Europe is warming at more than twice the global average, and heatwaves increasingly coincide with extreme wildfires, rainfall, floods and storms, creating growing health security risks while intensifying an ongoing health and care workforce crisis. Governments across the European Region have scaled-up action to establish heat-health action plans, supported by comprehensive WHO guidance. However, health and care workers remain largely absent from these strategies, which continue to place their focus on protecting populations rather than the workforce responsible for delivering care. Workforce measures are fragmented, poorly coordinated and rarely linked to broader health security and resilience agendas. This policy commentary argues that health and care workers should be recognised within heat-health action plans as both a vulnerable population and critical group for health security infrastructure. Drawing on policy documents, published literature, WHO guidance, and expert insights, we identify key policy gaps and argue for a dedicated HCWF strategy and integrated transsectoral governance that recognises workforce resilience as a prerequisite for health system resilience.

Europe is currently facing novel security threats in many different areas, reinforcing the need for a well prepared and protected health and care workforce to ensure health system resilience and service provision for the population under conditions of a poly-crisis. However, the health and care workforce is weakened by persisting shortages, competency gaps and mismatches, and poor working and mental health conditions. Health and care workers are not prepared for yet another crisis and a systematic strategy is lacking. This policy commentary argues for health and care workforce preparedness and protection as a structural pillar and integral part of an emerging EU health and security landscape, calling for a coherent European Union strategy and highlighting capacities for implementation and co-benefits for democratic societies and economies. Key policy recommendations include: developing a coordinated EU strategy that is capable to protect, prepare and retain health and care workers; closing the competencies gaps to align preparedness for military aggression, cyberattacks, climate change, and new infectious diseases; investing in research and data spaces to strengthen evidence-based information and policy; creating governance structures and building on existing EU programs and budgets to freeing resources for the health and care workforce.

The 74th WHO Europe Regional Committee introduced a set of health priorities comprising core areas of public health and expanded tasks to respond to multiple crises and emergent needs of populations and health systems. No systematic procedure of competencies development and routine review has been established to align changing health policy priorities and workforce. We argue for a transformative approach to competencies development from theoretical constructs to actionable pathways. A rapid qualitative assessment of three of the most relevant public health workforce competencies frameworks in the WHO European region was undertaken using selected priorities and the public health workforce as cases. The results highlight that existing competencies frameworks provide some helpful guidance, but gaps exist in specific and generic competencies and leadership. Further research and policy are needed, calling European and national policymakers to action to invest in public health competencies development to respond to evolving priorities.

Around the world, institutional trust is declining while democratic discontent is rising. What role do health and health systems play in this crisis? We review decades of interdisciplinary research to describe how health and health systems are linked to democratic trust and engagement. When individuals or communities experience a decline in their health, they feel "let down" by the health system and other public institutions meant to support their well-being. Consequently, they are less likely to vote. Those who continue to vote are increasingly drawn to anti-establishment, anti-democratic parties that promise to radically reform the system. Once in power, however, these parties often weaken public health protections or exclude select populations from the health system. The result can be a self-reinforcing feedback loop between declining health and political discontent. We conclude by offering concrete suggestions for improving population health while rebuilding trust in health systems and democratic institutions more broadly.

Background Interest in community health workers (CHWs) and the benefits for health systems are growing globally, but research is focused on low- and middle-income countries and high-income Anglo-American countries. Objective This comparative assessment focuses on community health systems and health and care workers as advocates and boundary spanners, aiming to connect global evidence to high-income European countries and assessing the capacities for transformative change. Methods A qualitative comparative approach and case study design were chosen, aligning global expertise of the CHW pioneers, Brazil and South Africa, and selected European countries: Denmark, Germany, Netherlands, Portugal, Romania, UK/England. Case studies were collected in April/May 2025, drawing on country experts and secondary sources; thematic analysis was performed following an explorative interactive consensus-based procedure. Results European countries create diverse occupational pathways into health systems that move beyond primary healthcare, clinical tasks, and CHWs as defined globally. Promising capacities emerge if occupational programs are interconnected with health system reform, community-based social and care services, the establishment of a regulated multi-professional community-centred group, and strengthening of public health and social support services. No country uses these capacities effectively. Conclusions Community-centred health and care workers need greater attention in Europe to drive health system transformations and global policy learning.

The global migration of the health and care workforce (HCWF) has intensified, leading to complex policy scenarios and diverse migration patterns. While the traditional narrative of individual health and care workers (HCWs) migrating from low- and middle-income countries to high-income countries in search of higher income, career prospects and working conditions remains relevant, it now coexists with many other drivers, incentives, and dynamics at individual and policy level. The evolving dynamics of HCW migration have profound implications extending far beyond health labour markets, influencing broader societal and political landscapes. Despite their significance, the qualitative shifts in HCWF migration patterns and the governance challenges they present are poorly understood and under-researched, and policies have thus been limited in their effectiveness. In this policy comment we argue for a global response and an enhanced focus on policy implementation, using selected case studies to illustrate the argument. The cases highlight complexities of HCW migration patterns and opportunities for strengthening implementation of the WHO Global Code of Practice to respond effectively to the diverse needs of health systems and individual HCWs.

Background Primary healthcare has emerged as a powerful global concept, but little attention has been directed towards the pivotal role of the healthcare workforce and the diverse institutional setting in which they work. This study aims to bridge the gap between the primary healthcare policy and the ongoing healthcare workforce crisis debate by introducing a health system and governance approach to identify transformative capacities in health system contexts. Methods A qualitative comparative methodology was employed, and a rapid assessment of the primary healthcare workforce was conducted across nine countries: Denmark, Germany, Kazakhstan, Netherlands, Portugal, Romania, Serbia, Switzerland, and the United Kingdom/ England. Results Our findings reveal both convergence and pronounced diversity across the healthcare systems, with none fully aligning with the ideal attributes of primary healthcare suggested by WHO. However, across all categories, Denmark, the Netherlands, and to a lesser extent Kazakhstan, depict closer alignment to this model than the other countries. Workforce composition and skill-mix vary strongly, while disparities persist in education and data availability, particularly within Social Health Insurance systems. Policy responses and interventions span governance, organisational, and professional realms, although with weaknesses in the implementation of policies and a systematic lack of data and evaluation. The WHO primary healthcare model only marginally informs policy decisions, with the exception being in Kazakhstan. Conclusion We conclude that aligning primary healthcare and workforce considerations within the broader health system context may help move the debate forward and build governance capacities to improve resilience in both areas. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any specific funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data generated and analysed during this study are included in this published article and supplementary information files. * APN : Advanced Practice Nurse EU : European Union HCW : Healthcare workers HCWF : Healthcare workforce NHS : National health service PHC : Primary healthcare SDGs : Sustainable Development Goals SHI : Social health insurance UHC : Universal health coverage UK : United Kingdom WHO : World Health Organisation

Inadequate numbers, maldistribution, attrition, and inadequate skill-mix are widespread health and care workforce (HCWF) challenges. Intersectoral-inclusive of different government sectors, non-state actors, and the private sector-collaboration and action are foundational to the development of a responsive and sustainable HCWF. This review presents evidence on how to work across sectors to educate, recruit, and retain a sustainable HCWF, highlighting examples of the benefits and challenges of intersectoral collaboration. We carried out a scoping review of scientific and grey literature with inclusion criteria around intersectoral governance and mechanisms for the HCWF. A framework analysis to identify and collate factors linked to the education, recruitment, and retention of the HCWF was carried out. Fifty-six documents were included. We identified a wide array of recommendations for intersectoral activity to support the education, recruitment, and retention of the HCWF. For HCWF education: formalise intersectoral decision-making bodies; align HCWF education with population health needs; expand training capacity; engage and regulate private sector training; seek international training opportunities and support; and innovate in training by leveraging digital technologies. For HCWF recruitment: ensure there is intersectoral clarity and cooperation; ensure bilateral agreements are ethical; carry out data-informed recruitment; and learn from COVID-19 about mobilising the domestic workforce. For HCWF retention: innovate around available staff, especially where staff are scarce; improve working and employment conditions; and engage the private sector. Political will and commensurate investment must underscore any intersectoral collaboration for the HCWF.

Abstract Background We adopt a health system and governance perspective to address the mental health needs of healthcare workers, considering the nature of interventions and the levels and actors involved in governance. The aim is to move the debate forward by identifying governance gaps hampering the implementation of health workforce policies and exploring strategies to effectively increase mental health support. Methods A qualitative comparative methodology is applied based on a case study design utilising a multi-level intersectoral governance matrix. The assessment matrix comprises four key categories: health policy and data, social policy and psycho-social conditions, organisation of work, and job and professional conditions. We conducted a rapid assessment of healthcare workforce developments in the European context, drawing on secondary sources and country experts. The country sample comprises Germany, Portugal, Romania, Switzerland and the United Kingdom. Results Awareness of mental health threats among healthcare workers increased, but policy discourse is driven by service delivery and labour market demands. The attention to healthcare workers’ needs is stronger on the international level especially supported by WHO action, and weakest at national/regional levels. Although organisations and professions demonstrate varying degrees of activity, their efforts are scattered and lack sustainability. Similar challenges were identified across healthcare systems, including limited action, disconnected actors, missing coordination, and a lack of attention to governance gaps and system weaknesses. Conclusions There are similar problems across countries. Mental health policy is driven by labour market needs and ignores research evidence and the individual needs. Successful mental health policy implementation needs multi-level governance and coherent coordination mechanisms, and generally greater attention to the ‘human side’ of the healthcare workforce. Speakers/Panelists Sara Alidina Central Administration of the Health System, Lisbon, Portugal Tomas Zapata WHO/Europe, Copenhagen, Denmark

Objectives: We conduct a rapid review of the post-COVID-19 vaccination efforts undertaken by Denmark, the United States, and Canada. The main areas of focus are threefold: 1) To analyze the timeline of the rollout and access/barriers to vaccinations considering the changing dynamics of COVID-19 and the launch of new generation booster -vaccines across the case countries. 2) To examine sociopolitical factors related to this juxtaposition between lower booster acceptance, despite higher rates of initial vaccine series, in each of the three cases. 3) To determine how each country is moving forward with their ongoing COVID-19 strategies for long-term mitigation planning. Methods: We followed a Most Similar Systems Design (MSSD) framework to select our cases. We analyze country responses amongst high -income, OECD countries, who shared Western or liberal Democracy, with a formal framework of rule of law, presence of a legal authority and the independence of the judiciary, but differ in their rollout and uptake of the vaccine booster. Results: Despite variation in booster uptake, all three countries ' COVID-19 mitigation responses became more similar over time, and each country experienced lower than expected booster uptake. Conclusions: Decline in booster doses across each country was related to broad declines in concern about the virus in each location. However, cases with higher uptake of the initial series and use of NPIs, in Denmark and Canada, continue to fare better in morbidity and mortality from COVID-19, despite dwindling booster uptake. Public Interest Summary: This study looks at how three high income western democracies (Denmark, the United States and Canada) handled the COVID-19 pandemic and booster vaccinations. We briefly look at the initial outbreak of the pandemic, contextualize the initial (pre -booster) vaccination uptake and then assess the booster vaccine uptake. We find that although the countries differ in their approach during the initial stages of COVID-19 and vaccination policy, they all share similarly low booster vaccine uptake. Yet, even with a similarly low booster uptake, each of the countries continue to exhibit differences in morbidity, mortality and disparities associated with COVID-19. The implications of this research are clear - providing access to vaccinations, boosters, testing, and treatment are essential in combating inequalities in COVID-19 outcomes. Overlaying these implications is the importance of a continuously updated national strategy for future pandemics is important.