背景:大衰退,2008年金融危机之后,导致许多政府采取紧缩计划。这对卫生系统功能产生了持久的影响,资源,工作人员(数字,动机和士气)和患者的结果。这项研究旨在了解卫生系统弹性如何受到影响,以及这如何影响后续冲击的准备情况。
方法:一项现实主义者的综述确定了与紧缩(近端结果)相关的遗产,以及这些遗产如何影响卫生系统韧性的远端结果。EMBASE,CINAHL,MEDLINE,EconLit和WebofScience进行了搜索(2007-2021年5月),导致1081篇文章。进一步的理论驱动搜索导致了另外60项研究。描述性的,感应,演绎和逆向现实主义分析(利用Excel和Nvivo)辅助上下文-机制-结果配置(CMOC)的发展,以及利益相关者的参与,以确认或反驳新出现的结果。因果途径,以及导致近端和远端结果的背景和机制之间的相互作用,被揭露。完善的CMOC和政策建议主要侧重于劳动力弹性。
结果:五个CMOC展示了在外部代理人的优先事项驱动下,紧缩驱动的政策决策如何影响卫生系统。这创造了一个真正的或感知的转变,远离卫生专业人员的价值观和利益,对决策过程的不信任和对变革的抵制。他们的价值观与在持续的限制性工作条件下执行此类政策决定的现实不符(工作人员的配给,耗材,治疗方案)。对专业的看法减弱,无法提供高质量的服务,公平,和需求主导的护理,除了停滞或退化的工作条件,导致道德困扰。这可能会伪造遗产,这些遗产可能会在面对未来的冲击时对复原力产生不利影响。
结论:这篇综述揭示了透明的重要性,开放的沟通,除了共同制定的政策,以避免可能对劳动力和卫生系统复原力有害的情况。
The Great Recession, following the 2008 financial crisis, led many governments to adopt programmes of
austerity. This had a lasting impact on health system functionality, resources, staff (numbers, motivation and morale) and patient outcomes. This study aimed to understand how health system resilience was impacted and how this affects readiness for subsequent shocks.
A realist review identified legacies associated with
austerity (proximal outcomes) and how these impact the distal outcome of health system resilience. EMBASE, CINAHL, MEDLINE, EconLit and Web of Science were searched (2007-May 2021), resulting in 1081 articles. Further theory-driven searches resulted in an additional 60 studies. Descriptive, inductive, deductive and retroductive realist analysis (utilising excel and Nvivo) aided the development of context-mechanism-outcome configurations (CMOCs), alongside stakeholder engagement to confirm or refute emerging results. Causal pathways, and the interplay between context and mechanisms that led to proximal and distal outcomes, were revealed. The refined CMOCs and policy recommendations focused primarily on workforce resilience.
Five CMOCs demonstrated how
austerity-driven policy decisions can impact health systems when driven by the priorities of external agents. This created a real or perceived shift away from the values and interests of health professionals, a distrust in decision-making processes and resistance to change. Their values were at odds with the realities of implementing such policy decisions within sustained restrictive working conditions (rationing of staff, consumables, treatment options). A diminished view of the profession and an inability to provide high-quality, equitable, and needs-led care, alongside stagnant or degraded working conditions, led to moral distress. This can forge legacies that may adversely impact resilience when faced with future shocks.
This review reveals the importance of transparent, open communication, in addition to co-produced policies in order to avoid scenarios that can be detrimental to workforce and health system resilience.