Background In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy of teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in each hospital and significant modifications in hospitals’ financing. Since the reform aimed to improve its predecessor policy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as enhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were never realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of trustees’ policy did not achieve its perceived objectives. Methods We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 and 10 participants, respectively) with experts at high, middle, and low levels of Iran’s health system, using purposive and snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed verbatim and analyzed thematically, following a mixed inductive-deductive approach. Results Three main themes emerged from the analysis. The implementation approach (including the processes, views about the policy and the links between the policy components), using research evidence about the policy (local and global), and policy context (health system structure, health insurers capacity, hospitals’ organization and capacity and actors’ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization policies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration of the above factors in policy implementation into account. Conclusion The implementation of the board of trustees’ policy did not achieve its desired goals in teaching hospitals in Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not prepared appropriately and key stakeholders, particularly the government, did not support the decentralization of Iran’s health system.

Background A doctor’s competence and professionalism is often judged on the basis of attire. Our Lady of Lourdes (OLOL) is a leading Irish hospital in the implementation of Bare Below the Elbows (BBTE) policy, however surgical attire is not standardised and there is great variability in attire worn on wards. We aimed to evaluate patients attitude towards surgeons attire in OLOL. Methods A prospective survey of adult surgical in-patients was conducted from October 2013 to February 2014. A twelve-question questionnaire was used as data collection tool, using a five point Likert scale to assess patients response to each question. Data were collected on patient demographics, patients level of trust and confidence based on different surgical attire, and patients perception of different attire worn by surgical teams. Results There were 150 completed surveys during the study period with a male to female ratio of 44% to 56% respectively. The mean patient length of in-hospital stay (LOS) was 4.7 days (range 1–22). The most commonly represented age group was 30–40 years (18%), with a comparable spread among all age groups. The majority of patients found the attire worn by surgeons on the ward to be very appropriate (93%). Majority of responders believed scrubs to be the most appropriate attire for surgeons on wards (39%), followed by shirt and tie with white coat (38%) followed by short sleeved shirt and no tie (18%). Shirt and tie with white coat had a positive effect on patients trust in 63% of responders, a negative effect in 10% and no effect in 26%. Scrubs had a positive effect on patients trust in 63%, negative effect in 11% and no effect in 25%. Short sleeved shirt and no tie had a positive effect in 44%, negative effect in 25% and no effect in 30% of patients. Conclusion Patients in OLOL find attire worn by surgeons to be appropriate. Shirt and tie with white coat or scrubs remains the patient’s choice attire for surgeons. Shirt and tie with white coat or scrubs has a more positive effect on trust of patients compared to short sleeved shirt and no tie.

Background There is limited knowledge about the use of cigarettes by blacks outside the United States (U.S). Nigeria creates an opportunity to explore smoking behaviours, smoking cessation (nicotine dependence) and use of cigarettes in a country that has a large black population outside the U.S. Methods We conducted three Focus Group Discussions (FGDs) involving twenty-four male migrant workers who reported that they were current cigarette smokers. Interviews were audio-taped and transcribed. Results Four major themes namely: reasons for initiating and continuing to smoke cigarettes, factors affecting brand choice, barriers to quitting, effect of smoking mentholated cigarette brands were identified. Conclusion This study provides insight into the use of mentholated and non-mentholated cigarettes and suggests the need for further studies to explore smoking behavior among Nigerians.

Background One of the requirements of the Osun State smoke-free legislation is to ensure smoke-free enclosed and partially enclosed workplaces. This survey was conducted to assess the knowledge and attitude of workers in indoor bars, beer parlors and discotheques to smoke-free legislation in general and the Osun State smoke-free law in particular. Methods A convenience sampling of 36 hospitality centers was conducted. Interviewer-administered questionnaires were used to elicit responses about the objectives from non-smoking workers. The questionnaires had sections on knowledge of the Osun State smoke-free law, attitude toward the law and smoke-free legislation in general and exposure to second-hand tobacco smoke by the workers. Questions were also asked about the secondhand tobacco smoking status of these workers. The data were analyzed using SPSS version 15.0. Results We had 154 participants recruited into the study. There were 75 males (48.0%) and 79 females (52.0%). On the overall, respondents had a good knowledge of the effects of second-hand smoke on health (70.2%) with 75.0% of them being aware of the general smoke-free law and 67.3% being aware of the Osun State smoke-free law although none of them had ever seen a copy of the law. A high proportion (60.0%) was in support of the Osun smoke-free law although all of them think that the implementation of the law could reduce patronage and jeopardize their income. Attitude toward second-hand smoking was generally positive with 72.0% of them having no tolerance for second-hand tobacco smoke in their homes. Most participants (95.5%) had been exposed to tobacco smoke in the workplace within the past week. Conclusion Despite the high level of awareness of the respondents about the dangers of second hand smoke and their positive attitude to smoke-free laws, nearly all were constantly being exposed to second hand smoke at work. This calls for policy level interventions to improve the implementation of the smoke-free law.

Background Portugal has a strong tradition of conventional western healthcare. So it provides a natural case study for the relationship between Complementary/Alternative Medicine (CAM) and Western Medicine (WM). This work aims to test the relationship between CAM and WM users in the diagnosis and treatment stages and to estimate the determinants of CAM choice. Methods The forth Portuguese National Health Survey is employed to estimate two single probit models and obtain the correlation between the consumption of CAM and WM medicines in the diagnosis and treatment stages. Results Firstly, both in the diagnosis and the treatment stage, CAM and WM are seen to be complementary choices for individuals. Secondly, self-medication also shows complementarity with the choice of CAM treatment. Thirdly, education has a non-linear relationship with the choice of CAM. Finally, working status, age, smoking and chronic disease are determinant factors in the decision to use CAM. Conclusion The results of this work are relevant to health policy-makers and for insurance companies. Patients need freedom of choice and, for the sake of safety and efficacy of treatment, WM and CAM healthcare ought to be provided in a joint and integrated health system.

In this commentary, we establish a relationship between medical sociology and the study of medical tourism and cross-border healthcare by introducing Ronald Andersen’s behavioral model of healthcare use, and linking this model to the recent empirical study of Kovacs et al. on patients travelling to Hungary for orthopedic treatment. Finally, we plead for more measurement in the field of patient mobility.

Factors influencing cross-national diffusion of mental health policy are important to understand but complex to research. This commentary discusses Shen’s research study on cross-national diffusion of mental health policy; examines the extent to which the three questions researched by Shen (whether countries are more likely to have a mental health policy (a) the earlier a country becomes a member of World Health Organization (WHO), (b) the more international aid a country receives, and (c) the more neighbouring countries already have a mental health policy) are in fact able to assess WHO’s impact on cross-national diffusion of mental health policy. The commentary then suggests a range of more specific questions which may be used to further elucidate the impact of WHO on an individual country, and considers the relative value of published mental health policy compared with the integration of mental health into national health sector strategies and other sector reforms, and concludes with a call for more integration of mental health across all WHO activities at international, regional and country levels.

Recent disclosures of failures of care in the National Health Service (NHS) in England have led to debates about compassion deficits disallowing health professionals to provide high quality responsive care. While the link between high quality care and compassion is often taken for granted, it is less obvious how compassion – often originating in the individual’s emotional response – can become a moral sentiment and lead to developing a system of norms and values underpinning ethics of care. In this editorial, I argue why and how compassion might become a foundation of ethics guiding health professionals and a basis for ethics of care in health service organisations. I conclude by discussing a recent case of prominent healthcare failure in the NHS to highlight the relationship between compassion as an aspect of professional ethics on the one hand, and values and norms that institutions and specific policies promote on the other hand.

Jeremy Shiffman’s editorial appropriately calls on making all forms of power more apparent and accountable, notably productive power derived from expertise and claims to moral authority. This commentary argues that relationships based on productive power can be especially difficult to reveal in global health policy because of embedded notions about the nature of power and politics. Yet, it is essential to recognize that global health is shot through with power relationships, that they can take many forms, and that their explicit acknowledgement should be part of, rather than factored out of, any reform of global health governance.

There remains a conviction that the torrent of publications and the financial outlay on leadership development will create managers with the skills and characters of perfect leaders, capable of guiding healthcare organisations through the challenges and crises of the 21st century. The focus of much attention continues to be the search for the (illusory) core set of heroic qualities, abilities or competencies that will enable the development of leaders to achieve levels of supreme leadership and organisational performance. This brief commentary adds support to McDonald’s (1) call for recognition of the complexity of the undertaking.

This commentary explores some of the issues raised by Gilbert et al.short communication, Morality and Markets in the NHS. The increasing role of market mechanisms and the changing types of healthcare providers together with the use of choice and competition to drive improvements in quality in the National Health Service (NHS), all have important ethical implications. In order for the NHS to continue providing the level of service quality that out performs many high-income countries, despite spending much less on healthcare, we need a re-think of creeping marketization and privatisation and a consolidation of the NHS as a publically owned resource run for the benefit of patients and the public, not commercial interests.

The world has made a great deal of progress through the Millennium Development Goals (MDGs) to improve the health and well-being of people around the globe, but there remains a long way to go. Here we provide reflections on Rwanda’s experience in working to meet the health-related targets of the MDGs. This experience has informed our proposal of five guiding principles that may be useful for countries to consider as the world sets and moves forward with the post-2015 development agenda. These include: 1) advancing concrete and meaningful equity agendas that drive the post-2015 goals; 2) ensuring that goals to meet Universal Health Coverage (UHC) incorporate real efforts to focus on improving quality and not only quantity of care; 3) bolstering education and the internal research capacity within countries so that they can improve local evidence-based policy-making; 4) promoting intersectoral collaboration to achieve goals, and 5) improving collaborations between multilateral agencies – that are helping to monitor and evaluate progress towards the goals that are set – and the countries that are working to achieve improvements in health within their nation and across the world

A recent International Journal of Health Policy and Management (IJHPM) article by Fadi El-Jardali and colleagues makes an important contribution to the literature on health system strengthening by reporting on a survey of healthcare stakeholders in Low- and Middle-Income Countries (LMICs) about Systems Thinking (ST). The study’s main contributions are its confirmation that healthcare stakeholders understand the importance of ST but do not know how to act on that understanding, and the call for collective action by the global community of systems thinkers committed to healthcare improvement. We offer three basic considerations for next steps by this community, derived from our recent work in ST and the related field of Knowledge Translation (KT): resist the temptation to adopt a reductionist approach; recognize not everyone needs to understand ST; and do not wait for everything to be in place before getting started.