All societies face the need to make judgments about what interventions (both public health and personal medical) to provide to their populations under reasonable resource constraints. Their decisions should be informed by good evidence and arguments from health technology assessment (HTA). But if HTA restricts itself to evaluations of safety, efficacy, and cost-effectiveness, it risks being viewed as insufficient to guide health decision-makers; if it addresses other issues, such as budget impact, equity, and financial protection, it may be accused of overreaching. But the risk of overreaching can be reduced by embedding HTA in a fair, deliberative process that meets the conditions required by accountability for reasonableness.

Background Understanding the prevalence of symptoms associated with sexually transmitted infections (STIs) and how care is sought for those symptoms are important components of STIs control and prevention. People’s preference between public and private service providers is another important part of developing a well-functioning STIs surveillance system. Methods This cross-sectional survey was carried out in spring 2011, using a nonrandom quota sample of 1190 participants (52% female) in 4 densely-populated cities of Tehran, Kerman, Shiraz, and Babol. Two predictive logistic regression models were constructed to assess the association between the socio-demographic determinants (independent variables) and the dependent variables of history of STIs-associated symptom and seeking care. Results Around 57% (677 out of 1190; men: 29.70% and women: 81.80%) had experienced at least one STIsassociated symptom during the previous year. History of experiencing STIs-associated symptoms among men, was negatively significantly associated with older age (adjusted odds ratio [AOR] = 0.34, CI 95%: 0.17-0.67). Women who were married, in older ages, and had higher educations were more likely to report a recent (past year) STIs symptom, however all were statistically insignificant in both bivariate and multivariable models. Among those who have had STIs-associated symptoms in the last year, 31.15% did nothing to improve their symptoms, 8.03% attempted self-treatment by over-the-counter (OTC) medications or traditional remedies, and 60.93% sought care in health facilities. In both bivariate and multivariable analyses, care seeking among men was insignificantly associated with any of the collected demographic variables. Care seeking among women was positively significantly associated with being married (AOR = 2.48, 95% CI: 1.60-3.84). Conclusion The reported prevalence of STIs-associated symptoms among our participants is concerning. A considerable number of participants had delayed seeking care and treatment or self-medicated. People should be informed about their sexual health and the consequences of delaying or avoiding seeking care for STIs. Participants preferred seeking care at private sectors which calls for engaging both public and private health sectors for reporting and following up STIs cases.

Background Both rising healthcare costs and the global financial crisis have fueled a search for policy tools in order to avoid unsustainable future financing of essential health benefits. The scope of essential health benefits (the range of services covered) and depth of coverage (the proportion of costs of the covered benefits that is covered publicly) are corresponding variables in determining the benefits package. We hypothesized that a more comprehensive health benefit package may increase user costsharing charges. Methods We conducted a desktop research study to assess the interrelationship between the scope of covered health benefits and the height of statutory spending in a sample of 8 European countries: Belgium, England, France, Germany, the Netherlands, Scotland, Sweden, and Switzerland. We conducted a targeted literature search to identify characteristics of the healthcare systems in our sample of countries. We analyzed similarities and differences based on the dimensions of publicly financed healthcare as published by the European Observatory on Health Care Systems. Results We found that the scope of services is comparable and comprehensive across our sample, with only marginal differences. Cost-sharing arrangements show the most variation. In general, we found no direct interrelationship in this sample between the ranges of services covered in the health benefits package and the height of public spending on healthcare. With regard to specific services (dental care, physical therapy), we found indications of an association between coverage of services and cost-sharing arrangements. Strong variations in the volume and price of healthcare services between the 8 countries were found for services with large practice variations. Conclusion Although reducing the scope of the benefit package as well as increasing user charges may contribute to the financial sustainability of healthcare, variations in the volume and price of care seem to have a much larger impact on financial sustainability. Policy-makers should focus on a variety of measures within an integrated approach. There is no silver bullet for addressing the sustainability of healthcare.

Background In this article, we analyze one case instance of how proposals for change to the priority setting and resource allocation (PSRA) processes at a Canadian healthcare institution reached the decision agenda of the organization’s senior leadership. We adopt key concepts from an established policy studies framework – Kingdon’s multiple streams theory – to inform our analysis. Methods Twenty-six individual interviews were conducted at the IWK Health Centre in Halifax, NS, Canada. Participants were asked to reflect upon the reasons leading up to the implementation of a formal priority setting process – Program Budgeting and Marginal Analysis (PBMA) – in the 2012/2013 fiscal year. Responses were analyzed qualitatively using Kingdon’s model as a template. Results The introduction of PBMA can be understood as the opening of a policy window. A problem stream – defined as lack of broad engagement and information sharing across service lines in past practice – converged with a known policy solution, PBMA, which addressed the identified problems and was perceived as easy to use and with an evidence-base from past applications across Canada and elsewhere. Conditions in the political realm allowed for this intervention to proceed, but also constrained its potential outcomes. Conclusion Understanding in a theoretically-informed way how change occurs in healthcare management practices can provide useful lessons to researchers and decision-makers whose aim is to help health systems achieve the most effective use of available financial resources.

A central problem in designing effective models of provider governance in health systems has been to ensure an appropriate balance between the concerns of public sector and/or government decision-makers, on the one hand, and of non-governmental health services actors in civil society and private life, on the other. In tax-funded European health systems up to the 1980s, the state and other public sector decision-makers played a dominant role over health service provision, typically operating hospitals through national or regional governments on a command-and-control basis. In a number of countries, however, this state role has started to change, with governments first stepping out of direct service provision and now de facto pushed to focus more on steering provider organizations rather than on direct public management. In this new approach to provider governance, the state has pulled back into a regulatory role that introduces market-like incentives and management structures, which then apply to both public and private sector providers alike. This article examines some of the main operational complexities in implementing this new governance reality/strategy, specifically from a service provision (as opposed to mostly a financing or even regulatory) perspective. After briefly reviewing some of the key theoretical dilemmas, the paper presents two case studies where this new approach was put into practice: primary care in Sweden and hospitals in Spain. The article concludes that good governance today needs to reflect practical operational realities if it is to have the desired effect on health sector reform outcome.

Strengthening the health workforce and universal health coverage (UHC) are among key targets in the heathrelated Sustainable Development Goals (SDGs) to be committed by the United Nations (UN) Member States in September 2015. The health workforce, the backbone of health systems, contributes to functioning delivery systems. Equitable distribution of functioning services is indispensable to achieve one of the UHC goals of equitable access. This commentary argues the World Health Organization (WHO) Global Code of Practice on International Recruitment of Health Personnel is relevant to the countries in the South East Asia Region (SEAR) as there is a significant outflow of health workers from several countries and a significant inflow in a few, increased demand for health workforce in high- and middle-income countries, and slow progress in addressing the “push factors.” Awareness and implementation of the Code in the first report in 2012 was low but significantly improved in the second report in 2015. An inter-country workshop in 2015 convened by WHO SEAR to review progress in implementation of the Code was an opportunity for countries to share lessons on policy implementation, on retention of health workers, scaling up health professional education and managing in and out migration. The meeting noted that capturing outmigration of health personnel, which is notoriously difficult for source countries, is possible where there is an active recruitment management through government to government (G to G) contracts or licensing the recruiters and mandatory reporting requirement by them. According to the 2015 second report on the Code, the size and profile of outflow health workers from SEAR source countries is being captured and now also increasingly being shared by destination country professional councils. This is critical information to foster policy action and implementation of the Code in the Region.

This paper discusses whether European institutions should devote so much attention and funding to cross-border healthcare or they should instead prioritise guaranteeing universal health coverage (UHC), inequalities and tackling the effects of austerity measures. The paper argues through providing the evidence in both areas of research, that the priority at European level from a public health and social justice perspective should be to guarantee UHC for all the population living in Europe and prioritise protective action for those who are most in need.

Forest and colleagues have persuasively made the case that policy capacity is a fundamental prerequisite to health reform. They offer a comprehensive life-cycle definition of policy capacity and stress that it involves much more than problem identification and option development. I would like to offer a Canadian perspective. If we define health reform as re-orienting the health system from acute care to prevention and chronic disease management the consensus is that Canada has been unsuccessful in achieving a major transformation of our 14 health systems (one for each province and territory plus the federal government). I argue that 3 additional things are essential to build health policy capacity in a healthcare federation such as Canada: (a) A means of “policy governance” that would promote an approach to cooperative federalism in the health arena; (b) The ability to overcome the ”policy inertia” resulting from how Canadian Medicare was implemented and subsequently interpreted; and (c) The ability to entertain a long-range thinking and planning horizon. My assessment indicates that Canada falls short on each of these items, and the prospects for achieving them are not bright. However, hope springs eternal and it will be interesting to see if the July, 2015 report of the Advisory Panel on Healthcare Innovation manages to galvanize national attention and stimulate concerted action.

The death of the English National Health Service (NHS) may be slow in coming but that does not mean that it is not the Conservative-led UK government’s desired end state. The government is displaying tactical cunning in achieving its long-term purpose to remould the British state. Powell seeks greater clarity amidst the confusion but the lack of clarity is a principal weapon in the government’s assault on the public realm, including the NHS. Moreover, there is ample supporting evidence to caution against Powell’s tendency to complacency concerning the ultimate fate of the NHS.

Whistleblowing by health professionals is an infrequent and extraordinary event and need not occur if internal voices are heard. Mannion and Davies’ editorial on “Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations” asks the question whether whistleblowing ameliorates or exacerbates the ‘deaf effect’ prevalent in healthcare organisations. This commentary argues that the focus should remain on internal processes and hearer courage.

Public health management is a pillar of public health practice. Only through effective management can research, theory, and scientific innovation be translated into successful public health action. With this in mind, the U.S. Centers for Disease Control and Prevention (CDC) has developed an innovative program called Improving Public Health Management for Action (IMPACT) which aims to address this critical need by building an effective cadre of public health managers to work alongside scientists to prepare for and respond to disease threats and to effectively implement public health programs. IMPACT is a 2-year, experiential learning program that provides fellows with the management tools and opportunities to apply their new knowledge in the field, all while continuing to serve the Ministry of Health (MoH). IMPACT will launch in 2016 in 2 countries with the intent of expanding to additional countries in future years resulting in a well-trained cadre of public health managers around the world.

It is inevitable that healthcare workers throughout their careers will witness actual or potential threats to patient safety in the course of their work. Some of these threats will result in serious harm occurring to others, whilst at other times such threats will result in minimal harm, or a ‘near miss’ where harm is avoided at the last minute. Despite organizations encouraging employees to ‘speak up’ about such threats, healthcare systems globally struggle to engage their staff to do so. Even when staff do raise concerns they are often ignored by those with a responsibility to listen and act. Learning how to create the conditions where employees continuously raise and respond to concerns is essential in creating a continuous and responsive learning culture that cherishes keeping patients and employees safe. Workplace culture is a real barrier to the creation of such a learning system but examples in healthcare exist from which we can learn.

Whistleblowing is defined by the retaliation that those who speak out receive. Why some organizations find it almost impossible not to retaliate depends more on the properties of the organization than the act of the individual whistleblower. These properties are, to greater or lesser degree, present in all organizations. Not all organizations retaliate against whistleblowers, but the whistleblower represents a threat to every organization. And to every individual within the organization, because the whistleblower challenges the morality and ethics of the rest of us.

The paper “Regional incentives and patient cross-border mobility” received three commentaries, each adopting a different perspective on patients’ mobility issue. Starting with Neri,1 the author deeply examines the paper, by considering and commenting each step of the analysis.

Complementary and Alternative Medicine (CAM) is frequently used in Portugal and it contributes to the improvement of people’s health. CAM and Western Medicine (WM) are taken as complements both in the diagnosis and the treatment stage. The Portuguese health system is able to generate certified CAM professionals but the provision of CAM care and services is not included in the national health system. In times of austerity, this is not expected to change and access to CAM care continues to be out-of-pocket health expenditure. But the future for health in Portugal may well involve including CAM therapies in an integrated health system.