Introduction: The ongoing war in Ukraine has triggered a large-scale humanitarian crisis, significantly affecting the mental health and psychosocial well-being of the population. In this context, Mental Health and Psychosocial Support (MHPSS) has become a vital component of humanitarian response, requiring coordinated and integrated systems aligned with global standards, such as the Inter-Agency Standing Committee (IASC) framework. Purpose: This research explores how MHPSS coordination mechanisms operate in wartime Ukraine, identifies key actors and systemic barriers, and evaluates the impact of coordinated approaches on access, resilience, and psychosocial well-being. Approach: The study employs a desk-based narrative synthesis methodology, drawing on peer-reviewed literature, humanitarian reports, and policy documents, including the Ukrainian government’s Concept for the Development of Mental Health Care until 2030. Analytical lenses include the IASC MHPSS intervention pyramid and localization theory. The study also proposes visual tools to analyze coordination structures and service delivery pathways. Results: The study finds that Ukraine’s MHPSS coordination system demonstrates notable adaptability and well-developed structures. Core activities such as 4W mapping, non-specialist training programs, and policy alignment initiatives have expanded access, particularly to community-based care. However, challenges including stigma, provider burnout, insufficient funding, and limited rural access continue to constrain effectiveness. Innovative strategies like telehealth platforms and mobile clinics reflect adaptive resilience. Overlapping mandates and data fragmentation further complicate service alignment. Nonetheless, coordinated efforts have reached over 1.2 million individuals in 2023, with early evidence suggesting reductions in psychological distress among internally displaced populations. These findings underscore the critical role of context-sensitive, decentralized approaches in building sustainable MHPSS systems in conflict-affected settings. Conclusions: Ukraine’s MHPSS coordination system demonstrates adaptability and effectiveness in crisis settings, but enduring structural challenges remain. Future priorities should include strengthening local leadership, ensuring long-term financing, and integrating services to ensure sustainable support in crisis contexts.
Rihab Imam Mukhtar Elsharief, Magda Elhadi Ahmed Yousif, Abeer Abd ELrhman ELnour ELtilib
Background: Armed conflict has catastrophic effect on public health and overall wellbeing including causalities during war, long lasting physical and psychological effects, the reduction in human and financial resources which available to meet social needs and creation of setting in which violence is primary domain this issues clearly appeared in Sudan since conflict between Sudan army force and Rapid response force in 15th of April 2023. Methodology: This review aimed to reflect the effect of armed conflict on public health especially vulnerable groups and create plan for reform of collapsed health system during and after war in Sudan. Comprehensive review for previous related article using Pub –med, Google scholar Lancet and records from Federal and Local Ministry of Health in Sudan was done. Also SWOT analysis for current complexes was done to detect problems and achieve solutions. Results: The study reflects the effect of armed conflict on public health in countries suffered from war. The vulnerable populations those sufferings during war are elderly, children, neonates and women. SWOT analysis for current situation in Sudan reflects devastating effect of war in healthcare system. The study also offering a plan for strengthening of healthcare system which build on decentralization policy, Innovation related to community healthcare workers (CHWs) adoption and health-financing system strengthens. Conclusion: Strengthening of healthcare systems after disasters is an urgent concern, especially in countries that have experienced armed conflict due to great impact on public health. However, since few studies have been conducted concerning this topic in Sudan, further research is recommended.
Abstract This chapter offers an in-depth look at health politics and the tax-financed health system in Kosovo, a system which is in a process of transition towards social health insurance. It traces the development of Kosovo’s healthcare system, characterized by the establishment of a decentralized free-for-all-at-point-of-delivery health system during communism. After the end of the Kosovo War in 1999, Kosovo started actively seeking independence. Until the declaration of independence in 2008, politics in the country was mainly focused on the state-building process, while health policy was not a priority. Although facilitated by international organizations, legislation for establishing a social health insurance has been passed, the social health insurance system has not been implemented yet. Thus, healthcare services still remain financed by state and municipal budgets, medical professionals are public employees, and the private sector is not integrated into the public insurance system. Key healthcare issues have been high out-of-pocket payments, mainly for pharmaceuticals and private services, inequalities in health access, and high unemployment rates, which are likely to undermine the collection of social insurance contributions in the future.
This Note addresses the implementation of health insurance reform in Yemen. As a result of a system of user fees and a lack of health insurance, the current regime poses serious barriers to health care access for Yemen's uninsured citizens. When the dust settles from the ongoing conflict with Houthi rebels, the time will be ripe for replacing Yemen's health financing system. In order to rebuild trust and curb abuse in the public health system, legal reforms are required to implement health insurance through decentralized decision-making and accountability measures. The Welfare Regime Framework accommodates these general reforms through policies that reflect the particular circumstances of Yemen. The implementation of health insurance reform will require policy reforms that bring together local, national, and international stakeholders to finance and develop management capacity for community-based health insurance in Yemen.
This article analyzes the process through which WHO was established on the basis of the experience of the League of Nations Health Organization (LNHO). The article particularly focuses on the LNHO technocrats. Through their prewar experiences, technocrats realized that international health governance could promote international cooperation, while it could be utilized by various national representatives as one of their diplomatic strategies. Technocrats tried to alleviate this vulnerability by balancing big powers with smaller powers, national representatives with specialists, and centralization with decentralization. Their efforts and the development of international security in which economic and social cooperation were evaluated as a means towards international security resulted in the international health governance's autonomous establishment under the UN system, which can be termed as the origin of “human security.” The development of social cooperation in the postwar period can be considered to be an extension of their efforts in the League of Nations.
BACKGROUND: The Ministry of Defense budget constitutes 16% of the state budget. The budget for the Ministry of Health and for civilian health care is derived from the state budget. The health care funds receive their budgets from several sources. The capitation formula, which is determined by law, is the main factor that affects the size of the budget each fund receives. OBJECTIVE: The objective of this study is to describe the manner of planning, managing, monitoring, and controlling the budget allocated to medical services, which is a public budget for soldiers. METHODS: Several parameters are suggested for comparison, including the interface with the civilian health system, the method for budgeting a health care system, possible results of managing a medically centered budget, and the possibilities for monitoring the provided services. We also examine the potential for decentralization of authority. CONCLUSIONS: Managing the budget and locating appropriate alternatives, as well as the availability and accessibility of medical services, are important for procurement and for forming contracts with both military and civilian systems. Turnover based on updated information might serve to improve future health services.
This policy analysis provides insight into the ongoing process of mental health reform and the difficulty of sustaining such reform in post-conflict areas. It is based on experiences in Bosnia Herzegovina and Kosovo in the former Yugoslavia. This could be the first health policy analysis specifically on the subject of mental health reform in post-conflict areas. Mental health reforms started in 1995 in Bosnia Herzegovina and in Kosovo in 1999, immediately following the end of armed conflict in these regions. As a result, there are now sufficient literature studies and experience available in both areas to make an initial evaluation and policy analysis. Both areas were studied during various stages of the implementation of mental health reform, and because of this provided insight into the different phases of this ongoing process. The insights provided by this study could have implications for things such as the development of strategies for improving the sustainability of mental health reform in similar situations in future. Mental health problems account for five of the 10 leading causes of disability worldwide, which amounts to 12% of the total global burden of disease.1 In general, war-related disabilities (physical injuries) and mental disorders have an increasing impact on the global burden of disease. Projections for 2020 rank unipolar major depression and war-related disabilities in first and eighth place, respectively, in their impact on the global burden of diseases; in 1990 they ranked fourth and sixteenth.1 Mental health reform refers to a shift from institutional mental health care towards community mental health and mental health care. The WHO's World Health Report 2001 showed worldwide interest in community mental health care, considered to be more cost-effective than institutional care. Care of this kind makes it possible to intervene early when mental disorders are developing, and to limit the stigma attached to treatment.2,3 This shift from institutional mental health care towards community mental health and mental health care marks an important change in the whole of Eastern Europe and the former Soviet Union.4,5 Mental health reforms in the post-conflict areas of Bosnia Herzegovina and Kosovo have specific characteristics and dynamics, and are taking place within the context of huge foreign donor influence, overall health care reforms and reform of health care financing systems. There are many definitions of sustainability.6 Sustainability is defined here as a lasting, successful shift from a system where the main focus is on institutional, clinical mental health care to a system focusing on community mental health and integrated mental health care. The successful continuity of these new services also depends on cultural and financial characteristics. The following examples illustrate the difficulty of sustaining mental health reform in Bosnia Herzegovina and Kosovo: Planned community mental health centres are being implemented slowly.7–10 The general public is unaware of the mental health reforms and does not understand them.8–10 There are increasing problems of economic access to mental health care and services.11–14 Literature study of ‘grey’ policy documents and articles on health policy (including mental health policy) in Bosnia Herzegovina and Kosovo was undertaken. Policy documents were collected from many different actors such as the World Bank, several non-governmental organizations (NGOs) including Médecins Sans Frontières, HealthNet International (HNI) and the International Organization for Migration, the WHO, the United Nations High Commission for Refugees, key mental health and other health professionals and local ministries of health. For Bosnia Herzegovina, key informant interviews took place in August 2001 with: Various mental health and other health professionals (psychiatrists, psychologists, nurses and social workers) and patients in 15 mental health institutions, including university hospitals with psychiatric departments, psychiatric clinics, psychiatric wards of general hospitals and community mental health centres all over Bosnia Herzegovina; Several NGOs (HNI, Medica Zenica, Vive Zene and War Child); WHO office for Bosnia Herzegovina; International Committee of the Red Cross; Swiss Agency for Development and Cooperation, Coordination office Sarajevo, Embassy of Switzerland; Assistant Minister of Human Rights of the state of Bosnia Herzegovina; Entity Ministry of Health of the Republika Srpska. For Kosovo, key informant interviews took place in March 2002 in Geneva with those WHO mental health professionals consulted on mental health reform in Kosovo. In addition, there were email contacts with mental health professionals working in Kosovo (in the Pristina university hospital and in community mental health centres) and with WHO support staff in Kosovo. Walt's analytical framework15,16 was used here to analyse the data collected in Bosnia Herzegovina and Kosovo. This framework distinguishes context, content and process, and the various actors involved in mental health reform. It is a systematic framework that can broadly analyse the implementation of health policies (involving many disciplines and sectors); such a broad analysis is necessary here for evaluating mental health reform. For the context analysis, data were collected on political history, the history of mental health services, psychiatric epidemiology, foreign influences, health care financing systems, medical anthropology and societal values. For the content analysis, data were collected on principles of mental health reform and implementation characteristics (like the establishment of community mental health centres and education of mental health professionals). For the process analysis, data were collected on the timing and pace of mental health reform. For the actors (or stakeholders) analysis, Michael Reich's initial political mapping17,18 was used within Walt's framework to show political and other support for and opposition to the various actors in mental health reform in these highly complex, political environments. Data were collected through on-the-spot interviews and literature study. In particular, the interviews with local actors could prevent information bias by the literature, which is mainly oriented towards international donors. A great deal of grey literature (all types of policy documents) was used, which is common practice for policy analysis. To strive for the maximum degree of reliability, triangulation of this qualitative information was done by double-checking information during the interviews and using information from various local and international sources with different interests. This triangulation resulted in further convergence towards the results. Meta-analysis of the results detected the most important central theme: the role of foreign influence. This resulted in the main findings on the role of foreign influence in mental health reforms in post-conflict areas. The collected qualitative and some quantitative data from the interviews and available literature were structured within Walt's framework. Tables 1 and 2 give the most important interview and literature data. The references cited within the tables refer to the relevant literature and Internet sources for each topic. Context of mental health reform in Bosnia Herzegovina and Kosovo Table 1 shows the most important context analysis data for mental health reform in Bosnia Herzegovina and Kosovo. Table 2 shows the most important content and process analysis data for Bosnia Herzegovina and Kosovo. Content and process of mental health reform in Bosnia Herzegovina and Kosovo Figure 1 is explained more extensively because this figure's characteristics are not as familiar in public health literature. Figure 1 shows political support for and opposition to different actors in mental health reform in Bosnia Herzegovina and Kosovo. The assessment of the amount of power per actor is interpreted from the interviews and policy documents.8–13 The footnotes to this figure explain the characteristics of the relevant health ministries. In general, figure 1 makes clear the processes of decentralization, economic dependency and involvement of professionals in mental health and health policy. Informal networking between the actors and other micropower processes are beyond the scope of this analysis. A more extensive explanation follows to give more specific insights into the interpretation of supporting or opposing power for every actor. Political mapping: showing political support for and opposition to different mental health reform actors in Bosnia Herzegovina and Kosovo In Bosnia Herzegovina, international donors are very powerful because they are funding the reform in an economically unstable country. After decentralization, the National Ministry of Health lost power in terms of responsibility for the health care system (such as financing and determining the essential drug list). On the other hand, the Federation's cantonal ministries and the entity ministry of Republika Srpska gained a great deal of power. Mental health professionals have a lot of power because they play key roles in implementing this reform and because some health professionals hold key positions in the different ministries. Some key mental health professionals oppose the reform, especially in Republika Srpska's entity ministry and in a number of the Federation's cantonal ministries. They prefer to maintain the pre-war institutional mental health care organization, and support further specialization of mental health care services, such as specialized clinics for patients with post-traumatic stress disorder (PTSD). The public is not well organized (as in strong patient organizations), is not involved in policy making and so is not very powerful. Still, the public does have some power because they are the actual users of community mental health services. In Kosovo, international donors are very powerful for the same reason as they are in Bosnia Herzegovina. In 2002, decentralizing health care responsibilities towards the municipalities existed only on paper. Early in 2001, policy making and financial control of all health care was still a central responsibility of the United Nations (UN) Interim Administration Mission Kosovo Department of Health and Social Welfare. In 2002, this UN Department of Health started to transfer power to Kosovar ministries. From the beginning, mental health professionals have been heavily involved in drawing up the strategic plan for mental health reform in Kosovo; they reported no opposition to this. Public power has the same characteristics as those mentioned for Bosnia Herzegovina. Having all the data available in tables 1 and 2 and figure 1, triangulation and meta-analysis of these data resulted in further convergence towards the most important results on the identified central theme of foreign influence. The role of foreign influence was a central theme in many of the results. The context and process analysis showed that both areas became UN international protectorates and financially highly dependent on foreign donor funding. As a result, they became economically and politically dependent on the international community. The initiation, funding and also part of the operationalization of mental health reform was done by international organizations. For example, during the armed conflicts NGOs started new ambulatory emergency mental health services, and after the end of armed conflicts many NGOs entered the areas with their temporary ambulatory mental health activities focusing mainly on traumatization. Western health care financing models (mixed public–private insurance models) were quickly introduced in Bosnia Herzegovina, and health care financing became highly dependent on foreign donor funding. Local health administrators had to work according to new Western principles of efficiency and cost-effectiveness. The content analysis showed that many different mental health professionals were trained by a number of international organizations in the new concept of community mental health and mental health care. The actors analysis confirmed the power of international organizations to provide political support for mental health reform and also identified the concept of decentralization of political health care responsibilities supported by the international community. Particularly in the Federation of Bosnia Herzegovina, drastic decentralization took place using a Swiss cantonal model, which resulted in many small cantonal ministries of health.19 The input of qualitative data from the literature used was comparable for both Bosnia Herzegovina and Kosovo. The input of qualitative data from personal interviews differed between Bosnia Herzegovina and Kosovo. Although extensive personal interviews were held with many actors in Bosnia Herzegovina, owing to practical limitations the same kind of personal interviews were not possible inside Kosovo. This may have affected the input of qualitative data for Kosovo. To reduce this difference, thorough personal interviews took place with those WHO mental health professionals who were consultants on mental health reform there, and e-mail contacts were established with key mental health professionals. All these effects of foreign influence leave us with the following question: do they have a positive effect on mental health reform and its sustainability? Foreign technical and economic support versus lack of local awareness and lack of local ownership. Clearly, foreign influence, with its technical, political and economic support, pushed the reform forward just after the end of armed conflict. In particular, the foreign training of many different mental health professionals in the new concept of community mental health and mental health care was an important positive contribution to mental health reform. However, many years after the reform's initiation the general public is still not aware of this new concept, and some mental health professionals perceive it as a reform from abroad. This public lack of awareness together with the perception by professionals creates a lack of local ownership for mental health reform. Obviously, this endangers the reform's sustainability. Although it may be very difficult to change local beliefs on mental health-seeking behaviour and professional perceptions, the following two possible strategies could influence these firmly held beliefs and attitudes more successfully. Possible strategies. First of all, there could be more methodical ‘marketing'. In other words, taking local beliefs into account when developing mental health promotion strategies for the new concept of community mental health and mental health care could result in more successful sustainability of mental health reform. Examples of such marketing within the Bosnian and Kosovar context are mental health promotion within family, school and religious networks, and integrating community mental health services into existing somatic health services. Also, more anthropological research on mental health-seeking behaviour patterns could help tailor mental health promotion strategies. Secondly, the example of Kosovo showed that immediate involvement of local mental health professionals in strategic plans for mental health reform results in more sustainable reform. This is because local key mental health professionals will not perceive the changes as a reform from abroad, and will therefore be less likely to develop opposition to the reform in a later phase. Considering the epidemiology with its high prevalence of PTSD, it was logical for the different NGOs to start mental health programmes that focused on this mental health problem. However, parallel and overlapping mental health activities (‘trauma businesses') appeared that were unmanaged and chaotic. These were temporary, and because of this, endangered the sustainability of overall mental health reform, which includes all mental health problems. Possible strategies. If NGOs better combined their mental health activities, with PTSD treatment as a first priority, with existing mental health and somatic health services now under reform, sustainable mental health reform would probably stand a better chance. Introducing Western insurance models and privatization created increasing problems of access to mental and other health care. Private insurance schemes were implemented only by law, not in practise. Bosnia Herzegovina in particular did not seem to be ready for an insurance model. In 2001 Kosovo did not yet have a health care financing system, and even the World Bank suggested reintroducing the old national health insurance or tax model with payroll tax. Possible strategies. Introducing a financing system closer to the original existing system and taking into account to what extent the area is ready for this could result in increased chances for both sustainable mental health reform and a more sustainable health care system in general. The concept of decentralization promoted by many international organizations aimed at more local involvement was in part counterproductive, especially in Bosnia Herzegovina. It produced microbureaucratic procedures for many health care financing issues like insurance logistics. This created increasing access problems to mental and other health care. Local health care administrators used to centralized bureaucratic principles suddenly had to work from a decentralized, powerful position according to new utilitarian principles like cost-effectiveness and efficiency. One cannot expect a centralized East European post-conflict country to be immediately ready to switch to a decentralized Swiss cantonal model. Possible strategies. Introducing decentralization less drastically at a local level and at a slower pace by well-trained administrators ready to take over responsibilities would probably reduce the risk of additional access problems and increase local involvement and the chances for sustainability. As shown by the examples of Bosnia Herzegovina and Kosovo, this policy analysis provides insight into the difficult policy and process of mental health reform in post-conflict areas. These examples show the difficulty of sustaining mental health reform several years after the end of armed conflict and the initiation of such reform. This insight was gained by collecting all kinds of data (mostly qualitative, some quantitative) on many different topics and themes and from many different sources from various political positions. The method of analysis used—Walt's framework together with Michael Reich's political mapping—was a useful way to structure all these different and extensive qualitative data. This manner of structuring, along with ongoing triangulation and meta-analysis of the data, resulted in convergence towards the most important results, which follow here. As illustrated by the examples of Bosnia Herzegovina and Kosovo, foreign influence in post-conflict areas appeared to be a central theme of these results. Foreign influence has the following effects on mental health reform and its sustainability: Foreign influence has a stimulating effect on the initiation of mental health reforms by introducing this new concept and by technical and economic support along with technical education. Foreign influence by various actors can threaten the sustainability of mental health reform in the following ways: by creating a lack of local ownership of the new concept of community mental health and mental health care; by creating chaos with many overlapping short-term mental health programmes (mainly dealing with traumatization); by forcing rapid changes in health care financing systems (such as privatization), and introducing new insurance models too rapidly; and by forcing rapid decentralization of health care responsibilities. In conclusion, to achieve sustainable mental health reform, foreign aid provided in these difficult post-conflict situations has to achieve a balance between measured foreign influence and involvement of existing local structures. This policy analysis provides insight into mental health reform and the difficulty of sustaining such reform in post-conflict areas. Foreign influence accelerates mental health reform in post-conflict areas, but can also threaten its sustainability in various ways. The insights help to develop strategies for studying and improving sustainability of health reforms in similar (post-conflict) situations. Walt's analytical framework with Michael Reich's political mapping is a suitable method to analyse health reforms in post-conflict areas. Foreign influence in post conflict areas can threaten health reforms by creating chaos and a lack of local ownership and by forcing quick privatization and decentralization.
At first thought, there would appear to be little or no obvious connection between Landmarks in Hepatology and the essay recently published in the New England Journal of Medicine by 1986 Nobel Peace Prize Laureate Elie Wiesel.1 In 40 articles published over the past 4 years, the Landmarks series has not only documented the background of numerous discoveries in hepatology that have resulted from observation and experimentation, but it has also celebrated the physicians and investigators who brought us these new hepatological insights, investigations, and therapies. The Landmarks essays have been embellished with play on words and other attempts at humor, biography, history, politics, and the arts, and have presented for the readership abstruse facts and historical trivia to enhance the appreciation and enjoyment of the science and clinical innovation of hepatology. In contrast, Professor Wiesel's essay reminded us of one of the saddest eras in medical experimentation that serves as an archetype for inhumanity perpetrated by physicians, often but not always in the name of science, on hapless human subjects who had no choice but to participate in the most cruel and brutal experiments. It goes without saying that there was no semblance of informed consent. Wiesel refers, of course, to the medical experiments carried out by Nazi physicians and their henchmen and lackeys during the Dark Age known as the Third Reich. Out of this sordid experience, portrayed in the accounts of survivors and eyewitnesses, historical documents, and in the testimonies of those physicians who faced the Nuremberg Tribunal, ethical rules for experimentation on patients and volunteers were codified2 (Fig. 1). Surely, however, there is no connection between the celebration of hepatological discovery and the perversion of Nazi medical brutality—but there is. And because there is we have the opportunity, justification, and, in fact, the duty to confront the memory of these events so as to reinforce our vigilance and determination to uphold the highest ethical standards in hepatology and, indeed, in all of medicine, be it experimental science or routine clinical practice. This connection between discovery in hepatology and cruel experimentation was personified by one of the most prestigious and prodigious investigators in liver disease in the 1920s and 1930s; namely, Hans Eppinger. Observant and perceptive readers of Landmarks in Hepatology will surely have noticed that until now there has been no mention of Hans Eppinger nor any reference to his many contributions in the field. This purposeful exclusion came about, rightly or wrongly, because I felt unable to honor this physician-scientist for his early discoveries, knowing full well about his later utterly ethically unacceptable activities as a medical leader, physician-scientist, and human being. This month's article will therefore redress the balance with respect to both components of that man's extraordinary career, which ended ignominiously in self-destruction. My decision to revisit those tragic events was not taken lightly; it is also in full keeping with the commitment expressed in the first paragraph of the very first article in this series,3 which promised enlightenment in order to avoid repetition of past mistakes. Whereas it is hard to believe that anything as terrible as occurred under the auspices of Nazi medicine could happen now or in the future, we can never be reminded too often of the needs for obtaining true informed consent, for full disclosure in explaining the likely outcome of our actions as physicians, and of partnering with rather than patronizing our patients and study volunteers. Physicians have an abiding responsibility toward their patients and experimental subjects, whose rights must be protected and championed even when the good of the community, of the state, and of humankind appears to be at stake. It is timely to address this issue now in the closing days of the year that simultaneously commemorated the 60th anniversary of the liberation of the Nazi extermination camps at the end of the Second World War and saw the wide distribution and acclaim of the movie Hotel Rwanda, which poignantly and painfully chronicled a recent modern genocide so graphically. We have yet to learn the full extent of physician participation and complicity in the abuse and torture of detainees at Abu Ghraib.4, 5 To paraphrase Elie Wiesel in his interview with Professor Georg Klein6 on December 10, 2004, in connection with the Nobel Peace Prize that he was awarded for his work on genocide and for his message of peace, atonement, and human dignity, "It was not hatred that perished at Auschwitz….only the victims died." Hans Eppinger was born in Prague in 1879 supposedly into a part-Jewish family of so-called "Privileged Jews"7-10 who, thus entitled by the Emperor, enjoyed social, civil, and professional liberties that were out of reach to their less favored co-religionists. It may appear paradoxical that Eppinger was also apparently accredited years later as an "Official Aryan" by the National Socialist authorities, a designation that was clearly linked to his joining the Nationalsozialistische Deutsche Arbeiter-Partei (NSDAP); i.e., the National Socialist German Workers' Party, nicknamed the Nazi Party. Yet it was not uncommon that exemptions to the 1935 Nuremberg Racial Laws were granted to certain Mischlinge; i.e., Jewish half-breeds, and incongruously many Deutschblütigkeitserklärüngen (Certificates of German Blood) were actually signed by Adolf Hitler himself, thereby officially classifying the recipients as Aryans when such outright hypocrisy suited the Führer and his kind.11 An astounding number of these Mischlinge were promoted to high rank in the German Armed Forces, and some even prospered politically.11 It should be noted, however, that the truth about Eppinger's ethnicity is still not known, and more discovery about it is needed. In 1902, more than 30 years before these grotesque events transpired, Eppinger was awarded his Doctorate in Medicine in Graz, where 20 years earlier his father, Hans Eppinger senior, had been appointed Professor of Pathological Anatomy. After staying for a few years, Eppinger moved to the famed Allgemeine Krankenhaus (General Hospital) in Vienna, where he rose to become First Assistant in the First Medical Clinic, which was headed by the internationally acclaimed cardiologist Karel Frederik Wenckebach. Later, when he was a full Professor of Medicine, Eppinger accepted the position of Chair of Medicine in Freiburg im Breisgau, after turning down offers from Strassburg, Halle, Königsberg, Leipzig, Frankfurt, and even Berlin. He left for Cologne in 1930, but it was there that in April 1933—ironically, probably because of his part-Jewish heritage—he fell foul of the Brown Shirts, Hitler's Sturmabteilung (SA or Storm Division). He hurriedly returned to Vienna to head the First Clinic but, importantly, because of his tussle with the German Reich, this appointment was permitted only after the intervention of Kurt von Schuschnigg, the Austrian Education Minister, who was to succeed Engelbert Dollfuss as Chancellor when the latter was assassinated in July 1934. Eppinger's professional interests and expertise ran the gamut of internal medicine and pathology, and he published extensively on topics as diverse as bundle branch block, diaphragmatic defects, cardiac asthma, circulatory dysfunction, nephrosis, hemolytic anemia, the inflammatory reaction, parathyroid disease, and many more besides.7 He was a fanatical and overzealous experimenter and at the same time a much sought-after clinical consultant for monarchs, heads of state, and other notables, including Josef Stalin and the Dowager Queen Marie of Rumania. It was rumored that he had also attended Adolf Hitler, but this possibility was dismissed by the late Fritz Redlich (1910-2004) in his biography of the German dictator,12 on the grounds that Hitler did not like famous and overbearing academic physicians and was pathologically as secretive about his health as he was over other details of his personal life and history. By coincidence, Redlich, who was Chair of Psychiatry (1950-1967) and Dean of the Medial School (1967-1972) at Yale University, had been a medical student and resident in Vienna when Eppinger was Chair of Medicine, before he emigrated to the United States in 1938. There are several associations between Eppinger and modern hepatology. First, of course, was his fascination with liver disease, in which he undertook many studies. Arguably his most important—one could say "Landmark"—contribution was in helping to dispel the myth that jaundice in hepatitis, so-called "catarrhal jaundice," is due to biliary obstruction caused by ascending duodenal inflammation, swelling of the ostium of the bile duct, and mucus biliary plugging, as Gabriel Andral and his many followers maintained.13, 14 Eppinger reasoned instead that toxins absorbed from the intestines injured the endothelium in the liver ("capillaritis"), causing intralobular edema and allowing serum to escape from the blood and deposit in the space of Disse.15 Eppinger's monograph on liver pathology and therapy, in which this hypothesis of "serous hepatitis" is also discussed,16 was, in its time, the handbook or bible for anyone interested in liver disease. The second link between Eppinger and modern hepatology was his mentorship of and complex relationship with the late Hans Popper (1903-1988), the undisputed father of hepatology in the latter part of the 20th Century.8-10, 17 Hans Popper worked in Eppinger's laboratory both in Vienna as a medical student and later in Freiburg in 1928.9, 10 When Eppinger returned to Vienna in 1933, he persuaded Popper to transfer from the Institute of Pathology to the First Medical Clinic as an Assistant Physician. Next, Eppinger appointed Popper and Hans Kaunitz (who, like Popper, was Jewish) to supervise a new ward that he opened. During all of his activities, Eppinger's brilliance and achievements were indelibly stained by defects of personality and character, which were well recognized by all who knew him and of him. Notwithstanding Popper's admiration for him as a scientist and his profound debt to him as a mentor and supporter, these flaws alone were grave enough to mar Eppinger as a role model for young scientists and physicians. As John Cornwell points out in the opening of his book on Hitler's scientists,18 quoting François Rabelais,19 "Science without conscience is the ruin of the soul" — Science sans conscience n'est que ruine de l'âme — a warning that might have been written with Eppinger in mind. Eppinger had no scruples10; he stole case histories from other physicians and had to be supervised while watching operations in case he stole instruments as well. He was banned from the University library after being caught cutting pages out of books and bound journals. He stole gallbladders from Wenckebach's laboratory and later, using these specimens without due acknowledgment, he published the phenomenon of gallbladder edema in patients who died of beriberi. Eppinger's callous handling of his patients was no less dishonorable or overt. In his autobiography, the esteemed German theologian Helmut Thielicke described the cruel, dangerous, and demeaning treatment he received from Eppinger, whose advice he had sought for severe tetany following inadvertent parathyroid injury.20 Otto Fleming, who had been a medical student in the 1930s in Vienna and who later was a general practitioner in south Yorkshire, UK, recalled how he and all his fellow students were shocked by Eppinger's brutality when he reduced a patient to tears by explaining to those present in the lecture theater that this man with nephritis was in the "final act of the tragedy" of his disease.21 Apparently even those in NSDAP circles in Vienna complained about, among other criticisms, Eppinger's brutality to his patients and his reckless driving.22 Werner Creutzfeldt, Professor Emeritus and former Chair of Medicine at the University of Göttingen for 28 years, recalled Hans Popper inferring that Eppinger had a hole in his brain where other people have a conscience. Creutzfeldt also related to me that even almost a score of years after Eppinger's departure from Freiburg, senior nurses still in practice there vividly remembered Eppinger's heartless attitude towards his patients, a contrast to the warmth of their nostalgia for Siegfried Thannhauser, who succeeded him briefly. There is no doubt that Eppinger was an ardent Nazi, as Redlich described him,12 and played a key role in the dastardly Sea Water Experiments in the Dachau concentration camp.22-24 However, these signature activities in his curriculum vitae are either glossed over euphemistically or omitted completely from the many available, albeit brief, biographical accounts of Eppinger's life.7-10, 25, 26 Eppinger was dismissed from his position in the University of Vienna after the war, in June 1945, because he had been a member of the then-illegal Nazi Party in Austria before the Anschluss; i.e., the annexation of Austria by Germany.27 He had also been a clandestine member of the nationalistic Deutschen Klub, to which he had paid dues since November 1937.22 He stood idly by when 153 of the 197 medical faculty in Vienna were sacked within weeks of the Anschluss, mostly for being Jewish.28 Eppinger may not have been driven by extreme racist views per se—after all, he had appointed several Jews like Popper and Kaunitz to high positions in his Clinic. Rather, Eppinger fervently believed that the goals of the Third Reich offered the best future for Germans everywhere. Whether this was the main philosophy of so many other physicians, who it must be remembered represented the highest enrollment (45%) in the NSDAP of any professional group,29 is far from clear. Also, by joining forces with the NSDAP he sought to further his own megalomania for research opportunities and material support. Whatever his motivation, Eppinger did abet the militantly prejudiced, recently appointed Dean, Eduard Pernkopf, in ruthlessly promoting the Nazi medical ethos in the Vienna school. Hans Eppinger even celebrated the first anniversary of the "cleansing" of the faculty by authoring an upbeat newspaper article in the Neues Wiener Tagblatt, in which he declared, "Now that all disease (my italics) has been eradicated, the Viennese School of Medicine can in future dedicate itself to its great task without inhibition."28 Pernkopf, incidentally, rose to become the Rector of the University in 1943; after spending 2 years imprisoned by the Allies after the war, he was free to complete his notorious "Atlas of Topographical and Applied Human Anatomy," for which the bodies of almost 1,400 people executed by the Gestapo, mostly for "political" reasons, served as artists' models.30 To Eppinger, who threw in his lot wholeheartedly with the philosophy, doctrines, policies, and hierarchy of the Third Reich, it was but a small step to invest his medical research expertise in the planning and conduct of human studies for the benefit of the German military effort. Although Eppinger's other activities have not yet been exhaustively researched, there has been no evidence presented thus far that he also participated medically in the sickening racial hygiene work that aimed to perfect techniques of mass extermination and sterilization, nor in studies that sought to document and preserve the anatomical characteristics of inferior racial groups, those people referred to as Untermenschen, or "subhumans," considered to have Lebensunwertes Leben, i.e., lives unworthy to be lived, and other individuals, such as the enfeebled, retarded, and those with neurological or physical defects. Neither did he seem to engage in futile sadistic experiments, such as excruciatingly painful attempts at muscle, bone, and even whole limb transplantation. In this context, it is chilling to point out that numerous German physicians had already played key practical roles in forcible sterilizations (some 300,000 to 400,000 victims) and in legalized killings, mostly by gassing and cremation, of individuals with mental or physical handicaps. Therein was the prototype for the extermination process of the Final Solution of the Jews, which physicians not an of the German physicians to the Nazi the and the or and were of using their medical such as the early of the so-called of and have been The of how to and and in the for of time the and military The to in and studies were to this end on both of the military To a at the German over the of the of with an so-called which some already was true with an Eppinger and from that a be to the of and with that of or complete for to to the best of health and even may be by the Eppinger also that his recently promoted in Vienna, conduct the which had to be at the Dachau concentration because the of volunteers at the medical were so late in the The experiments were in the of but the of including the of a liver without not to mention that the experimental subjects of would and other in attempts to some The of and including between the of the Medical of the and Reich of the and Reich of the it that Eppinger was no but was instead a key the offered on was the that there was no of during the of the the that the physicians were only following the of their or the of the the that the Allies and other had experiments the that the victims were to and the that there were no or for human experimentation that could The also that to as would the of medical and it that their among some of the and on the Although it is true that human experiments have been in almost even after the Nuremberg was have the and human of the Third Reich. act of not Also, or not the no with or or the this responsibility has been expressed in all over the Also, the was recognized in where for human experimentation also had been before During his to with his was and his that there had been any of the that had and Eppinger's to that on his was to years of the other physicians and in the were of were to by 5 to life 2 to for years, and to 10 were Eppinger was not but he was to appear before the However, on the of 25, one before the of the was he and it not for the extraordinary events that occurred almost 40 years later, the of Hans Eppinger may well have with him. However, in the late the and of the that he in Freiburg in and the of many and in liver research that and to a for and in liver studies. he to his Hans Popper, the father of hepatology of the for advice on a for the and Popper the name of Eppinger. Werner Creutzfeldt, for was at the in the of Eppinger's and from other than Hans Popper himself, and so he Popper the Popper was on of his for Eppinger as a liver scientist and his to After all, when Popper Vienna in under the of the Gestapo, among the he with him were his his his and a signed of that he later to that of his own the it must be that it was and that Popper knew of Eppinger's role in and did as he his for The must be however, that Popper's was At the very he should have his mentor more knowing well of his and the that he had on in Vienna in the medical even when its faculty had been by The Eppinger which Popper to a Nobel Prize of was awarded first to in but he nor recipients were likely to have had any as to Eppinger's name In the early Professor of Medicine at Yale University and of the for in Medicine at the Yale University School of Medicine, of the and it with the Eppinger whose he had as a medical student and about he had later in the of The case was taken by the and Eppinger's name was from the but only after the on the of the New on November The New article caused great to who were the of the for the of in that very Armed with few facts at that time, were and between those who of the and those who were and that was The the years of Hans Popper's as he was of his earlier of but he no over the of the As he me while on a to he knew that when he to work for Eppinger in he had a with the years later, the for for the same to the name of Eppinger from a that had received its designation by the in on the anniversary of its latter and, we the between Hans Eppinger and modern us full to the at the of this namely, how to with the flaws of the when these are related to the conduct of the science itself and human and life are In this can be considered under the of which often to from studies that were or like the at who recently published that no from experiments should be by in the that experiments by such are likely to be as well as being there was evidence that even in Dachau the were this is not a since some and investigations, like the Nazi and for the link between and were even were on the same racial hygiene that to and have that the benefit of the research is of such that it more lives than were the and the could not or would not have been in any other without such human we should and the and at the same time the highest and to the time the are This the however, of on the and by our we their To between these is too a to As might be by such the to medicine would be for This was to the in the when the of the New England Journal of Medicine to the of Nazi studies that were to be in In the case of Eppinger, the decision is an of his earlier work is clearly it can be to have been and ethically yet at the same time and at one should him and for the he did and one should never his name to be as an for or as a role The more by however, and one that is both more and more to is so many physicians the and in so many have the their of and a commitment to Yet for all Wiesel still in us as a I in that medicine is still a he the highest ethical the still for And for us all, We to him. in of this the was of Professor that there was no evidence that Eppinger had any Jewish It was a that Eppinger's was of from the on both of Jewish of of the of The with and by and with and and with Werner Creutzfeldt and Elie Wiesel The also the for his and in the of this essay in Whereas the and of these the his a of and documents, the are his
Israel's ongoing health reform provides lessons regarding attempts to combine universal coverage under national health insurance with a version of managed competition. Based on principles of 'justice, equality and mutual aid," Israel's National Health Insurance Law, 1994 guarantees access to a broad basket of basic services to be provided by four competing sick funds, and the availability of resources adequate to finance the basket. The new rights of citizens to universal coverage and to move freely among sick funds constituted a major policy breakthrough. However, successive amendments to the Law reflect continuing controversy over the amount of resources required to finance the basic basket. Despite the intention to base the system on decentralization and competition, successive amendments have placed more control over health system finance and sick fund management in the hands of the Ministries of Finance and Health. Updating the basic basket to take account of new technologies and drugs has raised unresolved dilemmas. In the Israeli case the dialectic of management vs. competition and of government vs. market, obscures fundamental issues related to the right of citizens to health services. The process set in motion by adoption of The National Health Insurance Law, 1994 calls on public managers and politicians to design institutions which can set priorities within a limited budget and effectively regulate the health care system.