Health System Performance Assessment: Does Germany provide good access to healthcare?

Abstract Background Providing equal access to health care is a major goal of health systems and a criterion for health system performance assessment (HSPA). The first systematic HSPA for Germany has been piloted in 2021. Access is one dimension of the conceptual framework (others are, e.g., population health, quality, and efficiency), which will be analysed in the following. Methods Nine indicators to measure access were selected based on a systematic search of established instruments in (inter)national HSPA initiatives. Included indicators are availability and accessibility of services (e.g., waiting times) and financial risk protection, among others. Other criteria for the inclusion of indicators were data availability and international comparability. Indicators were evaluated in terms of their trend over time (2000-2020), in international comparison (e.g., Austria, Denmark, France), and according to various equity categories (e.g., age, gender, region). Results The indicator access to palliative care could not be evaluated due to lack of data. Overall, access is good in Germany. Internationally, Germany performs better than average on most of the indicators, and its performance has improved over time. Physician density in the inpatient and outpatient sectors has increased since 2000 and is above the average of comparator countries. For some specialties, physician density in rural areas is lower than in urban areas, but the gap has decreased in recent years and does not apply to primary care. Furthermore, only 0.3% of the total population report having foregone care, although they had considered it necessary. Conclusions Nine indicators were identified and calculated to assess the performance of the German health system in terms of access to healthcare. Access can be assessed as predominantly positive, but inequities exist. Identified gaps and future extensions, e.g., additional data sources, can provide impetus for evidence-based policy management. Key messages • First systematic Health System Performance Assessment for Germany has been piloted. • Access to health care is good in Germany, both over time and in international comparison, but inequities exist.


Background:
WHO's Immunization Agenda 2030 has placed renewed focus on catch-up vaccination across the life course to meet global targets for reduction in vaccine-preventable diseases through increased vaccine coverage, including among migrant groups who may require catch-up vaccination to align them with host country vaccination schedules.

Methods:
We did a global rapid review (01/2010 to 04/2022) to explore drivers of vaccine hesitancy among migrants followed by an indepth qualitative study (semi-structured, telephone interviews) among recently arrived adult migrants (foreign-born, >18 years old, residing in the UK < 10 years). Interviews explored views on routine vaccination including accessibility, confidence and awareness. Data were analysed iteratively using thematic analysis.

Results
: 63 papers were included in the rapid review, including data from 22 countries/regions. Multiple factors driving underimmunisation and hesitancy in migrants were reported, including language barriers, low health literacy, social exclusion, low cultural competency and accessibility in healthcare systems. Our qualitative study recruited 40 migrants (mean age: 36.7 years; 62.5% female) resident in the UK (6 refugees, 19 asylum-seekers, 8 undocumented, 7 labour migrants). Major barriers to catch-up vaccination included a lack of provider recommendation and low awareness, with vaccination viewed as only relevant to children. Hesitancy around specific vaccines, such as MMR, was often influenced by misinformation. Participants suggested that novel strategies such as walk-in or mobile access points, consistent provider recommendations, and translation of information into relevant languages, may enhance accessibility and uptake of routine vaccinations.

Conclusions:
Targeted and tailored information campaigns, versatile and proactive access pathways and education for healthcare staff on cultural competency will be needed to ensure uptake of catchup vaccination among marginalised migrant groups.

Key messages:
Newly arrived adult migrants face barriers to catch-up vaccination in host countries, which may hinder immunisation coverage and increase the risk of vaccine-preventable disease outbreaks. Health systems must develop novel mechanisms to proactively offer culturally competent and accessible catch-up vaccination services to adult migrants on and after arrival.

Background:
Providing equal access to health care is a major goal of health systems and a criterion for health system performance assessment (HSPA). The first systematic HSPA for Germany has been piloted in 2021. Access is one dimension of the conceptual framework (others are, e.g., population health, quality, and efficiency), which will be analysed in the following.

Methods:
Nine indicators to measure access were selected based on a systematic search of established instruments in (inter)national HSPA initiatives. Included indicators are availability and accessibility of services (e.g., waiting times) and financial risk protection, among others. Other criteria for the inclusion of indicators were data availability and international comparability. Indicators were evaluated in terms of their trend over time , in international comparison (e.g., Austria, Denmark, France), and according to various equity categories (e.g., age, gender, region).

Results:
The indicator access to palliative care could not be evaluated due to lack of data. Overall, access is good in Germany. Internationally, Germany performs better than average on most of the indicators, and its performance has improved over time. Physician density in the inpatient and outpatient sectors has increased since 2000 and is above the average of comparator countries. For some specialties, physician density in rural areas is lower than in urban areas, but the gap has decreased in recent years and does not apply to primary care. Furthermore, only 0.3% of the total population report having foregone care, although they had considered it necessary.

Introduction:
Gender inequalities in morbidity and mortality are important problem in countries of Central and Eastern Europe. Mortality difference between men and women in Lithuania is one of the largest in Europe. The aim of this analysis was to identify factors that influence this difference in population-based sample of middle-and older-age men and women from Lithuanian arm of the HAPIEE Study.

Methods:
Data come from the Lithuanian part of international Health, Alcohol and Psychosocial Factors In Eastern Europe (HAPIEE) longitudinal cohort study. The analytical sample included 3729 women and 3062 men aged 45-74 years at the study baseline.
The study outcomes were all-cause, CVD and cancer mortality (mean follow-up approx. 10 years). Gender difference in study outcomes, and the role of wide range of socioeconomic, demographic, behavioural, metabolic and psychosocial covariates in this association was tested by regression modelling.

Results:
There were 913 deaths (576 in men) during the follow-up. Men had higher odds of mortality compared to women: for allcauses OR 2.42 (95% CI 2.09-2.81); for CVD 2.48 (2.03-3.08); for cancer 1.92 (1.54-2.38). BMI was identified as an effect modifier for all-cause and cancer mortality. When adjusted for confounders such as smoking, alcohol consumption or paid work, and stratified for BMI, the gender difference reduced a little for CVD mortality but remained virtually unchanged for all-cause and cancer mortality.

Conclusions:
We found substantial and statistically significant gender inequalities in mortality in this Lithuanian study. We found that men aged 45+ years were approximately two times more likely to die than women, with CVD mortality difference being even larger. Additionally, most of gender difference in mortality remained unexplained by the main social, psychosocial, behavioural and metabolic risk factors. Key messages: Large gender inequalities in mortality have been observed in this Lithuanian study of middle-and older-age men and women.
Most of the inequalities have not been explained by available social, psychosocial, behavioural and metabolic risk factors.

Background:
To investigate contextual factors that influence the implementation of obesity prevention interventions in school addressing children with low socioeconomic status (SES) is very important. Evidence about these factors helps to improve the implementation, which can promote the health of children with low SES and therefore reduce health inequity. We aimed to systematically identify, critically appraise and summarize the evidence on implementation of school-based interventions promoting obesity prevention for children with low SES.

Methods:
A systematic search in seven databases was conducted with the main inclusion criteria 1) school-based interventions and 2) age group 5-14 years. In the following are examples for reported aspects in the subcategories. In the sub-category D.2 Existing policy, policy in line with the intervention was a facilitator for implementation (N = 2), whereas lack of control over administrative changes and food served in cafeteria due to policy were reported as barriers (N = 2).

Conclusions:
Intervention research as well as applied health promotion should consider the complexity and interdependency of influencing factors for successful implementation. Albeit contextual factors are hardly changeable, they should be considered and addressed to reduce health inequity.

Key messages:
More research is needed with detailed reporting of influencing factors, as detailed information is those of relevance for practice. Contributing to standardized analysis and reporting in implementation research by using a comprehensive framework.