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Is better health the fundamental goal, and will politicians collaborate effectively?

The collapse of the Soviet Union was a massive natural experiment that has provided many insights that help our understanding of the determinants of population health. This paper identifies a series of lessons learnt from this experience: Rapid transition can damage health.When undertaking comparative research, it is essential to have a common understanding of what different terms mean in different places.When looking at exposures and outcomes, it is important to appreciate that the delay between exposure to a risk factor and the appearance of disease can range from almost none to several decades.Contrary to the views of some commentators, modern healthcare has made a substantial contribution to the health of populations in industrialised countries.Science can flourish only where it is free from ideology.Public health and basic science achieve most when they work together.Without functioning democracy, the outlook for better health is poor.

Richard Stone, Some British Empiricists in the Social Sciences, 1650–1900 Arup Maharatna, The Demography of Famines: An Indian Historical Perspective Timothy W. Guinnane, The Vanishing Irish: Households, Migration, and the Rural Economy in Ireland, 1850–1914 Gail Kligman, The Politics of Duplicity: Controlling Reproduction in Ceausescu's Romania Rosalind P. Petchesky and Karen Judd (Eds.), Negotiating Reproductive Rights: Women's Perspectives Across Countries and Cultures

Imagine a health professional in any European country who fell asleep in 1960 and awoke in a health facility in 2019. Much of what the observer saw would be quite different. There would be many more patients who were surviving into old age thanks to advances in therapy. Many of the treatments that they were receiving would be much more complex, involving radically new techniques such as laparoscopic or even robotic surgery, and they would be amazed by the advances in diagnostic capacity. Yet, in many health systems, some things would have changed very little. Among them would be the traditional roles of different types of health worker, with responsibility for certain task being reserved for those with particular qualifications based on custom and practice rather than on evidence. This opinion argues that this situation must change. There is now an impressive body of evidence that things can often be done differently. This does not mean that they should be. Change is only appropriate where it helps to achieve the goals of the health system and allows it to provide better care in ways that are more responsive to the needs of users. Tasks can be shifted from health workers to patients and their carers, to machines, and to other health workers. Where these shifts have been evaluated, they often, but not always, are associated with outcomes that are as good or even better than with the status quo. However, the results are often context dependent, and it cannot be assumed that what works in one situation will apply equally to another. What matters is the evidence, rather than traditional, but often obsolete rules. If a health system can ensure that tasks are being undertaken by those most appropriate to do them, it will enhance patient care. However, change is often difficult. Those involved must be convinced of the rationale for change and must be supported in implementing it. This should recognise that any change in roles will have implication for their status and thus existing hierarchies. It may also be necessary to challenge outdated legislative or regulatory barriers. Finally, it is essential the changes are evaluated, results are documented, and lessons are learned, both in relation to what works and in what circumstances. Task shifting, where it is based on robust evidence and implemented effectively, can make a major contribution to health outcomes and to the sustainability of health systems. It is not, however, a panacea for all of the challenges health systems face. ; Představte si zdravotnického odborníka v kterékoli evropské zemi, který usnul v roce 1960 a probudil se ve zdravotnickém zařízení v roce 2019. Hodně z toho, co by pozorovatel viděl, by bylo úplně jiné. Bylo by mnohem více pacientů, kteří přežili do stáří díky pokrokům v terapii. Mnoho z ošetření, které dostávali, by bylo mnohem složitější, zahrnovalo radikálně nové techniky, jako je laparoskopická nebo dokonce robotická chirurgie, a byl by ohromen pokrokem v diagnostickém rozsahu. Přesto by se v mnoha zdravotnických systémech některé věci změnily jen velmi málo. Mezi nimi by byly tradiční role různých typů zdravotnických pracovníků, přičemž odpovědnost za určitý úkol by byla vyhrazena těm, kteří mají zvláštní kvalifikaci založenou spíše na zvyklostech a praxi než na důkazech. Toto stanovisko tvrdí, že se tato situace musí změnit. Nyní existuje impozantní soubor důkazů, že věci lze často dělat jinak. To neznamená, že by měli být jinak dělány. Změna je vhodná pouze tam, kde pomáhá dosahovat cílů zdravotnického systému a umožňuje jí poskytovat lepší péči způsoby, které lépe reagují na potřeby uživatelů. Úkoly lze převádět ze zdravotnických pracovníků na pacienty a jejich pečovatele, na stroje a další zdravotnické pracovníky. Tam, kde byly tyto posuny vyhodnoceny, jsou často, ale ne vždy, spojeny s výsledky, které jsou stejně dobré nebo dokonce lepší než za současného stavu. Výsledky jsou však často závislé na kontextu a nelze předpokládat, že to, co funguje v jedné situaci, se bude vztahovat stejně na jiné. Důležitý je důkaz spíše než tradiční, ale často zastaralá pravidla. Pokud zdravotní systém může zajistit, že osoby, které jsou pro ně nejvhodnější, plní správně alokované úkoly, zlepší se péče o pacienty. Změna je však často obtížná. Zúčastněné strany musí být přesvědčeny o důvodech změny a musí být podporovány při jejich provádění. Musí uznat, že každá změna rolí bude mít dopad na jejich stav, a tedy na existující hierarchie. Může být také třeba změnit zastaralé legislativní nebo regulační překážky. Nakonec je nezbytné, aby byly změny vyhodnoceny, výsledky zdokumentovány a vedly k ponaučení, co funguje a za jakých okolností. Posun úkolů, činností a kompetencí, pokud je založen na spolehlivých důkazech a je účinně prováděn, může významně přispět k lepším výsledkům v oblasti zdraví a k udržitelnosti zdravotních systémů. Nejedná se však o všelék na všechny výzvy, kterým zdravotnické systémy čelí. ; Imagine a health professional in any European country who fell asleep in 1960 and awoke in a health facility in 2019. Much of what the observer saw would be quite different. There would be many more patients who were surviving into old age thanks to advances in therapy. Many of the treatments that they were receiving would be much more complex, involving radically new techniques such as laparoscopic or even robotic surgery, and they would be amazed by the advances in diagnostic capacity. Yet, in many health systems, some things would have changed very little. Among them would be the traditional roles of different types of health worker, with responsibility for certain task being reserved for those with particular qualifications based on custom and practice rather than on evidence. This opinion argues that this situation must change. There is now an impressive body of evidence that things can often be done differently. This does not mean that they should be. Change is only appropriate where it helps to achieve the goals of the health system and allows it to provide better care in ways that are more responsive to the needs of users. Tasks can be shifted from health workers to patients and their carers, to machines, and to other health workers. Where these shifts have been evaluated, they often, but not always, are associated with outcomes that are as good or even better than with the status quo. However, the results are often context dependent, and it cannot be assumed that what works in one situation will apply equally to another. What matters is the evidence, rather than traditional, but often obsolete rules. If a health system can ensure that tasks are being undertaken by those most appropriate to do them, it will enhance patient care. However, change is often difficult. Those involved must be convinced of the rationale for change and must be supported in implementing it. This should recognise that any change in roles will have implication for their status and thus existing hierarchies. It may also be necessary to challenge outdated legislative or regulatory barriers. Finally, it is essential the changes are evaluated, results are documented, and lessons are learned, both in relation to what works and in what circumstances. Task shifting, where it is based on robust evidence and implemented effectively, can make a major contribution to health outcomes and to the sustainability of health systems. It is not, however, a panacea for all of the challenges health systems face.

The complex nature of many chronic diseases, which affect people many different ways, requires a multifaceted response that will meet the needs of the individual patient. Yet while everyone agrees that the traditional relationship between an individual patient and a single doctor is inappropriate, there is much less agreement about what should replace it. . . Many countries are now experimenting with new approaches to delivering care in ways that do meet the complex needs of people with chronic disorders, redesigning delivery systems to coordinate activities across the continuum of care. Yet w

Health-care systems in developed countries must respond to increasingly diverse populations given greater population movements in our globalized world. The chapters in this book discuss countries and population groups that illustrate different responses to claimant groups.