Achieving the Millennium Development Goals has proven to be a real challenge. Providing evidence on cost-effective interventions did not prove to be sufficient to secure the trust of national authorities, health care providers and patients. Introducing change in a health system requires a good understanding of the relationships between the actors of the system. Social network analysis can provide a new avenue to analyse the diffusion of innovations within a health system or a health organisation and analyse the structure and the properties of a health system. Evidence has been generated on the necessity of not only identifying the actors of a system but also qualifying the relationships between these actors.

Being healthy is important for living well and achieving longevity. In the business realm, furthermore, employers want healthy employees, as these workers tend to be more productive, have fewer rates of absenteeism, and use less of their health insurance resources. This article provides an overview of corporate “wellness” efforts in the American workplace and the concomitant challenges which employers will confront in implementing these programs. Consequently, employers and managers must reflect upon wellness policies and objectives, consult with professionals, and discuss the ramifications thereof prior to implementation. The authors herein explore how employers are implementing policies that provide incentives to employees who lead “healthy” lifestyles as well as ones that impose costs on employees who lead “unhealthy” lifestyles. The distinctive contribution of this article is that it proactively explores wellness program implementation challenges and also supplies “best practices” in the modern workplace, so employers can be better prepared when they promulgate wellness policies, and then take practical steps to help their employees become healthier and thereby help to reduce insurance costs. The article, moreover, addresses how wellness policy incentives—in the form of “carrots” as well as penalties—in the form of “sticks” could affect employees, especially “non-healthy” employees, as well as employers, particularly legally. Based on the aforementioned challenges, the authors make practical recommendations for employers and managers, so that they can fashion and implement wellness policies that are deemed to be legal, ethical, and efficacious.

Today, on the contrary of the last ten decades, the necessity of teaching hygienic issues, and caring the children’s health, is pretty obvious. Avicenna (10 AC), the famous Iranian physician and philosopher, scrutinized the health and hygiene with a deep insight to the matter. He considered the wellness not only as the recovery from the disease, but emphasized the maintenance of health by suggesting special points and instructions. In Islamic education, paying attention to cleanliness, health and physical strength is very important and considered as the intermediate goals for the achievement of “pure life”, which is the ultimate goal. Avicenna paid special attention to physical purity, health and wellness, and devoted the major parts of his book to them. The present article analyzes the Avicenna’s educational opinions, specially his viewpoints regarding hygiene and health in three stages of childhood, teenage years, and youth.

Background HIV/AIDS and Tuberculosis (TB) are major contributors to the burden of disease in sub-Saharan Africa. The two diseases have been described as a harmful synergy as they are biologically and epidemiologically linked. Control of TB/HIV co-infection is an integral and most challenging part of both national TB and national HIV control programmes, especially in contexts of instability where health systems are suffering from political and social strife. This study aimed at assessing the provision of HIV/TB co-infection services in health facilities in the conflict-ridden region of Goma in Democratic Republic of Congo. Methods A cross-sectional survey of health facilities that provide either HIV or TB services or both was carried out. A semi-structured questionnaire was used to collect the data which was analysed using descriptive statistics. Results Eighty facilities were identified, of which 64 facilities were publicly owned. TB care was more available than HIV care (in 61% vs. 9% of facilities). Twenty-three facilities (29%) offered services to co-infected patients. TB/HIV co-infection rates among patients were unknown in 82% of the facilities. Only 19 facilities (24%) reported some coordination with and support from concerned diseases’ control programmes. HIV and TB services are largely fragmented, indicating imbalances and poor coordination by disease control programmes. Conclusion HIV and TB control appear not to be the focus of health interventions in this crisis affected region, despite the high risks of TB and HIV infection in the setting. Comprehensive public health response to this setting calls for reforms that promote joint TB/HIV co-infection control, including improved leadership by the HIV programmes that accuse weaknesses in this conflict-ridden region.

Background Elimination of suicide attempts is impossible, but they can be reduced dramatically by an organized planning. The present study aimed to survey the suicide trends in Fars province (Iran), during 2004-2009 to better understand the prevalence and status of suicide. Methods This survey was a cross-sectional study. The demographic data were collected from the civil status registry between 2004 and 2009. Suicide and suicide attempt data were collected of three sources including the affiliated hospitals of Shiraz University of Medical Sciences, mortality data of Vice Chancellery of Health in Fars province and data from forensic medicine. Then, they were analyzed by Excel and SPSS. Chi-square and regression analyses were used for data analysis. Results During the study, 10671 people attempted suicide, of which 5697 (53%) were women and 4974 (47%) were men. Among them, 1047 people (9.8%) died, of which 363 (34%) were women and 679 (64%) were men. There was a significant relationship between gender and fatal suicide. The mean suicide attempt for both genders was 53 per 100,000 and 49, 57 for men and women, respectively. The trends in the incidence of Suicidal attempts were decreasing. Conclusion Without implementing effective preventive measures, the health care system in Iran will face a further burden of fatal suicides among young people. Therefore; enhancing the primary health care and specialized mental health services for those with unsuccessful suicide attempts can effectively reduce the burden of suicide.

Background To identify the prevalence of behavioural (Pre-pregnancy), obstetrical and medical risks of pregnancy in Iranian women. Methods A total of 2993 postpartum women who delivered in 23 randomly selected hospitals of six provinces were enrolled in this nationwide cross-sectional study. A structured questionnaire was completed based on interviewees’ self-reports and medical record data, consisting of socio-demographic characteristics, behavioural, obstetrical and medical risks, before and during pregnancy. Results Less than 6.0% had no health insurance and 5.0% had no prenatal visit before labour. Unintended pregnancy was reported by 27.5% of women. Waterpipe and/or cigarette smoking was reported by 7.1% of them and 0.9% abused opiates during pregnancy. Physical abuse by husband in the year before pregnancy occurred in 7.5% of participants. The rate of cesarean section was 50.4%. Preterm birth, low birth weight, and stillbirth were seen in 6.8, 7.7, and 1.2% of deliveries respectively. The most frequent medical risk factors were urinary tract infection (32.5%), anemia (21.6%), and thyroid disease (4.1%). Conclusion More effort should be devoted by health policymakers to the establishment of a preconception counselling (health education and risk assessment) and surveillance system; although obstetrical and medical risks should not be neglected too.

Health systems across the world are concerned with the quality and safety of patient care. This includes investing in research and development to progress advances in the treatment and management of individuals and healthcare organisations. The concept of evidence- based healthcare has gained increasing currency over the last two decades; yet questions persist about the time it takes for new research evidence to find its way into day to day healthcare decision-making. This paper explores the reasons for this apparent gap between research and healthcare practice, management and policy-making. In particular, the paper argues that different meanings attached to the word ‘evidence’ fundamentally influence the way in which the research-practice gap is conceptualised and subsequent strategies that are implemented to increase the uptake of research.

In “Buying Health: the Costs of Commercialization and an Alternative Philosophy”, Larry R. Churchill and Shelley C. Churchill discuss the commercialization of health and, in particular, the commercialization of nutrition. In this commentary on their article, I draw a connection between Churchill and Churchill’s account of the commercialization of nutrition and Michael Pollan’s critique of “nutritionism”. I also offer a friendly amendment to Churchill and Churchill’s account, suggesting that the commercialization of nutrition is not a monolithic experience but it is rather widely challenged.

The key argument of this commentary is that patient choice has a broader meaning than suggested by consumerist choice models. In increasingly marketized health care systems with diversified and knowledge-based service arrangements, patients are continuously obliged to choose insurers, physicians or hospitals and treatments—whether they like it or not. However, health care users refer to a wide range of roles and resources while taking health-related decisions. They are patients, consumers and co-producers at the same time. Therefore, as it is argued, healthcare policies have to recognize users’ multiple identities by providing more balanced choice frameworks. In particular, two aspects are crucial: first, opportunities for users to voice worries and concerns and to co-design default options of health care choices; secondly, taking the significance of interpersonal trust in choice-making processes into account.

Churchill and Churchill’s editorial discusses negative (health) effects of commercialism in the provision of health care and nutrition. Three parts of their argument are commented: the claim that the fundamental problem of markets is the decomposition of the whole into parts (“reductionism”); the call for individual responsibility; and the notion of holism. On the three aspects the commentary concludes thus: Because provision of health and food must be controlled and managed in some form, an alternative to some kind of decomposition is hard to see. The call for individual responsibility is controversial due to its lack of attention to socioeconomic inequalities. The concept of “holism” is problematic due to its epistemological and normative status.

Nowhere are the barriers to a functional health infrastructure more clearly on display than in the Goma region of Democratic Republic of Congo. Kaboru et al. report poorly integrated services for HIV and TB in this war-torn region. Priorities in conflict zones include provision of security, shelter, food, clean water and prevention of sexual violence. In Goma, immediate health priorities include emergency treatment of cholera, malaria, respiratory illnesses, provision of maternal care, millions of measles vaccinations, and management of an ongoing rabies epidemic. It is a daunting task to determine an essential package of medical services in a setting where there are so many competing priorities, where opportunity costs are limited and epidemiologic information is scarce. Non-governmental agencies sometimes add to the challenge via an insidious reduction of state sovereignty and the creation of new levels of income inequality. Kaboru et al. have successfully highlighted many of the complexities of rebuilding and prioritizing healthcare in a conflict zone.

Whereas public information campaigns have failed to reverse the rising trend in obesity, economists support food taxes as they suggest they can force individuals to change their eating behavior and make the agro-food industry think more about healthy food products. Excise taxes based on the unhealthy nutrient content would be more effective since they impact more on unhealthy food products than VAT (value-added-tax) taxes. Taxes based only on junk food products would avoid perverse effects on healthy nutrient. However, as eating behavior of consumers is complex, a modeling analysis would allow to assess unexpected effects on other unhealthy nutrients or products.

This commentary is a brief response to Nir Eyal’s argument that health policies should not make healthy behaviour a condition or prerequisite in order to access healthcare as it could result in the people who need healthcare the most not being able to access healthcare. While in general agreement due to the shared concern for equity, I argue that making health behaviour a condition to accessing healthcare can serve to develop commitment to lifestyle changes, make the health intervention more successful, help appreciate the value of the resources being spent, and help reflect on the possible risks of the intervention. I also argue that exporting or importing the carrot and stick policies to other countries without a solid understanding of the fiscal and political context of the rise of such policies in the US can lead to perverse consequences.

I agree entirely with Nir Eyal’s perspective that denying treatment to obese patients is morally wrong. However, the reasons for this belief differ in some ways from Eyal’s analysis. In this commentary, I will try to explain the similarities and differences in our perspectives. My primary claim is that the denial of treatment to obese patients is wrong principally because (i) it eschews a whole-population approach to the problem of poor nutrition and is therefore likely to be ineffective; (ii) it is likely to expand obesity-related health inequities; and (iii) it is likely to intensify stigma against already-marginalized social groups. I shall consider each in turn, and explore the extent to which Eyal would be likely to agree with my claims.

The obesity epidemic raises important and complex issues for clinicians and policy-makers, such as what clinical and public health measures will be most effective and most ethically-sound. While Nir Eyal’s analysis of these issues is very helpful and while he correctly concludes that “conditioning the very aid that patients need in order to become healthier on success in becoming healthier” is wrong, further discussions of these issues must include unequivocal support for safeguarding the fundamental moral basis of the doctor-patient relationship. Regardless of any patients’ failures to demonstrate effective responsibility for their own health, each patient needs and deserves a physician whose caring is never in doubt. Policy- makers need to ensure that our health systems always make this a top priority.

I want to thank Block and Willett (1) for their comments on my paper (2). Their remarks are substantial, thoughtful and they help us to discuss more profoundly one example of a food tax, the tax on Sugar-Sweetened Beverages (SSBs). Indeed, not all food taxes are created equal and next to a more general debate, we need to discuss into details every kind of attempt to tackle the increasing prevalence of obesity and diabetes. Though SSBs were not in particular what I had in mind, of course they are included in the debate. Let me reply to some of their arguments, given the limited word count of this format. I want to apologize for not being able to get into all of the arguments.

I would like to thank Dr. Benjamin Ewert (1) for his commentary on my short paper ‘Is patient choice the future of health care systems?’ (2) for three reasons. First, because I take heart from his support for my key thesis about the need to replace simplistic economic constructs underlying policy assumptions to explain how patients make health-related decisions in real life. Second, because it gives me the opportunity to, on the one hand, clarify my arguments on how health users’ embeddedness in social relations and patients’ multiple identities and personal circumstances influence these decisions; and to elaborate on the role of trust in this processes in more detail on the other hand. Third, because Dr. Ewert’s contribution helped me re-think issues concerning the importance of patient choice in the context of new challenges that public health systems face such as the threat to free and universal provision of health care services. Although I fully agree with the rejection of the obsolete conception of choice that tends to dominate current policy debates, I do believe that his conviction concerning the inescapability of choice requires some further qualifications. This stems from the recognition of users expressed desire to trade off choice against other more important attributes of health care which have to do with their values and norms originating in the ethics of care, and which makes provision of health services possible.