταφοράς πολιτικών της Ευρωπαϊκής Ένωσης (ΕΕ) στα κράτη μέλη, είναι έννοια επίκαιρη, αφορώντας ολοένα και περισσότερα πεδία άσκησης πολιτικής. Σκοπός του άρθρου είναι η διερεύνηση της έκτασης και έντασης του εξευρωπαϊσμού στο πεδίο της πολιτικής υγείας και η δημιουργία ενός θεωρητικού, ταξινομητικού πλαισίου των μηχανισμών μέσω των οποίων αυτός συντελείται. Τα αποτελέσματα της μελέτης δείχνουν, πρώτον, ότι ο εξευρωπαϊσμός στο πεδίο της πολιτικής υγείας ως θεσμική πρακτική υφίσταται και συνεχώς διευρύνεται και, δεύτερον, ότι, ενώ πριν την εκδήλωση της οικονομικής κρίσης επιλέγονταν κύρια οριζόντιοι μη υποχρεωτικοί μηχανισμοί εξευρωπαϊσμού, κατά την περίοδο της κρίσης παρατηρείται μετακίνηση σε κάθετους υποχρεωτικούς μηχανισμούς, που αυξάνουν την ένταση των παρεμβάσεων της ΕΕ στο χώρο της υγείας., Europeanization, defined as the process of designing and transferring European Union (EU) policies to member states, is a topical issue affecting multiple areas of policy practice. The aim of this paper is to explore the width and depth of Europeanization in health systems and develop a classification framework of the mechanisms of Europeanization most commonly applied in health policy. Our results indicate that Europeanization is a gradually widening institutional practice in healthcare. The most recent economic crisis was marked by a clear shift from horizontal non-mandatory Europeanization practices to vertical and mandatory ones, increasing significantly EU’s intervention in domestic health policies.

Background: Migrants globally, including refugees and asylum seekers, have experienced adverse clinical and socioeconomic impacts of the COVID-19 pandemic. For approximately 56,000 refugees and asylum seekers in Reception and Identification Centers (RICs) and Reception Sites (RS) in Greece, living in severely substandard living conditions, prevention measures have been impossible with limited provision in terms of routine testing, surveillance, and access to healthcare. These migrant populations have experienced prolonged lockdowns and restricted movement since the pandemic began. We aimed to assess the impact of COVID-19 on refugees and asylum seekers in reception facilities in Greece and explore implications for policy and practice. Methods: A retrospective analysis of policy documents and national surveillance data was conducted to identify COVID-19 outbreaks and estimate incidence among asylum seekers and refugees residing in these camps during the first 9 months of the epidemic in Greece (26th February – 15th November 2020). Incidence proportion (IP) of COVID-19 confirmed cases was calculated for three population groups (refugees and asylum seekers in RICs, refugees and asylum seekers in RSs, and the general population in Greece) during three time periods (first wave, second wave, and overall across the 9-month period). Findings: Twenty-five COVID-19 outbreaks were identified in refugee and asylum seeker reception facilities, with 6 (85.7%) of 7 RICs and 18 (56.3%) of 32 RSs reporting at least one outbreak during the study period. The overall 9-month COVID-19 IP among refugee and asylum seeker populations residing in RSs on the Greek mainland was 1758 cases per 100,000 population; in RICs the incidence was 2052 cases per 100,000 population. Compared to the general population the risk of COVID-19 infection among refugees and asylum seekers in reception facilities was 2.5 to 3 times higher (p-value

Background: Migrants globally have experienced adverse clinical and socio-economic impacts of the COVID-19 pandemic. For approximately 56,000 refugees and asylum seekers in Reception and Identification Centres (RICs) and Reception Sites (RS) in Greece, living in severely substandard living conditions, prevention measures have been impossible with limited provision in terms of routine testing, surveillance, and access to healthcare. These migrant populations have experienced prolonged lockdowns and restricted movement since the pandemic began. We aimed to assess the impact of COVID-19 on migrants residing in reception facilities in Greece and explore implications for policy and practice. Methods: A retrospective analysis of policy documents and national surveillance data was conducted to identify COVID-19 outbreaks and estimate incidence among asylum seekers and refugees residing in these camps during the first 9 months of the epidemic in Greece (26th Feb - 15th Nov 2020). Incidence proportion (IP) of COVID-19 confirmed cases was calculated for three population groups (migrant populations in RICs, migrant populations in RSs, and the general population in Greece) during three time periods (first wave, second wave, and overall across the 9-month period). Findings: Twenty-five COVID-19 outbreaks were identified in migrant reception facilities, with 6 (85.7%) of 7 RICs and 18 (56.3%) of 32 RSs reporting at least one outbreak during the study period. The overall 9-month COVID-19 IP among refugee and asylum seeker populations residing in RSs on the Greek mainland was 1,758 cases per 100,000 population; in RICs the incidence was 2,052 cases per 100,000 population. Compared to the general population the risk of COVID-19 infection among migrants in reception facilities was 2.5 to 3 times higher; the risk of acquiring COVID-19 infection was higher among migrant populations in RSs on the Greek mainland (IP ratio: 2.45; 95% CI: 2.25-2.68) but higher still among migrant populations in RICs in the Greek islands and the land border with Turkey (IP ratio: 2.86; 95% CI: 2.64-3.10), where living conditions are particularly poor. Interpretation: We identified high levels of COVID-19 transmission among migrants in reception facilities in Greece. The risk of infection among these enclosed population groups has been significantly higher than the general population of Greece, and risk increases as living conditions deteriorate. These data have immediate implications for policy and practice. Strategies are now needed to ensure refugee and asylum seeker populations are included in national response plans to reduce transmission in at-risk groups for COVID-19, alongside inclusion in plans for COVID-19 vaccine roll out. Funding: No funding was received for this piece of research. Declaration of Interests: MO is Executive Director of Lancet Migration: global collaboration to advance migration health. All other authors declare no conflicts of interest. Ethics Approval Statement: No ethics approval was required, as al the data sources are anonymous and freely available online.

IntroductionDuring economic recessions, health professionals face reduced income and labour opportunities, hard conditions often exacerbated by governments’ policy responses to crises. Growing evidence points to non-negligible effects on national health workforces and health systems—decrease in motivation, burnout, migration—arising from the combination of crisis-related factors. However, no theoretical conceptualisation currently exists framing the impacts recessions have on human resources for health (HRH), or on their reactions.Methods and analysisThis paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts’ input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970–2019 period—the modern age of global economic recessions—and full texts in English, Spanish, Italian, French, Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A ‘best-fit’ framework synthesis will be applied to summarise the findings, using an a priori, theoretically driven framework. That preliminary framework was built by the research team to inform the searches, and will be appraised by external experts.Ethics and disseminationIn addition to peer-reviewed publications, the new framework will be presented in global health systems research conferences and inform regional policy dialogue workshops in Latin America on economic recessions and health systems.PROSPERO registration numberCRD42019134165.

The General Agreement on Trade in Services (GATS), established in 1994, has been a key element of market liberalization of health care services. Brazil had the provision of health care services partially protected from international competition until 2015, when a constitutional change opened the national health care market to international provision. We performed a retrospective and prospective policy analysis based on a systematic policy document review, general literature review, and secondary data analysis mapping, describing and analyzing the international trade agreements signed by Brazil with the World Trade Organization (WTO) and the available legislation relevant to health care services. The provision of health care services was not included in the WTO commitments signed by Brazil during the analyzed period (1994–2018). Financing of private health insurance was part of the agreement since 1994. There was a mild liberalization of the private health insurance sector, while provision of health care services was forbidden to foreign investors until 2015. The mode 3 of GATS presents the greatest potential impact as it exposes health care provision to international competition. The international liberalization of the provision of health care services in Brazil is now legal and an observable consequence of the pressure to gradually lift trade barriers in the health and health care sector.

Douglas and colleagues correctly say that refugees, asylum seekers, and migrants are vulnerable to epidemics.1 Social distancing in the overcrowded places where they commonly reside is impossible, and early detection of cases is difficult owing to their exclusion from national healthcare plans. Local outbreaks among refugees and migrants are expected in epidemics, outbreaks that might go unchecked or even concealed.2 In the covid-19 pandemic, the World Health Organization, the UN Refugee Agency, and the International Organisation for …

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a population’s well-being. Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Health’s total expenditures fell by 23.7% between 2009 and 2011. In a time of economic turmoil, rising health care needs and increasing demand for public services collide with austerity and privatization policies, exposing Greece’s population health to further risks.

A proposed amendment to the law will give special administrators powers to reconfigure health services well beyond those provided by the trusts they are administering. Allyson Pollock and colleagues argue that this will undermine equal access to care in England

The main educational aim of our primary care attachment is to advocate community primary care oriented to the health needs of the population. In the case of the Greek National Health System, only Rural Health Centres (RHCs) offer community based health care. In urban areas primary care services are delivered from private physicians and social insurance funds’ health units (polyclinics). The cost of travel and accommodation for medical students is a matter of continuous consideration, especially in a time of economic recession such as the one Greece is currently facing. Collaboration with RHCs in the areas of students’ family residence was preferred, as well as RHCs that could provide free accommodation. Even though such an approach might raise more organisational issues, it also drives to the increase of collaborating teaching RHCs, necessary in the case of medical schools where more than 300 students practise each academic year.

Context Exposure of undergraduate medical students to general practice and community healthcare services is common practice in the international medical curricula. Nevertheless, proponents of the hospital and biotechnology based paradigm, which is still dominant within the medical academic environment, question both the scope and the setting of this training procedure. Regarding the latter, the quality of teaching is often questioned in settings such as rural primary health centers, where health professionals have neither incentives nor accredited training skills. Therefore, the success of community based medical education depends substantially on the procedures implemented to involve non-academic staff as clinical teachers. Issue This report describes the steps taken by the Aristotle University of Thessaloniki (AUTH) Medical School to establish and maintain a Rural Primary Health Care (PHC) Teaching Network in order to implement community oriented PHC and GP undergraduate medical education. A multi-professional teachers' network of healthcare staff, working in Rural Primary Health Centers, has been chosen, in order to expose students to the holistic approach of PHC. The enrollment of teachers to the Teaching Network was solely on a voluntary basis. The novelty of this procedure is that each professional is approached personally, instead through the Health Center (HC) that usually offers this service as a package in similar activities. In an attempt to attract health professionals committed to medical education, a self-selection procedure was adopted. Collaboration with the medical school was established but it was characterized by the School's inability to compensate teachers. A series of 'Training the Trainers' seminars were completed during the first implementation period in order to enhance the awareness of health professionals regarding undergraduate teaching in PHC; to present the educational needs of medical students; to expose them to the principles of medical teaching; and to strengthen their communication skills. Lessons learned Setting up sustainable community oriented medical education activities in a more or less unfriendly environment is a difficult task that calls for wisely selected functional steps. Pilot educational activities determine the quality of the implemented programs by evaluating difficulties and constraints. Recruiting teachers on a voluntary basis proved to be critical in enhancing the quality of this educational activity, and overcoming distance constraints. The educational activities which were offered created a homogenous group of PHC teachers with explicit educational aims and objectives.

The economic crisis in Greece1 may offer an opportunity for the reorganisation of the health system,2 and although primary healthcare reform is high on the political agenda, questions remain about the direction of restructuring. Weaknesses in the Greek health system include poor continuity of care, excessive use of curative services, lack of preventive measures, low levels of satisfaction, high rates of out-of pocket payments, and significant inequalities in the range and quality of health services.3,4 In the past a plethora of occupational funds had offered different packages of primary healthcare coverage. In some cases they used their own infrastructure (GP-led health clinics) and/or contracted private physicians and laboratories, situated mainly in urban and semi-urban areas.5 In 1953 the state established the first public medical posts in rural areas a few years later, obliging medical graduates to offer their services to local populations as fully employed civil servants. In 1983 the Greek National Health System (Ethniko Systima Ygeias [ESY]) was founded following the Alma Ata Declaration's emphasis on primary care.6 It foresaw the replacement of the existing primary healthcare infrastructure with ESY urban and rural health centres and the unification of social health insurance schemes. In the next decade 176 health centres and 19 small hospitals4 were established in rural areas offering health services accessible to all, comprehensive and free at the point of use. Unfortunately, the 220 urban health centres envisaged by the ESY implementation plan,4 were never established. The sickness funds' primary care infrastructure and variable benefits remained untouched, due to opposition from physicians engaged in private practice, and social groups …

Background Empirical evidence on how ownership type affects the quality and cost of medical care is growing, and debate on these topics is ongoing. Despite the fact that the private sector is a major provider of hospital services in Greece, little comparative information on private versus public sector hospitals is available. The aim of the present study was to describe and compare the operation and performance of private for-profit (PFP) and public hospitals in Greece, focusing on differences in nurse staffing rates, average lengths of stay (ALoS), and Social Health Insurance (SHI) payments for hospital care per patient discharged. Methods Five different datasets were prepared and analyzed, two of which were derived from information provided by the National Statistical Service (NSS) of Greece and the other three from data held by the three largest SHI schemes in the country. All data referred to the 3-year period from 2001 to 2003. Results PFP hospitals in Greece are smaller than public hospitals, with lower patient occupancy, and have lower staffing rates of all types of nurses and highly qualified nurses compared with public hospitals. Calculation of ALoS using NSS data yielded mixed results, whereas calculations of ALoS and SHI payments using SHI data gave results clearly favoring the public hospital sector in terms of cost-efficiency; in all years examined, over all specialties and all SHI schemes included in our study, unweighted ALoS and SHI payments for hospital care per discharge were higher for PFP facilities. Conclusions In a mixed healthcare system, such as that in Greece, significant performance differences were observed between PFP and public hospitals. Close monitoring of healthcare provision by hospital ownership type will be essential to permit evidence-based decisions on the future of the public/private mix in terms of healthcare provision.

A recent paper suggests that suicidal rates remained stable in Greece during the last decade,1 despite the unprecedented economic downturn that the country has and is still facing. The authors of the paper insist on misinterpreting the data concerning suicide mortality rates in Greece, based on two false assumptions. The first is their argument that the period 2007–2010 covers only 1 year (2010) of economic hardship for Greece, and the second is that the suicide mortality trends show no variation between age groups and sex. As figures in table 1 show, the total suicide mortality …