If global trade were fair, it is argued, then international aid would be unnecessary and inequalities inherent to the economic system would be justifiable. Here, we argue that while global trade is unfair, in part because richer countries set the rules, we believe that additional interventions must go beyond trade regulation and short-term aid to redress inequalities among countries that will persist and possibly worsen in spite of such measures. Drawing on an example of measures taken to redress the characteristics of a system that inherently increases inequality, the ability of dominant teams in the National Basketball Association (NBA) to recruit the most talented players, we argue that market-based competition even in the context of fair rules will create and amplify economic inequalities. We argue that, just as the NBA created a draft to reduce the emergence of severe inequalities among teams, systems of social support within richer countries should be paralleled by a global system to counterbalance persisting inequalities among countries that are produced by market forces. We explain how such a mechanism might operate among integrated market economies, and identify the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) as an example of such an emerging form of global social support.

Background Priority setting in healthcare is a key determinant of health system performance. However, there is no widely accepted priority setting evaluation framework. We reviewed literature with the aim of developing and proposing a framework for the evaluation of macro and meso level healthcare priority setting practices. Methods We systematically searched Econlit, PubMed, CINAHL, and EBSCOhost databases and supplemented this with searches in Google Scholar, relevant websites and reference lists of relevant papers. A total of 31 papers on evaluation of priority setting were identified. These were supplemented by broader theoretical literature related to evaluation of priority setting. A conceptual review of selected papers was undertaken. Results Based on a synthesis of the selected literature, we propose an evaluative framework that requires that priority setting practices at the macro and meso levels of the health system meet the following conditions: (1) Priority setting decisions should incorporate both efficiency and equity considerations as well as the following outcomes; (a) Stakeholder satisfaction, (b) Stakeholder understanding, (c) Shifted priorities (reallocation of resources), and (d) Implementation of decisions. (2) Priority setting processes should also meet the procedural conditions of (a) Stakeholder engagement, (b) Stakeholder empowerment, (c) Transparency, (d) Use of evidence, (e) Revisions, (f) Enforcement, and (g) Being grounded on community values. Conclusion Available frameworks for the evaluation of priority setting are mostly grounded on procedural requirements, while few have included outcome requirements. There is, however, increasing recognition of the need to incorporate both consequential and procedural considerations in priority setting practices. In this review, we adapt an integrative approach to develop and propose a framework for the evaluation of priority setting practices at the macro and meso levels that draws from these complementary schools of thought.

Background ß-Thalassemia is a prevalent genetic disease in Mediterranean countries. The most common treatments for this disease are blood transfusion plus iron chelation (BTIC) therapy and bone marrow transplantation (BMT). Patients using these procedures experience different health-related quality of life (HRQoL). The purpose of the present study was to measure HRQoL in these patients using 2 different multiattribute quality of life (QoL) scales. Methods In this cross-sectional study, data were gathered using 3 instruments: a socio-demographic questionnaire, EQ-5D, and SF-36. A total of 196 patients with ß-thalassemia were randomly selected from 2 hospitals in Shiraz (Southern Iran). Data were analyzed using logistic regression and multiple regression models to identify factors that affect the patients’ HRQoL. Results The average EQ-5D index and EQ visual analog scale (VAS) scores were 0.86 (95% CI: 0.83–0.89) and 71.85 (95% CI: 69.13–74.58), respectively. Patients with BMT reported significantly higher EQ VAS scores (83.27 vs 68.55, respectively). The results showed that patients who lived in rural area and patients with BMT reported higher EQ VAS scores (rural; ß=10.25, P=.006 and BMT; ß=11.88, P=.000). As well, SF-36 between 2 groups of patients were statistically significant in physical component scale (PCS). Conclusion Patients in the BMT group experienced higher HRQoL in both physical and mental aspects compared to those in the BTIC group. More studies are needed to assess the relative cost-effectiveness of these methods in developing countries

Inequalities in the social determinants of health (SDH), which drive avoidable health disparities between different individuals or groups, is a major concern for a number of international organisations, including the World Health Organization (WHO). Despite this, the pathways to changing inequalities in the SDH remain elusive. The methodologies and concepts within system science are now viewed as important domains of knowledge, ideas and skills for tackling issues of inequality, which are increasingly understood as emergent properties of complex systems. In this paper, we introduce and expand the concept of adaptive policies to reduce inequalities in the distribution of the SDH. The concept of adaptive policy for health equity was developed through reviewing the literature on learning and adaptive policies. Using a series of illustrative examples from education and poverty alleviation, which have their basis in real world policies, we demonstrate how an adaptive policy approach is more suited to the management of the emergent properties of inequalities in the SDH than traditional policy approaches. This is because they are better placed to handle future uncertainties. Our intention is that these examples are illustrative, rather than prescriptive, and serve to create a conversation regarding appropriate adaptive policies for progressing policy action on the SDH.

This paper represents a commentary to Marianna Fotaki’s Editorial: ‘Why and how is compassion necessary to provide good quality healthcare?’ Within this commentary, I discuss some of the issues raised by Marianna Fotaki, and conclude that we should work towards an organizational culture which considers the important concept of compassion by focusing on the well-being and teamwork of all involved.

This is a short commentary to the editorial issued by Marianna Fotaki, entitled: “Why and how is compassion necessary to provide good quality healthcare.” It introduces the necessity of a more cognitive approach to explore further the determinants of behavior towards compassionate care. It raises questions about the importance of training towards a more patient-care and values driven healthcare system.

This article discusses what ethicists have called “unacceptable trade-offs” in health policy choices related to universal health coverage (UHC). Since the fiscal space is constrained, trade-offs need to be made. But some trade-offs are unacceptable on the path to universal coverage. Unacceptable choices include, among other examples from low-income countries, to expand coverage for services with lower priority such as coronary bypass surgery before securing universal coverage for high-priority services such as skilled birth attendance and services for easily preventable or treatable fatal childhood diseases. Services of the latter kind include oral rehydration therapy for children with diarrhea and antibiotics for children with pneumonia. The article explains why such trade-offs are unfair and unacceptable even if political considerations may push in the opposite direction.

The United States President’s Emergency Plan for AIDS Relief (PEPFAR) emphasizes health systems strengthening as a cornerstone of programmatic success. Health systems strengthening, among other things, includes effective capacity building for clinical care, administrative management and public health practice. Avante Zambéziais a district-level in-service training program for administrative staff. It is associated with improved accounting practices and human resources and transportation management but not monitoring and evaluation. We discuss other examples of successful administrative training programs that vary in the proportion of time that is spent learning on the job and the proportion of time spent in classrooms. We suggest that these programs be more rigorously evaluated so that lessons learned can be generalized to other countries and regions.

Background Maternal health remains a central policy concern in Vietnam. With a commitment to achieving the Millennium Development Goal (MDG) 5 target of maternal mortality rate (MMR) of 70/100 000 by 2015, the Ministry of Health (MoH) issued the National Plan for Safe Motherhood (NPSM) 2003-2010. In 2008, reproductive health, including safe motherhood (SM) became a national health target program with annual government funding. Methods A case study of how SM emerged as a political priority in Vietnam over the period 2001-2008, drawing on Kingdon’s theory of agenda-setting was conducted. A mixed method was adopted for this study of the NPSM. Results Three related streams contributed to SM priority in Vietnam: (1) the problem of high MMR was officially recognized from high-quality research, (2) the strong roles of policy champion from MoH in advocating for the needs to reducing MMR as well as support from government and donors, and (3) the national and international events, providing favorable context for this issue to emerge on policy agenda. Conclusion This paper draws on the theory of agenda-setting to analyze the Vietnam experience and to develop guidance for SM a political priority in other high maternal mortality communities.

Background Health literacy presents an enormous challenge in the delivery of effective healthcare and quality outcomes. We evaluated the impact of low health literacy (LHL) on healthcare utilization and healthcare expenditure. Methods Database analysis used Medical Expenditure Panel Survey (MEPS) from 2005-2008 which provides nationally representative estimates of healthcare utilization and expenditure. Health literacy scores (HLSs) were calculated based on a validated, predictive model and were scored according to the National Assessment of Adult Literacy (NAAL). HLS ranged from 0-500. Health literacy level (HLL) and categorized in 2 groups: Below basic or basic (HLS <226) and above basic (HLS =226). Healthcare utilization expressed as a physician, nonphysician, or emergency room (ER) visits and healthcare spending. Expenditures were adjusted to 2010 rates using the Consumer Price Index (CPI). A Pvalue of 0.05 or less was the criterion for statistical significance in all analyses. Multivariate regression models assessed the impact of the predicted HLLs on outpatient healthcare utilization and expenditures. All analyses were performed with SAS and STATA®11.0 statistical software. Results The study evaluated 22 599 samples representing 503 374 648 weighted individuals nationally from 2005-2008. The cohort had an average age of 49 years and included more females (57%). Caucasian were the predominant racial ethnic group (83%) and 37% of the cohort were from the South region of the United States of America. The proportion of the cohort with basic or below basic health literacy was 22.4%. Annual predicted values of physician visits, nonphysician visits, and ER visits were 6.6, 4.8, and 0.2, respectively, for basic or below basic compared to 4.4, 2.6, and 0.1 for above basic. Predicted values of office and ER visits expenditures were $1284 and $151, respectively, for basic or below basic and $719 and $100 for above basic (P < .05). The extrapolated national estimates show that the annual costs for prescription alone for adults with LHL possibly associated with basic and below basic health literacy could potentially reach about $172 billion. Conclusion Health literacy is inversely associated with healthcare utilization and expenditure. Individuals with below basic or basic HLL have greater healthcare utilization and expendituresspending more on prescriptions compared to individuals with above basic HLL. Public health strategies promoting appropriate education among individuals with LHL may help to improve health outcomes and reduce unnecessary healthcare visits and costs.

Invasive meningococcal disease (IMD) is a severe bacterial infectious disease with high mortality and morbidity rates worldwide. In recent years, industrialised countries have implemented vaccines targeting IMD in their National Immunisation Programmes (NIPs). In 2002, the Netherlands successfully implemented a single dose of meningococcal serogroup C conjugate vaccine at the age of 14 months and performed a single catch-up for children =18 years of age. Since then the disease disappeared in vaccinated individuals. Furthermore, herd protection was induced, leading to a significant IMD reduction in non-vaccinated individuals. However, previous studies revealed that the current programmatic immunisation strategy was insufficient to protect the population in the foreseeable future. In addition, vaccines that provide protection against additional serogroups are now available. This paper describes to what extent the current strategy to prevent IMD in the Netherlands is still sufficient, taking into account the burden of disease and the latest scientific knowledge related to IMD and its prevention. In particular, primary MenC immunisation seems not to provide long-term protection, indicating a risk for possible recurrence of the disease. This can be combatted by implementing a MenC or MenACWY adolescent booster vaccine. Additional health benefits can be achieved by replacing the primary MenC by a MenACWY vaccine. By implementation of a recently licensed MenB vaccine for infants in the NIP, the greatest burden of disease would be targeted. This paper shows that optimisation of the immunisation strategy targeting IMD in the Netherlands should be considered and contributes to create awareness concerning prevention optimisation in other countries.

The authors of “Management matters: a leverage point for health systems strengthening in global health,” raise a crucial issue. Because more effective management can contribute to better performing health systems, attempts to strengthen health systems require attention to management. As a guide toward management capacity building, the authors outline a comprehensive set of core management competencies needed for managing global health efforts. Although, I agree with the authors’ central premise about the important role of management in improving global health and concur that focusing on competencies can guide management capacity building, I think it is important to recognize that a set of relevant competencies is not the only way to conceptualize and organize efforts to teach, learn, practice, or conduct research on management. I argue the added utility of also viewing management as a set of functions or activities as an alternative paradigm and suggest that the greatest utility could lie in some hybrid that combines various ways of conceptualizing management for study, practice, and research.

In their study, Brenna and Spandonaro analyzed the mobility into Italian regions. In particular, it analyzes the situation of 5 regions, with very different backgrounds. With this paper, we try to better define the meaning of health mobility and to find its underlying causes. Furthermore, we propose a strategy that could help in controlling mobility flows that currently are the source of health inequalities.

Disconnects and defects in care – such as duplication, poor integration between services or avoidable adverse events – are costly to the health system and potentially harmful to patients and families. For patients living with multiple chronic conditions, such disconnects can be particularly detrimental. Lean is an approach to optimizing value by reducing waste (eg, duplication and defects) and containing costs (eg, improving integration of services) as well as focusing on what matters to patients. Lean works particularly well to optimize existing processes and services. However, as the burden of chronic illness and frailty overtake episodic care needs, health systems require far greater complex, adaptive change. Such change ought to take into account outcomes in population health in addition to care experiences and costs (together, comprising the Triple Aim); and involve patients and families in co-designing new models of care that better address complex, longer-term health needs.

Healthcare decisions are often made under pressure, with varying levels of information in a changing clinical context. With limited resources and a focus on improving patient outcomes, healthcare managers and health professionals strive to implement both clinical and cost-effective care. However, the gap between research evidence and health policy/clinical practice persists despite our best efforts. In an attempt to close the gap through behaviour change interventions, there has been a strong held belief that ‘more is better,’ without understanding the mechanisms and circumstances of knowledge translation (KT). We argue that even a singleintervention or strategy in translating evidence into healthcare policy or practice is rarely simple to implement. Nor is the evidence compelling on the best approach. As Harvey and Kitson argued, designing and evaluating KT interventions requires flexibility and responsiveness. If we are to move forward in translation science then we need to use rigorous designs such as randomised controlled trials to test effectiveness of interventions or strategies with embedded process evaluations to understand the reason interventions do or do not work!

Global Health 2035, the report of The Lancet Commission on Investing in Health, laid out a bold, highly ambitious framework for making rapid progress in improving global public health outcomes. It showed that with the right health investments, the international community could achieve a “grand convergence” in global health—a reduction in avertable infectious, maternal, and child deaths down to universally low levels—within a generation. Rwanda’s success in rapidly reducing such deaths over the last 20 years shows that convergence is feasible. Binagwaho and Scott have argued that 5 lessons from this success are the importance of equity, quality health services, evidence-informed policy, intersectoral collaboration, and effective collaboration between countries and multilateral agencies. This article re-examines these lessons through the lens of the Global Health 2035 report to analyze how the experience in Rwanda might be generalized for other countries to making progress towards achieving a grand convergence.

We would like to thank Lapão 1 and Schwarcz et al 2 for their thoughtful additions related to our article “Implementation of a health management mentoring program: Year-1 evaluation of its impact on health system strengthening in Zambézia Province, Mozambique,” 3 and for sharing their practical lessons and insights into the state of health system strengthening activities. In our article, we described a health management mentoring strategy and suggested results in district health system functioning after its first year of implementation.