Regional variation in access to and quality of acute stroke care: results of Germany's Health System Performance Assessment pilot, 2014-2020.

BACKGROUND: Health System Performance Assessments (HSPA) and analyses of unwarranted regional variation in health care both aim at identifying strengths and weaknesses of health systems to improve care. Applying HSPA's conceptual approach of interrelated health system dimensions (e.g., access, quality) to regional levels might help to better understand variation in care to reduce inequity and improve performance. METHODS: We use four indicators identified and analysed in a pilot study for a German HSPA to assess variation in access to and quality of acute stroke care between Germany's 16 federal states and urban vs. rural regions from 2014 to 2020. Stroke unit (SU) density, share of the population reaching a SU within 30 min by car, share of inpatient stroke cases treated in a hospital with a SU, and inpatient mortality were computed based on hospital quality reports and discharge data covering all acute care hospitals. Inpatient mortality was adjusted for age, sex, stroke type, and comorbidities. RESULTS: About 500 SU were identified, i.e., 2.0 per 1,000 inpatient stroke cases. Almost 95% of Germans could reach a SU hospital within 30 min (rural: 90%; urban: 99%; > 88% in all states but one). The share of inpatient stroke cases treated in a SU hospital increased to 93% with a decreasing span between rural (92%) and urban (95%) regions and between states (74-98%). Inpatient mortality stagnated around 8.5% and increased to 9.0% in 2020 (rural: 8.7%; urban: 9.2%; states: 7.0-9.7%, one outlier of 13.3%). CONCLUSIONS: The results especially revealed varying performance patterns in access to and quality of acute stroke care between the federal states, indicating different areas for improvement which might be addressed by more targeted policy measures in the future.

We Need a Combination of Approaches to Evaluate Health System Resilience Comment on "Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic".

Health system resilience has become a desirable health system attribute in the current permacrisis environment. The article by Saulnier and colleagues reviews the literature on health system resilience and refines the concept, pinpointing dimensions of resilience governance that have not reached consensus, or that are missing from the literature. In this commentary we complement the findings by discussing different conceptual frameworks for understanding resilience and introducing resilience testing, a method to assess health system resilience using a hypothetical shock scenario. Resilience testing is a mixed-methods approach that combines a review of existing data with a structured workshop, where health system experts collaboratively assess the resilience of their health system. The new method is proposed as a tool for policy-making, as the results can identify attributes of the current health system that may hinder or boost a resilient response to the next crisis.

A Spatio-Temporal Analysis of OECD Member Countries' Health Care Systems: Effects of Data Missingness and Geographically and Temporally Weighted Regression on Inference.

Determinants of health care quality and efficiency are of importance to researchers, policy-makers, and public health officials as they allow for improved human capital and resource allocation as well as long-term fiscal planning. Statistical analyses used to understand determinants have neglected to explicitly discuss how missing data are handled, and consequently, previous research has been limited in inferential capability. We study OECD health care data and highlight the importance of transparency in the assumptions grounding the treatment of data missingness. Attention is drawn to the variation in ordinary least squares coefficient estimates and performance resulting from different imputation methods, and how this variation can undermine statistical inference. We also suggest that parametric regression models used previously are limited and potentially ill-suited for analysis of OECD data due to the inability to deal with both spatial and temporal autocorrelation. We propose the use of an alternative method in geographically and temporally weighted regression. A spatio-temporal analysis of health care system efficiency and quality of care across OECD member countries is performed using four proxy variables. Through a forward selection procedure, medical imaging equipment in a country is identified as a key determinant of quality of care and health outcomes, while government and compulsory health insurance expenditure per capita is identified as a key determinant of health care system efficiency.

Understanding Impacts of Online Dual Practice on Health System Performance: A Qualitative Study in China.

The outbreak of the COVID-19 pandemic has boosted the global development of online healthcare platforms. An increasing number of public hospital doctors are providing online services on private third-party healthcare platforms, creating a new form of dual practice-online dual practice. To explore the impacts of online dual practice on health system performance as well as potential policy responses, we undertook a qualitative approach that uses in-depth interviews and thematic analysis. Following a purposive sampling, we interviewed 57 Chinese respondents involved in online dual practice. We asked respondents for their opinions on the effects of online dual practice on access, efficiency, quality of care, and advice on regulatory policy. The results suggest that online dual practice can generate mixed impacts on health system performance. The benefits include improved accessibility due to increased labor supply of public hospital doctors, better remote access to high-quality services, and lower privacy concerns. It can improve efficiency and quality by optimizing patient flows, reducing repetitive tasks, and improving the continuity of care. However, the potential distraction from designated work at public hospitals, inappropriate use of virtual care, and opportunistic physician behaviors may undermine overall accessibility, efficiency, and quality. Countries should mitigate these adverse consequences via regulations that are appropriate to their healthcare system context, policy priority, and governance capacity.

An assessment of the performance of the Mexican health system between 2000 and 2018.

This paper offers a comprehensive picture of the performance of the Mexican health system during the period 2000-18. Using high-quality and periodical data from the Organization for Economic Cooperation and Development, the World Bank, the Institute for Health Metrics and Evaluation and Mexico's National Survey of Household Income and Expenditure, we assess the evolution of seven types of indicators (health expenditure, health resources, health services, quality of care, health care coverage, health conditions and financial protection) over a period of 18 years during three political administrations. The reform implemented in Mexico in the period 2004-18-which includes the creation of 'Seguro Popular'-and other initiatives helped improve the financial protection levels of the Mexican population, expressed in the declining prevalence of catastrophic and impoverishing health expenditures, and various health conditions (consumption of tobacco in adults and under-five, maternal, cervical cancer and human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) mortality rates). We conclude that policies intended to move towards universal health coverage should count on strong financial mechanisms to guarantee the consistent expansion of health care coverage and the sustainability of reform efforts. However, the mobilization of additional resources for health and the expansion of health care coverage do not guarantee by themselves major improvements in health conditions. Interventions to deal with specific health needs are also needed.

Effective Coverage in Health Systems: Evolution of a Concept.

The manner in which high-impact, life-saving health interventions reach populations in need is a critical dimension of health system performance. Intervention coverage has been a standard metric for such performance. To better understand and address the decay of intervention effectiveness in real-world health systems, the more complex measure of "effective coverage" is required, which includes the health gain the health system could potentially deliver. We have carried out a narrative review to trace the origins, timeline, and evolution of the concept of effective coverage metrics to illuminate potential improvements in coherence, terminology, application, and visualizations, based on which a combination of approaches appears to have the most influence on policy and practice. We found that the World Health Organization first proposed the concept over 45 years ago. It became increasingly popular with the further development of theoretical underpinnings, and after the introduction of quantification and visualization tools. The approach has been applied in low- and middle-income countries, mainly for HIV/AIDS, TB, malaria, child health interventions, and more recently for non-communicable diseases, particularly diabetes and hypertension. Nevertheless, despite decades of application of effective coverage concepts, there is considerable variability in the terminology used and the choices of effectiveness decay steps included in the measures. Results frequently illustrate a profound loss of service effectiveness due to health system factors. However, policy and practice rarely address these factors, and instead favour narrowly targeted technical interventions.

Primary Care's Challenges and Responses in the Face of the COVID-19 Pandemic: Insights From AHRQ's Learning Community.

The COVID-19 pandemic dramatically disrupted health care systems and delivery in the United States. Despite emotional, psychological, logistical, and financial stress, primary care clinicians responded to the challenges that COVID-19 presented and continued to provide essential health services to their communities. As the lead federal agency for primary care research, the Agency for Healthcare Research and Quality (AHRQ) identified a need to engage and support primary care in responding to COVID-19. AHRQ initiated a learning community from December 2020-November 2021 to connect professionals and organizations that support primary care practices and clinicians. The learning community provided a forum for participants to share learning and peer support, better understand the stressors and challenges confronting practices, ascertain needs, and identify promising solutions in response to the pandemic. We identified challenges, responses, and innovations that emerged through learning community engagement, information sharing, and dialog. We categorized these across 5 domains that reflect core areas integral to primary care delivery: patient-centeredness, clinician and practice, systems and infrastructure, and community and public health; health equity was crosscutting across all domains. The engagement of the community to identify real-time response and innovation in the context of a global pandemic has provided valuable insights to inform future research and policy, improve primary care delivery, and ensure that the community is better prepared to respond and contribute to ongoing and future health challenges.

Health Literacy of People with Substitutive Private Health Insurance in Germany and Their Assessment of the Health System Performance According to Health Literacy Levels: Results from a Survey.

Health literacy (HL) is a competence to find, understand, appraise, and apply health information and is necessary to maneuver the health system successfully. People with low HL are, e.g., under the risk of poor quality and safety of care. Previous research has shown that low HL is more prevalent among, e.g., people with lower social status, lower educational level, and among the elderly. In Germany, people with substitutive private health insurance (PHI) account for 11% of the population and tend to have a higher level of education and social status, but in-detail assessments of their HL are missing so far. Therefore, this study aimed to investigate the HL of PHI insureds in Germany, and to analyze their assessment of the health system according to their HL level. In 2018, 20,000 PHI insureds were invited to participate in a survey, which contained the HLS-EU-Q16, and items covering patient characteristics and the World Health Organization health systems framework goals (e.g., access, quality, safety, responsiveness). Low HL was found for 46.2% of respondents and was more prevalent, e.g., among men and insureds with a low subjective social status. The health system performance was perceived poorer by respondents with low HL. Future initiatives to strengthen health systems should focus on promoting HL.

Status of the health information system in Ireland and its fitness to support health system performance assessment: a multimethod assessment based on stakeholder involvement.

BACKGROUND: Between 2019 and 2021, the first Irish health system performance assessment (HSPA) framework was developed. As routinely collected health data are necessary to continuously populate indicators of an HSPA framework, a purpose-driven assessment of the health information system (HIS) in Ireland and its fitness to support the implementation of an HSPA framework was conducted. This study reports on the status of the Irish HIS through a multimethod assessment based on continuous broad stakeholder involvement. METHODS: Between May and November 2020, over 50 informants were engaged in individual and group interviews and stakeholder consultation workshops as part of the HIS assessment process. Descriptive themes and high-level data availability heatmaps were derived from interview and workshop data using thematic analysis. Indicator "passports" for the HSPA framework were populated during stakeholder consultation workshops and analysed using univariate descriptive statistics. RESULTS: The HIS in Ireland was able to provide administrative, survey and registry-based data for public sector acute care services, focusing on structure, process and output metrics. Significant data availability gaps, most notably from primary care, private hospitals and community care, were reported, with little availability of electronic health record and people-reported data. Data on outcome metrics were mostly missing, as were linkage possibilities across datasets for care pathway monitoring. The COVID-19 pandemic highlighted the national HIS's shortcomings but also the capacity for rapid development and improvement. CONCLUSIONS: A tailor-made assessment of the HIS in Ireland, involving a broad set of relevant stakeholders, revealed strengths, weaknesses and areas for improvement in the Irish health data landscape. It also contributed to the development of a national HSPA framework and momentum to further strengthen data infrastructure and governance, while working towards a more data-driven and person-centred healthcare system. This work demonstrates the utility of an inclusive HIS assessment process and is applicable beyond Ireland, where this case study was conducted.

Interprofessional Primary Care and Acute Care Hospital Use by People With Dementia: A Population-Based Study.

PURPOSE: Interprofessional primary care has the potential to optimize hospital use for acute care among people with dementia. We compared 1-year emergency department (ED) visits and hospitalizations among people with dementia enrolled in a practice having an interprofessional primary care team with those enrolled in a physician-only group practice. METHODS: A population-based, repeated cohort study design was used to extract yearly cohorts of 95,323 community-dwelling people in Ontario, Canada, newly identified in administrative data with dementia between April 1, 2005 and March 31, 2015. Patient enrollment in an interprofessional practice or a physician-only practice was determined at the time of dementia diagnosis. We used propensity score-based inverse probability weighting to compare study groups on overall and nonurgent ED visits as well as on overall and potentially avoidable hospitalizations in the 1 year following dementia diagnosis. RESULTS: People with dementia enrolled in a practice having an interprofessional primary care team were more likely to have ED visits (relative risk = 1.03; 95% CI, 1.01-1.05) and nonurgent ED visits (relative risk = 1.22; 95% CI, 1.18-1.28) compared with those enrolled in a physician-only primary care practice. There was no evidence of an association between interprofessional primary care and hospitalization outcomes. CONCLUSIONS: Interprofessional primary care was associated with increased ED use but not hospitalizations among people newly identified as having dementia. Although interprofessional primary care may be well suited to manage the growing and complex dementia population, a better understanding of the optimal characteristics of team-based care and the reasons leading to acute care hospital use by people with dementia is needed.

Freedom of choice and health services' performance: Evidence from a national health system.

Public policies fostering the freedom of choice of provider in the healthcare sector are increasingly common in many countries and regions, where policymakers wish to empower patients and improve health service performance. However, in the literature there is not clear consensus about the impact of expanded patient choice on healthcare quality yet. This study investigates whether increasing patients' freedom of choice influences health system outcomes in terms of various non-clinical aspects of care, a dimension often overlooked by researchers in this field. Our study considers a "natural experiment" that took place within the Spanish National Health System in 2009 under which citizens of the Community (region) of Madrid were allowed to freely choose among any GP and/or specialist in their region. The empirical analysis was conducted by using Spanish microdata for the period 2002-2016 and used synthetic control estimation techniques. The key findings show the reform had a strong and long-lasting impact, reducing average waiting times and increasing patients' satisfaction with the specialist attention received. We did not detect any statistically significant impact of the reform on the other responsiveness domains analysed. Our analysis shows that freedom of choice policies could improve health system performance if they are combined with appropriate economic incentives for health providers.

Drivers of patient perceptions of health system responsiveness in Germany.

BACKGROUND: Health system responsiveness (HSR)-the ability of a health system to meet the non-medical legitimate expectations of patients-is a key to patient-centred health systems. Although responsiveness is essential to provide equitable and accountable health care, little is known about patient-side drivers of HSR. This study aims to narrow this gap. METHODS: A survey among 20,000 Germans with substitutive private health insurance included questions on HSR and patient characteristics such as health literacy (HL), experienced discrimination, and sociodemographic information. Survey data were linked to patient-level claims data. Logistic regression was applied to assess the association between HSR and patient characteristics. RESULTS: The sample (age 54.0 ± 16.1; 60.5% male) contains 2951 respondents with outpatient physician care in the past year. Of the nine HSR items, eight are rated as (very) good (74.4%-94.3%), except for coordination between providers (60.2%). Patient characteristics highly influence HSR: patients with high HL, for instance, are more likely to assess responsiveness as (very) good (e.g., clear explanations from physicians: OR 4.17). Poor assessment of responsiveness is seen among users who experienced discrimination. CONCLUSION: This study revealed new associations between HSR and patient characteristics. Incorporating this knowledge in practice would help strengthen patient-centred health services by considering patient experiences and expectations. This highlights that HSR can be used as a tool to evaluate and promote patient-centred health services. Future research should investigate additional drivers of HSR, both on the patient and the provider sides.

A Multi-Criteria Approach to Assess the Performance of the Brazilian Unified Health System.

Brazil's Unified Health System (SUS) provides universal free access to health services and is considered a model for the rest of the world. One of the tools used by the Brazilian government to assess this system is the Index of Unified Health System Performance (IDSUS). However, this method has a number of limitations, such as disregarding the opinion of healthcare decision makers. Thus, the aim of the present study was to propose a model based on the R-TOPSIS in order to assess the performance of the SUS. Methodologically, the main steps for proposing multi-criteria models were followed, and to validate the model, a real case study with a set of six cities (alternatives) of the state of São Paulo was used. The results provide a clearer picture of the differences in terms of potential and obtained access, as well as the effectiveness of health services in the cities analyzed. Likewise, the proposal of integrating multiple criteria as well as considering healthcare decision makers proved to be decisive for the results obtained, even in comparison with the other approaches. It was concluded that the proposed method provides a robust and adequate analysis of health systems performance.

Assessment of health system performance in Germany: Survey-based insights into the perspective of people with private health insurance.

INTRODUCTION: The World Health Organization (WHO) defined intermediate and overall goals to assess the performance of health systems. As the population perspective becomes more important for improving health systems, the aim of this study was to gain insights into the perspective of people with private health insurance (PHI) in Germany along the predefined WHO goals. METHODS: A cross-sectional survey was conducted in 2018 among people with PHI in Germany. The questionnaire included items on all intermediate (access, coverage, quality, and safety) and overall WHO goals (improved health, responsiveness, social and financial risk protection, and improved efficiency). Descriptive analyses were conducted for the total sample and subgroups (gender, age, income, and health status). RESULTS: In total, 3601 respondents (age 58.5 ± 14.6; 64.7% male) assessed the German health system. For example, 3.3%-7.5% of the respondents with subjective needs reported forgone care in the past 12 months due to waiting time, distance, or financial reasons and 14.4% suspected medical errors in their care. During the last physician visit 94.2% experienced respectful treatment but only 60.6% perceived coordination of care as good. Unnecessary health services were perceived by 24.2%. For many items significant subgroup differences were found, particularly for age groups (18-64 vs. 65+). CONCLUSION: Conducting a health system performance assessment from the population perspective gained new and unique insights into the perception of people with PHI in Germany. Areas to improve the health system were seen in, for example, coordination of care, financial risk protection, and quality of care, and inequalities between subgroups were identified.

Regional Variation in National Healthcare Expenditure and Health System Performance in Central Cities and Suburbs in Japan.

The increasing national healthcare expenditure (NHE) with the aging rate is a significant social problem in Japan, and efficient distribution and use of NHE is an urgent issue. It is assumed that comparisons in subregions would be important to explore the regional variation in NHE and health system performance in targeted municipalities of the metropolitan area of Tokyo (central cities) and the neighboring municipalities of Chiba Prefecture (suburbs). This study aimed to clarify the differences of the socioeconomic factors affecting NHE and the health system performances between subregions. A multiple regression analysis was performed to extract the factors affecting the total medical expenses of NHE (Total), comprising the medical expenses of inpatients (MEI), medical expenses of outpatients (MEO), and consultation rates of inpatients (CRI) and outpatients (CRO). Using the stepwise method, dependent variables were selected from three categories: health service, socioeconomic, and lifestyle. Then, health system performance analysis was performed, and the differences between regions were clarified using the Mann-Whitney U test. The test was applied to 18 indicators, classified into five dimensions referred to in the OECD indicators: health status, risk factors for health, access to care, quality of care, and health system capacity and resources. In the central cities, the number of persons per household was the primary factor affecting Total, MEI, MEO, and CRO, and the number of persons per household and the percentage of the entirely unemployed persons primarily affected CRI. In the suburbs, the ratio of the population aged 65-74 and the number of hospital beds were significantly positively related to Total, MEI, and CRI, but the number of workers employed in primary industries was negatively related to Total and MEI. The ratio of the population aged 65-74 was significantly positively related to MEO and CRO. Regarding health system performance, while risk factors for health was high in the central cities, the others, including access to care, quality of care, and health system capacity and resources, were superior in the suburbs, suggesting that the health system might be well developed to compensate for the risks. In the suburbs, while risk factors for health were lower than those in the central cities, access to care, quality of care, and health system capacity and resources were also lower, suggesting that the healthcare system might be poorer. These results indicate a need to prioritize mitigating healthcare disparities in the central cities and promoting the health of the elderly in the suburbs by expanding the suburbs' healthcare systems and resources. This study clarified that the determinants of NHE and health system performance are drastically varied among subregional levels and suggested the importance of precise regional moderation of the healthcare system.

'Inclusive' health systems increase healthy life expectancy.

INTRODUCTION: This article attempts to investigate whether inclusive health systems increase societal welfare, with the latter expressed through estimates of healthy life expectancy (HLE). METHODS: The analysis uses publicly available data by the Organisation for Economic Co-operation and Development and explores the relationship of HLE at the age of 65 years (HLE_65) with four variables that are representative of institutional inclusivity or extractiveness of health systems. RESULTS: Results indicate that HLE_65 is positively associated with healthcare system institutional inclusivity as expressed in terms of the share of public healthcare expenditure and the spending on preventive care. HLE_65 is inversely associated with the strength of extracting characteristics of the system, such as the market power of physicians and the share of specialists in the total number of physicians. CONCLUSION: In this light, the development of health policies that aim to strengthen inclusive institutions, such as the focus on prevention, financial protection and primary care, could have a significant positive impact in collective welfare and social cohesion - especially for populations in rural, remote and less developed parts of the world.

Health System Performance for Multimorbid Cardiometabolic Disease in India: A Population-Based Cross-Sectional Study.

Background: The prevalence of multimorbidity in low- and middle-income countries (LMICs) is thought to be rising rapidly. Research on the state of healthcare for multimorbidity in LMICs is needed to provide an impetus for integration of care across conditions, a baseline to monitor progress, and information for targeting of interventions to those most in need. Focusing on multimorbid cardiometabolic disease in India, this study thus aimed to determine 1) the proportion of adults with co-morbid diabetes and hypertension who successfully completed each step of the chronic disease care continuum from diagnosis to control for both conditions, and 2) how having additional cardiovascular disease (CVD) risk factors is associated with health system performance along the care continuum for diabetes, hypertension, and co-morbid diabetes and hypertension. Methods: Using a nationally representative household survey carried out in 2015 and 2016 among women aged 15-49 years and men aged 15-54 years, we created a 'cascade of care' for diabetes, hypertension, and co-morbid diabetes and hypertension by determining the proportion of those with the condition who had been diagnosed, were on treatment, and achieved control. We used Poisson regression with a robust error structure to estimate how having additional cardiovascular disease (CVD) risk factors (diabetes, hypertension, current smoking, and obesity) was associated with reaching each cascade step for diabetes, hypertension, and co-morbid diabetes and hypertension. Findings: Seven hundred thirty-four thousand seven hundred ninety-four adults were included in the analysis. Among individuals with co-morbid diabetes and hypertension, 28·8% (95% CI, 26·7%-31·0%), 16·1% (95% CI, 14·4%-17·9%), and 3·7% (95% CI, 2·8%-4·9%) - with these proportions varying between states by a factor of 4·8, 7·9, and 56·8 - were aware, treated, and achieved control of both conditions, respectively. Men, adults with lower household wealth, and those living in rural areas were less likely to reach each cascade step. Having additional CVD risk factors generally did not increase the probability of reaching each cascade step for diabetes, hypertension, and co-morbid diabetes and hypertension, except that having concurrent diabetes increased the probability of successfully transitioning through the hypertension care cascade. Interpretation: While varying widely between states and population groups, health system performance for co-morbid diabetes and hypertension is generally low in India, and there appears to be little integration of care across CVD risk factors. Funding: European Research Council.

Realizing the Dream: The Future of Primary Care Research.

Primary care research is central to the successful transformation of care delivery, providing the crucial evidence to overcome the longstanding and widespread threats and challenges to the realization of primary care's full potential. The Agency for Healthcare Research and Quality (AHRQ), as the federal agency specifically charged with conducting and supporting primary care research, plays a pivotal role in supporting the research and generating the evidence needed to advance primary care. Drawing upon decades of AHRQ-supported research studies, extensive stakeholder consultation, and a Primary Care Research Summit held in fall 2020, we discuss the primary care research central to successful primary care transformation and for realizing the vision of a high-performing US health system to effectively serve all Americans and their communities while advancing health equity.Realizing the potential of primary care will require wise investments in primary care research. Newly generated evidence needs to be rapidly incorporated into the design of the delivery system, clinical care, and community interventions. Investments in evidence-informed primary care redesign can catalyze progress to achieving the quintuple aim-improved health outcomes, increased value, better patient and clinician experience, and health equity. Primary care research can provide the evidence to help stem the twin epidemics of clinician burnout and lack of trust in the health system. Actualizing this vision will require a concerted and coordinated effort by policy makers, researchers, clinicians, and community members and a commitment to ensuring people and communities have ready access to primary care.Appeared as Annals "Online First" article.

EU health information progress: the harvest of policy supporting projects and networks.

BACKGROUND: The European Commission supports the initiation of health information related projects and networks serving comparative population health monitoring and health system performance assessment. Many of these projects and networks have produced relevant data, standards, methods, indicators and knowledge that may be lost as these networks become inactive. The aim of this project retrieval and review was to identify health information projects and networks and their produced output; and subsequently facilitate systematic access to this information for policy makers, researchers and interested others via a web-based repository. METHODS: The scope of this article covers 1. population health oriented topics and 2. health system/health services oriented topics. Out of scope are specific infectious diseases; individual rare diseases; and the occurrence and effects of specific medical treatments, interventions and diagnostics; cohort studies; or studies focusing on research methods. We searched bibliographic databases and EU project databases for policy supporting projects and networks and selected those fulfilling our inclusion criteria after more in-depth inspection. We searched for their outputs. In addition, we reviewed country participation in these projects and networks. RESULTS: We identified 36 projects and networks, 16 of which are population health oriented, 6 are health systems and services oriented and 14 cover both. Their total volume of output is not easily retrievable, as many project websites have been discontinued. Some networks and/or their outputs have found continuance within European agencies and/or national institutions. Others are struggling or have gone lost, despite their policy relevance. Participation in the projects was not evenly distributed across Europe. Project information was made available through the Health Information Portal. CONCLUSIONS: EU funded projects and networks have contributed greatly to the evidence-base for policy by providing comparative health information. However, more action is needed to evaluate and conserve their outputs and facilitate continued contribution to the field after project funding stops. The realization of a sustainable infrastructure for these projects and networks is urgent. The Health Information Portal can play an important role in conserving and reusing health information. Information inequalities may exist across Europe but need further investigating.

Healthcare system development in the Middle East and North Africa region: Challenges, endeavors and prospective opportunities.

Background: Countries in the Middle East and North Africa (MENA) region have been investing in the development of their health systems through implementing reforms to improve health care delivery for their nations. However, these countries are still facing challenges in providing equitable, high quality healthcare services. There is limited published literature supporting the previous and ongoing attempts that have been made to improve health system performance in MENA countries. Aims: This review aims to describe experiences of health system development efforts in the MENA region, highlight progress, identify challenges that need be addressed and future opportunities to achieve responsive and efficient health systems. It also aimed to provide recommendations to further support these health systems toward evolution and performance improvement. Methods: A literature review was conducted by searching different databases including PubMed, Scopus, Google Scholar and other electronic resources to identify articles and publications describing health systems development in the MENA region from 1975 to 2022. It also included grey literature, reports and policy and planning documents by international organizations. The identified references were reviewed to extract, analyze, organize and report the findings. Results: The review revealed emerging evidence describing governmental initiatives to introduce health system reforms at different levels in the MENA countries. These include initiatives targeting the various elements controlling health system reform: financing, payment, organization, regulation and behavior of providers and consumers. There are several challenges facing the health systems of MENA countries including the rising burden of chronic diseases, inequitable access to health services, deficiency in health workforce, shortage in the use of effective health information systems and leadership challenges. The review identified several key areas that can benefit from further improvement to support health system reforms. These include improving the structure, organization and financing of health systems, health workforce development, effective data management and engagement of key stakeholders to achieve adequate health system reforms. Conclusion: The MENA countries have made significant steps to improve the performance of their health systems; yet achieving a comprehensive health reform will require collaboration of various stakeholders including health policy makers, healthcare professionals, and central to the success of the reform, the patients.