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Objetivos: el trabajo lleva a cabo una aproximación global a la cohesión sanitaria en España tras dos décadas de vigencia de la Ley 16/2003. Metodología: se ha empleado la metodología habitual en las ciencias jurídicas; es decir, estudio de la legislación, de la doctrina y de la jurisprudencia. Resultados: en la primera parte del trabajo se identifican diversas señales de debilidad en el grado de cohesión efectiva del Sistema Nacional de Salud durante el período anterior a la crisis pandémica (2004-2019). En la segunda, se analiza la experiencia vivida en torno a la pandemia desde el punto de vista de la cohesión sanitaria. Conclusiones: se ha dejado pasar una circunstancia muy propicia para llevar a cabo rectificaciones de calado en la materia. Por eso, se formulan algunas propuestas para revertir la situación.

Ghana has committed politically, legislatively, and fiscally to providing universal health insurance coverage for its population with the intent of reducing financial barriers to utilization of health care.. However, under current cost and enrollment projections the system will not be financially sustainable in the long term, so there is more work to do. This book provides an important evidence-based review of the current performance of Ghana's health system and options for reform. As such, it provides an overall picture of the Ghana health sector, how things were and how things have changed, as well as a situational analysis of the performance of the health delivery and health financing systems using the latest available data. Finally, it discusses key reform issues and options in the context of the country's likely fiscal space. An important and valuable contribution of this book is its examination of how Ghana is performing compared to its neighboring countries and compared to other countries with similar incomes and health spending, providing global benchmarks for Ghana's health system performance.

Background In many universal health systems, waiting times act as a non-monetary rationing mechanism, one that should be based on clinical need rather than the ability to pay. However, there is growing evidence that among patients with similar levels of need, waiting times often differ according to socioeconomic status. The mechanisms underlying inequality in access remain unclear. Methods Using data for Spain, we study whether waiting times for primary and specialist care depend on patients’ socioeconomic status (SES). Additionally, we make use of the continuous nature of our data to explore whether the SES-related differences in waiting times found for specialist consultations vary among different points of the waiting time distribution. Results Our results reveal the presence of a SES gradient in waiting times for specialist services explained on the basis of education, employment status and income. In addition, for primary care, we found evidence of a slightly more moderate SES gradient mostly based on employment status. Furthermore, although quantile regression estimates indicated the presence of a SES gradient within the distribution of waiting times for specialist visits, the SES differences attenuated in the context of longer waiting times in the public sector but did not disappear. Conclusion Our findings suggest the principle of equal treatment for equal need, assumed to be inherent to national health systems such as the Spanish system, is not applied in practice. Determining the mechanism(s) underlying this selective barrier to healthcare is of crucial importance for policymakers, especially in the current COVID-19 health and economic crises, which could exacerbate these inequalities as increasing numbers of treatments are having to be postponed.

The third United Nations Sustainable Development Goal promotes health and well-being. Despite the existence of academic literature examining the relationship between health and income inequality, evidence on the role of healthcare systems in this inequality remains limited. This article aims to analyse the extent to which healthcare systems are associated with differences in economic inequality. To this end, a balanced panel of 27 European Union countries for the period 2005–2022 is used, applying t-tests for differences in means and linear regression models using S80/S20, Gini and Palma inequality measures. The main results show that countries with a Social Health Insurance System (SHIS) exhibit, on average, lower levels of income inequality, despite not being the highest spenders on healthcare. On the other hand, healthcare expenditure has a negative and statistically significant relationship with inequality, whereas in countries with a Mixed Healthcare System (MHS), this association is not statistically significant. A disaggregated analysis of public and private spending indicates that public expenditure is particularly relevant in SHIS countries being negatively associated with income inequality, whereas this relationship differs in countries with a National Health System (NHS). Thus, it is concluded that healthcare systems display significant differences in the relationship under study.

Background The Spanish National Health System (NHS) faces a significant shortage of clinical psychologists with only 5.58 per 100,000 inhabitants. This study aimed to estimate the required number of specialists and residents in Clinical Psychology to provide adequate psychological treatments to the population in the NHS. Methods A needs-based model was adapted to forecast the required total number of clinical psychologists and the annual increase in the positions of residents in Clinical Psychology (PIR). This model followed five steps: (1) obtaining Spanish prevalence rates for three broad mental disorder categories (depression, anxiety, and others or severe mental disorders) from the 2017 National Health Survey (ENSE); (2) multiplying the prevalence rates by the Spanish population aged ≥ 15 years; (3) defining the percentage of cases eligible for treatment under three predefined scenarios (protocolized, intermediate, and adjusted); (4) operationalizing the characteristics of the three treatment scenarios (session number and duration); and (5) calculating the total number of clinical psychologists and the annual increase required for PIR positions. Results Depending on the treatment scenario, the estimations show a need for clinical psychologists ranging from 1665 to 13,527 for treating depressive disorders, 1792–9799 for anxiety disorders, and 2074–8294 specifically for severe mental disorders. On the other hand, depending on the treatment scenario and the timeframe to achieve the estimated number of professionals (within 3, 5, 8, or 10 years), for example, to achieve those estimations of professionals within 3 years, and according to the adjusted treatment scenario, the Spanish health system should offer approximately 481 PIR positions yearly during 3 years. Conclusions A significant increase in the number of PIR positions is necessary to meet the growing demand for psychological treatment in the Spanish NHS. Investing in a mental-health workforce can lead to substantial health and economic benefits. This study provides valuable insights for workforce planning and highlights the importance of addressing the shortage of clinical psychologists in the NHS.

Greece is the country of “Xenios Zeus”, the Ancient Greek god of foreigners and hospitality; however, it is also the main point of entry to Europe. Since the beginning of 2014, 1,112,332 refugees crossed the borders of Greece. Overall, 33,677 children and adolescent refugees sought asylum in Greece from 2013 to 2017, while 57,042 refugees are currently being hosted. The rapid entry of refugees into Greece raised the critical issue of health policy. The Greek National Health Service (NHS) faces many challenges. Adequate economic and human support is essential if this situation is to be managed successfully. However, Greece still bears the burden of the economic downturn since 2009. In fact, the crisis led to shortages in crucial equipment, and unmet health needs for both locals and refugees. The NHS deals with traumatic experiences, as well as cultural and linguistic differences. Overcrowded reception centers and hotspots are highly demanding and are associated with severe disease burden. This highlights the importance of guidelines for medical screening, healthcare provision, and a well-managed transition to definitive medical facilities. Furthermore, non-governmental organizations make an essential contribution by ensuring appropriate support to refugee minors, especially when they experience poor access to the NHS.

In the Italian healthcare system, private facilities can supplement public ones in delivering services within the framework of the Italian National Health System, provided they meet specific conditions and obtain the necessary authorisations. This set of requirements is known as the ‘four As’ system, comprising authorisation for the construction of the facility, authorisation to provide healthcare services, accreditation, and contractual agreements. A crucial element in this regulatory framework is the system of tariffs for the remuneration of healthcare services, which are periodically established by the Ministry of Health through a complex procedure. This model of ‘administered competition’ aims to protect both citizens’ health and fair competition among healthcare providers. Proper integration of private facilities into the National Health System is intended to enhance the effi ciency of service delivery. Th e purpose of this paper is to examine the current regulatory framework governing the participation of private clinics in the Italian National Health System and to identify any critical issues.

PurposeOut of Pocket costs (OOP) sustained by cancer patients also in public NHS contribute to disease-related financial toxicity. Aim of the study was to investigate the amount and the types of OOP sustained by Italian cancer patients for care services.MethodsA sample survey was conducted by FAVO in December 2017-June 2018, in 39 adhering hospitals and 1289 patients diagnosed from 1985 to 2018, by standardized questionnaire inquiring on: yearly expenditure by cancer service, age, year of diagnosis, disease phase, cancer site, sex, marital status, education, residence. Univariate and multivariable regression analyses were performed between OOP and each variable. Multilevel mixed-effects negative binomial regression was used to assess the combined effects of patients characteristics on the differences in acquiring health services.ResultsThe yearly average OOP was 1841.81€, with the highest values for transports (359.34€) and for diagnostic examinations (259.82€). Significantly higher OOP were found in North and Centre than South and Islands (167.51 vs. 138.39). In the fully adjusted multivariable analysis, the variables significantly associated with higher than reference expenditure were: medium/high education (OR 1.22 [1.05–1.42], upper gastrointestinal tract cancer (OR 1.37 [1.06–1.77]), disease phase of treatments for cancer progression or pain therapy (OR 1.59 [1.30–1.93]).ConclusionItalian cancer patients in 2018 sustained OOP quite similar to those measured in 2012 to supplement NHS services. The main component of the OOP costs were diagnostic examination and transportation. The NHS should pay attention to potentiate its ability to answer unmet needs of patients with advanced cancer who are the most fragile ones.Implications for cancer survivorsReinforcing the services where the main OOP expenses are located can help in promoting public health actions and reduce socio-economic needs that could compromise the receipt of optimal care along the whole disease course, from diagnosis to rehabilitation.

This paper investigates the causal effect of co-payment exemption on the number of specialist visits in the Italian National Health System. Exploiting a discontinuity in the multiple eligibility criteria, we apply multiple regression discontinuity in a quasi-experimental setting, considering both age and income requirements. Differently from the standard regression discontinuity, this twofold discontinuity allows to identify the effect of co-payment on a particularly needy sub-population of less wealthy people and how it changes according to the eligibility criteria. We find positive effects of co-payment exemption and the effects are stronger for less wealthy and older individuals. The result may be useful to the policy maker to tailor ad-hoc policies aimed at disadvantaged sub-populations.

Introduction: Ensuring access to the right information at the right time can improve the safety, effectiveness and efficiency of care. A systematic and detailed collection of patient records, commonly known as electronic health records (EHRs), forms the core of the information system architecture in integrated health systems. Description: Since January 2021, seventeen years after the German legislation to implement EHRs (elektronische Patientenakte; ePA) came into force, the sickness funds in Germany have been offering their enrollees a downloadable application with which patients can access their personal EHRs through an electronic device. Looking at the ePA adoption process, it is now safe to argue that the deployment has been anything but successful. After two years of the launch, the number of ePA users amounts to not even 1% of the insured population in Germany, failing to move the needle on integrated care and health data integration. Based on a public policy theory, this article analyses the factors that are influencing the ePA implementation and secondary use of ePA data. Discussion: As the German experience shows, the feasibility of digital health projects depends on several contextual factors: countries with a high degree of self-governance and federal structures have to manage complex coordination processes that often slow down or otherwise impede digitalisation processes. In addition, cultural peculiarities such as concerns about data protection and security can be a hindering factor for digitalisation. Whereas the new German government and European initiatives such as the European Health Data Space (EHDS) create an advantageous situation for the ePA implementation and secondary use of health data, the structural and cultural issues in Germany should be acknowledged and tackled. Conclusion: Concerning the structural factors, a further reorganisation of the board of gematik, the key organisation of digital health solutions in Germany, should be considered. Cultural factors in Germany affect especially the secondary use of data; organising information campaigns, investing in (digital) health literacy of the population and designing a user-friendly ePA application are central in this context.   Zusammenfassung Einleitung: Der Zugang zu den richtigen Informationen zur richtigen Zeit kann die Sicherheit, Wirksamkeit und Effizienz der Gesundheitsversorgung verbessern. Eine systematische und detaillierte Sammlung von Patientenakten, bekannt als Electronic Health Records (EHRs), bildet den Kern der Informationssystemarchitektur in integrierten Gesundheitssystemen. Beschreibung: Seit Januar 2021, siebzehn Jahre nach Inkrafttreten der deutschen Gesetzgebung zur Einführung der elektronischen Patientenakte (ePA), bieten die Krankenkassen eine zum Download verfügbare Anwendung an, mit der Patienten über ein elektronisches Gerät auf ihre persönliche elektronische Patientenakte zugreifen können; bisher jedoch mit wenig Erfolg. Zwei Jahre nach der Inbetriebnahme beläuft sich die Zahl der ePA-Nutzer auf weniger als 1 % der gesetzlich versicherten Bevölkerung in Deutschland; es ist also nicht gelungen, die integrierte Versorgung und Datenintegration voranzutreiben. Basierend auf einer politikwissenschaftlichen Theorie, werden in dieser Studie Faktoren analysiert, welche die ePA-Einführung und die sekundäre Nutzung von ePA-Daten beeinflussen. Diskussion: Wie die Erfahrungen mit der ePA in Deutschland zeigen, hängt die Umsetzbarkeit digitaler Gesundheitsprojekte von einer Vielzahl von kontextuellen Faktoren ab: Länder mit einem hohen Maß an Selbstverwaltung und föderalen Strukturen müssen komplexe Koordinationsprozesse bewältigen, die den Digitalisierungsprozess oft verlangsamen oder anderweitig behindern. Darüber hinaus können kulturelle Eigenheiten wie Datenschutz- und Sicherheitsbedenken die Digitalisierung behindern. Obwohl die neue Bundesregierung und europäische Initiativen, wie der Europäische Gesundheitsdatenraum (European Health Data Space; EHDS), die ePA-Implementierung und die Sekundärnutzung von Gesundheitsdaten begünstigen, sollten strukturelle und kulturelle Probleme in Deutschland berücksichtigt und angegangen werden. Schlussfolgerung: Im Hinblick auf die strukturellen Faktoren sollte eine weitere Umstrukturierung der gematik, des wichtigsten Entscheidungsorgans für digitale Gesundheitslösungen in Deutschland, in Betracht gezogen werden. Kulturelle Faktoren in Deutschland beeinflussen vor allem die Sekundärnutzung von Daten; in diesem Zusammenhang sind das Organisieren von Informationskampagnen, die Förderung der (digitalen) Gesundheitskompetenz der Bevölkerung und die Gestaltung einer nutzerfreundlichen ePA-Anwendung von zentraler Bedeutung.   Schlüsselwörter: Elektronische Patientenakte; Akzeptanz von Innovationen; Verwaltung von Gesundheitsdaten; Integrierte Versorgung; Datenintegration; Nationales Gesundheitssystem; Deutschland