Global health research is essentially a normative undertaking: we use it to propose policies that ought to be implemented. To arrive at a normative conclusion in a logical way requires at least one normative premise, one that cannot be derived from empirical evidence alone. But there is no widely accepted normative premise for global health, and the actors with the power to set policies may use a different normative premise than the scholars that propose policies – which may explain the ‘implementation gap’ in global health. If global health scholars shy away from the normative debate – because it requires normative premises that cannot be derived from empirical evidence alone – they not only mislead each other, they also prevent and stymie debate on the role of the powerhouses of global health, their normative premises, and the rights and wrongs of these premises. The humanities and social sciences are better equipped – and less reluctant – to approach the normative debate in a scientifically valid manner, and ought to be better integrated in the interdisciplinary research that global health research is, or should be.

Background The purpose of implementing a system such as Clinical Governance (CG) is to integrate, establish and globalize distinct policies in order to improve quality through increasing professional knowledge and the accountability of healthcare professional toward providing clinical excellence. Since CG is related to change, and change requires money and time, CG implementation has to be focused on priority areas that are in more dire need of change. The purpose of the present study was to validate and determine the significance of items used for evaluating CG implementation. Methods The present study was descriptive-quantitative in method and design. Items used for evaluating CG implementation were first validated by the Delphi method and then compared with one another and ranked based on the Analytical Hierarchy Process (AHP) model. Results The items that were validated for evaluating CG implementation in Iran include performance evaluation, training and development, personnel motivation, clinical audit, clinical effectiveness, risk management, resource allocation, policies and strategies, external audit, information system management, research and development, CG structure, implementation prerequisites, the management of patients’ non-medical needs, complaints and patients’ participation in the treatment process. The most important items based on their degree of significance were training and development, performance evaluation, and risk management. The least important items included the management of patients’ non-medical needs, patients’ participation in the treatment process and research and development. Conclusion The fundamental requirements of CG implementation included having an effective policy at national level, avoiding perfectionism, using the expertise and potentials of the entire country and the coordination of this model with other models of quality improvement such as accreditation and patient safety.

Background Iran has a widespread diagnostics and clinical support services (DCSS) network that plays a crucial role in providing diagnostic and clinical support services to both inpatient and outpatient care. However, very little is known on the application of quality assurance (QA) policies in DCSS units. This study explores the extent of application of eleven QA strategies in DCSS units within Iranian hospitals and its association with hospital characteristics. Methods A descriptive cross-sectional study was conducted in 2009/2010. Data were collected from 554 DCSS units among 84 hospitals. Results The average reported application rate for the QA strategies ranged from 57%-94% in the DCSS units. Most frequently reported were checking drugs expiration dates (94%), pharmacopoeia availability (92%), equipment calibration (87%) and identifying responsibilities (86%). Least reported was external auditing of the DCSS (57%). The clinical chemistry and microbiology laboratories (84%), pharmacies, blood bank services (83%) reported highest average application rates across all questioned QA strategies. Lowest application rates were reported in human tissue banks (50%). There was no significant difference between the reported application rates in DCSS in the general/specialized, teaching/research, nonteaching/research hospitals with the exception of pharmacies and radiology departments. They reported availability of a written QA plan significantly more often in research hospitals. Nearly all QA strategies were reported to be applied significantly more often in the DCSS of Social Security Organization (SSO) and private-for-profit hospitals than in governmental hospitals. Conclusion There is still room for strengthening the managerial cycle of QA systems and accountability in the DCSS in Iranian hospitals. Getting feedback, change and learning through application of specific QA strategies (eg, external/internal audits) can be improved. Both the effectiveness of QA strategies in practice, and the application of these strategies in outpatient DCSS units require further policy attention.

Background Health policies are important instruments for improving population health. However, experience suggests that policies designed for the whole population do not always benefit the most vulnerable. Participation of vulnerable groups in the policy-making process provides an opportunity for them to influence decisions related to their health, and also to exercise their rights. This paper presents the findings from a study that explored how vulnerable groups and principles of human rights are incorporated into national sexual and reproductive health (SRH) policies of 4 selected countries (Spain, Scotland, Republic of Moldova, and Ukraine). It also aimed at discussing the involvement of vulnerable groups in SRH policy development from the perspective of policymakers. Methods Literature review, health policy analysis and 5 semi-structured interviews with policy-makers were carried out in this study. Content analysis of SRH policies was performed using the EquiFrame analytical framework. Results The study revealed that vulnerable groups and core principles of human rights are differently addressed in SRH policies within 4 studied countries. The opinions of policy-makers on the importance of mentioning vulnerable groups in policy documents and the way they ought to be mentioned varied, but they agreed that a clear definition of vulnerability, practical examples, and evidences on health status of these groups have to be included. In addition, different approaches to vulnerable group’s involvement in policy development were identified during the interviews and the range of obstacles to this process was discussed by respondents. Conclusion Incorporation of vulnerable groups in the SRH policies and their involvement in policy development were found to be important in addressing SRH of these groups and providing an opportunity for them to advocate for equal access to healthcare and exercise their rights. Future research on this topic should include representatives of vulnerable communities which could help to build a dialogue and present the problem from multiple perspectives.

Although Marianna Fotaki’s Editorial is helpful and challenging by looking at both the professional and institutional requirements for reinstalling compassion in order to aim for good quality healthcare, the causes that hinder this development remain unexamined. In this commentary, 3 causes are discussed; the boundary between the moral and the political; Neoliberalism; and the underdevelopment of reflection on the nature of care. A plea is made for more philosophical reflection on the nature of care and its implications in healthcare education.

In response to the International Journal of Health Policy and Management (IJHPM)editorial, this commentary adds to the debate about ethical dimensions of compassionate care in UK service provision. It acknowledges the importance of the original paper, and attempts to explore some of the issues that are raised in the context of nursing practice, research and education. It is argued that each of these fields of the profession are enacted in an escalating culture of corporatism, be that National Health Service (NHS) or university campus, and global neoliberalism. Post-structuralist ideas, notably those of Foucault, are borrowed to interrogate healthcare as discursive practice and disciplinary knowledge; where an understanding of the ways in which power and language operate is prominent. Historical and contemporary evidence of institutional and ideological degradation of sections of humanity, a ‘history of the present,’ serve as reminders of the import, and fragility, of ethical codes.

This commentary considers the vexed question of whether or not we should be spending time and resources on using multifaceted interventions to undertake implementation of evidence in healthcare. A review of systematic reviews has suggested that simple interventions may be just as effective as those taking a multifaceted approach. Taking cognisance of the Promoting Action on Research Implementation in Health Services (PARIHS) framework this commentary takes account of the evidence, context and facilitation factors in undertaking implementation. It concludes that a ‘horses for courses’ approach is necessary meaning that the specific implementation approach should be selected to fit the implementation task in hand whether it be a single or multifaceted approach and reviewed on an individual basis.

Martin Powell makes the point that the death of the National Health Service (NHS) is constantly asserted without criteria. This article suggests that the NHS is many things, which makes criteria unstable. The alignment of interests in the structure of the NHS enables both overheated rhetoric and political strength, and that pluralization of provision might actually undermine that alignment over time.

An earlier overview of systematic reviews and a subsequent editorial on single-component versus multifaceted interventions to promote knowledge translation (KT) highlight complex issues in implementation science. In this supplemented commentary, further aspects are in focus; we propose examples from (KT) studies probing the issue of single interventions. A main point is that defining what is a single and what is a multifaceted intervention can be ambiguous, depending on how the intervention is conceived. Further, we suggest additional perspectives in terms of strategies to facilitate implementation. More specifically, we argue for a need to depict not only what activities are done in implementation interventions, but to unpack functions in particular contexts, in order to support the progress of implementation science.

Health reform is the outcome of dispersed policy initiatives in different sectors, at different levels and across time. Policy work which can drive coherent health reform needs to operate across the governance structures as well as the institutions that comprise healthcare systems. Building policy capacity to support health reform calls for clarity regarding the nature of such policy work and the elements of policy capacity involved; and for evidence regarding effective strategies for capacity building.

It is difficult to disagree with the general argument that successful health reform requires a significant degree of policy capacity or that all players in the policy game need to move beyond self-interested advocacy. However, an overly broad definition of policy capacity is a problem. More important perhaps, health reform inevitably requires not just policy capacity but political leadership and compromise.

In 2014, a series of reforms, called as the Health Sector Evolution Plan (HSEP), was launched in the health system of Iran in a stepwise process. HSEP was mainly based on the fifth 5-year health development national strategies (2011-2016). It included different interventions to: increase population coverage of basic health insurance, increase quality of care in the Ministry of Health and Medical Education (MoHME) affiliated hospitals, reduce out-of-pocket (OOP) payments for inpatient services, increase quality of primary healthcare, launch updated relative value units (RVUs) of clinical services, and update tariffs to more realistic values. The reforms resulted in extensive social reaction and different professional feedback. The official monitoring program shows general public satisfaction. However, there are some concerns for sustainability of the programs and equity of financing. Securing financial sources and fairness of the financial contribution to the new programs are the main concerns of policy-makers. Healthcare providers’ concerns (as powerful and influential stakeholders) potentially threat the sustainability and efficiency of HSEP. Previous experiences on extending health insurance coverage show that they can lead to a regressive healthcare financing and threat financial equity. To secure financial sources and to increase fairness, the contributions of people to new interventions should be progressive by their income and wealth. A specific progressive tax would be the best source, however, since it is not immediately feasible, a stepwise increase in the progressivity of financing must be followed. Technical concerns of healthcare providers (such as nonplausible RVUs for specific procedures or nonefficient insurance-provider processes) should be addressed through proper revision(s) while nontechnical concerns (which are derived from conflicting interests) must be responded through clarification and providing transparent information. The requirements of HSEP and especially the key element of progressive tax should be considered properly in the coming sixth national development plan (2016-2021).

Martin Powell suggests that the death of the English National Health Service (NHS) has been announced so many times we are at risk of not noticing should it actually happen. He is right. If we ‘cry wolf’ too many times, we risk losing sight of what is important about the NHS and why.

Faced with the challenges of healthcare reform, skills and new capabilities are needed to support the reform and it is of crucial importance in Africa where shortages affects the health system resilience. Edwards et al provides a good example of the challenge of implementing a mentoring program in one province in a sub-Saharan country. From this example, various aspects of strengthening the capacity of managers in healthcare are examined based on our experience in action-training in Africa, as mentoring shares many characteristics with action-training. What practical lessons can be drawn to promote the strengthening so that managers can better intervene in complex contexts? Deeper involvement of health authorities and more rigorous approaches are seriously desirable for the proper development of health capacity strengthening programs in Africa.

We are grateful to our many colleagues who took the time to respond to our analysis of Shanghai’s declining “avoidable mortality.”1 The range of their perspectives across 5 recent commentaries reassures us that the topic is worthy of sustained study. Indeed, the presumption behind our comparative research on healthcare in world cities 2 is that the city is a strategic unit of analysis for understanding the health sector and that world cities share a host of important characteristics. Contrary to Cheng’s 3 comment that we compared“disparate cities whose only common characteristic is that they are of mega-size,” we have relied on a “most similar systems” approach to comparative analysis.4 World cities are characterized by high population size and density, similar commuting patterns between their outer rings and urban cores, and similar functions in the realms of international finance, culture, media, and provision of tertiary and quaternary medical care.

The sustainable development goals (SDGs) offer a unique opportunity for policy-makers to build on the millennium development goals (MDGs) by adopting more sustainable approaches to addressing global development challenges. The delivery of health services is of particular concern. Most African countries are unlikely to achieve the health MDGs, however, significant progress has been made particularly in the area of child and maternal health due in part to significant external support. The weak global recovery, and persistent inequalities in access to healthcare, however, call into question the sustainability of the achievements made. Building on the principles articulated in Binagwaho and Scott, this commentary argues that addressing inequalities and promoting more integrated approaches to health service delivery is vital for consolidating and sustaining the health sector achievements in Africa.