Cost-effectiveness data is useful for use in priority setting decisions in order to improve the efficiency of resources used. This paper thereby responds to Eckard et al. which addressed the use of cost-effectiveness data in the actual prioritization decisions in the Swedish national clinical guidelines for heart diseases. Based on a set of experiences on the use of economic evaluation in priority setting processes, this paper emphasizes the potential approach to incorporating cost-effectiveness data in the prioritization process to enhance transparency of the decisions, and highlights the importance of designing a fair decision-making process that can enforce the sustained implementation of cost-effectiveness data.

The leadership for mental health is not commensurate with the burden of mental, neurological, and substance (MNS) use disorders nationally or internationally. This is a sentiment I share with Prof. Jenkins (1) and Ms. Lee (2). With that said, I would like to make two clarifications about my study and two concomitant acknowledgements about its limitations (3). First, I conceptualized national mental health policy adoption as an isolated event. Policy adoption is one – albeit pivotal – node embedded in a ratification process. Second, I focused solely on external actors’ influence on policy adoption. Politics and policy are intertwined, and there are certainly actors situated inside, as well as outside, each country who are engaged with mental health policy-making, but they were not addressed by my study. I will elaborate on what I set out to do before giving pointed responses to their comments.

We are pleased that our recent paper, On Health Policy and Management (HPAM): mind the theorypolicy-practice gap (1), generated lively discussion. Most prominent among the respondents were Professors Jean de Kervasdoué (2) and David Hunter (3).

Actors working in global health often portray it as an enterprise grounded in principled concerns, advanced by individuals and organizations who draw on scientific evidence to pursue health equity. This portrait is incomplete. It is also a field of power relations—a social arena in which actors claim and draw on expertise and moral authority to gain influence and pursue career, organizational and national interests. A clear understanding of how power operates in this field is necessary to ensure that it is used productively to serve the aims of health equity and improved population health. Responding to commentaries on an editorial published in this journal, I offer 3 ideas toward this end: (1) be skeptical of the global health rationality project—the effort to rescue the field from the alleged indignities of politics through the application of scientific methods; (2) analyze global health as a field of power relations, a concept developed by sociologist Pierre Bourdieu; and (3) elevate the place of input legitimacy—inclusive deliberation, fair process and transparency—to address legitimacy and knowledge deficits in this field.

Background Decision-makers have begun to recognize Health-Related Quality of Life (HRQoL) as an important and measurable outcome of healthcare interventions; and HRQoL data is increasingly being used by policy-makers to prioritize health resources. Our objective was to measure HRQoL in a group of Type 2 Diabetes Mellitus (T2DM) patients receiving insulin treatment in Buenos Aires, Argentina. Methods We conducted a cross-sectional study of patients with T2DM over 21 years of age, treated with either Neutral Protamine Hagedorn (NPH) insulin or Insulin Glargine (IG), who had not changed their baseline schedule in the last 6 months. The recruitment was during 2006–7 in nine private diabetes specialists’ offices in Buenos Aires, Argentina. A standardized diabetes-specific HRQoL questionnaire, the Audit of Diabetes Dependent Quality of Life (ADDQoL), was used. Results A total of 183 patients were included (93 receiving NPH and 90 receiving IG). The mean QoL score was: 0.98 (SD: 0.89) and the diabetes specific QoL was: -1.49 (SD: 0.90). T2DM had a negative impact on HRQoL with a mean Average Weighted Impact (AWI) score on QoL of -1.77 (SD: 1.58). The greatest negative impact was observed for domains: ‘worries about the future’, ‘freedom to eat’, ‘living conditions’, ‘sex life’, and ‘family life’. The mean AWI score was -1.71 (SD: 1.48) in patients treated with IG and -1.85 (SD: 1.68) in patients receiving NPH, this difference was not statistically significant. Conclusion The ADDQoL questionnaire is a tool that can be used in Argentina to measure the QoL of patients with diabetes when evaluating diabetes care programs. The scores of QoL in our selected population did not differ from those reported in high-income countries. We expect that the results of this study will increase healthcare providers’ awareness of patients’ perceived QoL and help to overcome the barriers that delay insulin treatment; mainly clinical inertia and patient resistance.

In this commentary the findings from a systematic review that concluded there is no compelling evidence to suggest that implementing complicated, multi-faceted interventions is more effective than simple, single component interventions to changing healthcare professional’s behaviour are considered through the lens of Harvey and Kitson’s editorial. Whilst an appealing conclusion, it is one that hides a myriad of complexities. These include issues concerning how best to tailor interventions and how best to evaluate such efforts. These are complex issues that do not have simple solutions.

Background Snakebite has recently been declared a global public health emergency. Empirical data showing the true burden of snakebite is lacking. Treatment with specific antivenoms is considered the only cure. However, several factors have led to an ongoing antivenom crisis. This study offers recommendations concerning the improvement of antivenom access and control, by providing an overview of the factors limiting the successful implementation of international guidelines within the international industry and state institutions. It further investigates the reasons for the epidemiological knowledge gap regarding snakebites. Methods Data for this study was collected using surveys with closed- and open-ended questions, which allowed for descriptive and thematic analysis, respectively. Participants for this study were selected as follows: 46 manufacturers were contacted from the open-access World Health Organization (WHO) Database for antivenom producers; 23 National Health Authorities (NHAs) of high-burden countries were contacted; and 11 poison centers or experts were randomly contacted. Results In total, responses from 6/46 (13%) manufacturers, 10/23 (43%) NHAs, and 3/11 (27%) poison centers were received. The low response rates had a limiting effect on the coverage of this study, allowing only exploratory conclusions to be drawn. Based on the gathered information, a probable reason for the epidemiological knowledge gap is the low priority given to snakebites on public health agendas, driving interest and funding away from research in this field. As a consequence, the ensuing lack in funding is preventing state institutions and manufacturers from implementing international guidelines to the highest standards. Furthermore, manufacturers indicated that international guidelines were often not applicable in the field, lacking technical information and protocols. Conclusion Snakebite ranks low on international public health agendas, and partially due to this low priority, NHAs have shown limited efforts in conducting epidemiological studies, training health workers on snakebite management and creating national snakebite management strategies. The lack of NHA involvement is reflected in poor access to appropriate antivenoms as well as a lack of antivenom regulation. Manufacturers are taking positive steps toward full implementation of international guidelines and are improving quality control procedures. However, in order for international guidelines to become truly useful in the field, more technical guidance is required. This study reflects that there is a general lack of knowledge transfer amongst various actors: most producers, health authorities, and experts expect increased and improved communication and guidance from leading international bodies. Due to the low response rates observed in this study, conclusions drawn herein are not representative of the global situation; yet provide an exploratory insight on the difficulties facing antivenom management.

Despite a renewed focus in the field of global health on strengthening health systems, inadequate attention has been directed to a key ingredient of high-performing health systems: management. We aimed to develop the argument that management – defined here as the process of achieving predetermined objectives through human, financial, and technical resources – is a cross-cutting function necessary for success in all World Health Organization (WHO) building blocks of health systems strengthening. Management within health systems is particularly critical in low-income settings where the efficient use of scarce resources is paramount to attaining health goals. More generally, investments in management capacity may be viewed as a key leverage point in grand strategy, as strong management enables the achievement of large ends with limited means. We also sought to delineate a set of core competencies and identify key roles to be targeted for management capacity building efforts. Several effective examples of management interventions have been described in the research literature. Together, the existing evidence underscores the importance of country ownership of management capacity building efforts, which often challenge the status quo and thus need country leadership to sustain despite inevitable friction. The literature also recognizes that management capacity efforts, as a key ingredient of effective systems change, take time to embed, as new protocols and ways of working become habitual and integrated as standard operating procedures. Despite these challenges, the field of health management as part of global health system strengthening efforts holds promise as a fundamental leverage point for achieving health system performance goals with existing human, technical, and financial resources. The evidence base consistently supports the role of management in performance improvement but would benefit from additional research with improved methodological rigor and longer-time horizon investigations. Meanwhile, greater emphasis on management as a critical element of global health efforts may open new and sustainable avenues for advancing health systems performance.

Background The responsiveness of a health system is considered to be an intrinsic goal of health systems and an essential aspect in performance assessment. Numerous studies have analysed health system responsiveness and related concepts, especially across different countries and health systems. However, fewer studies have applied the concept for the evaluation of specific healthcare delivery structures and thoroughly analysed its determinants within one country. The aims of this study are to assess the level of perceived health system responsiveness to patients with chronic diseases in ambulatory care in Germany and to analyse the determinants of health system responsiveness as well as its distribution across different population groups. Methods and Analysis The target population consists of chronically ill people in Germany, with a focus on patients suffering from type 2 diabetes and/or from coronary heart disease (CHD). Data comes from two different sources: (i) cross-sectional survey data from a postal survey and (ii) claims data from a German sickness fund. Data from both sources will be linked at an individual-level. The postal survey has the purpose of measuring perceived health system responsiveness, health related quality of life, experiences with disease management programmes (DMPs) and (subjective) socioeconomic background. The claims data consists of information on (co)morbidities, service utilization, enrolment within a DMP and sociodemographic characteristics, including the type of residential area. Discussion RAC is one of the first projects linking survey data on health system responsiveness at individual level with claims data. With this unique database, it will be possible to comprehensively analyse determinants of health system responsiveness and its relation to other aspects of health system performance assessment. The results of the project will allow German health system decision-makers to assess the performance of nonclinical aspects of healthcare delivery and their determinants in two important areas of health policy: in ambulatory and chronic disease care.

Background Recognizing the significant impact of wait times for care for individuals with complex chronic conditions, we applied a LEAN methodology, namely – an adaptation of Value Stream Mapping (VSM) to meet the needs of people with multiple chronic conditions and to improve wait times without additional resources or funding. Methods Over an 18-month time period, staff applied a patient-centric approach that included LEAN methodology of VSM to improve wait times to care. Our framework of evaluation was grounded in the needs and perspectives of patients and individuals waiting to receive care. Patient centric views were obtained through surveys such as Patient Assessment of Chronic Illness Care (PACIC) and process engineering based questions. In addition, LEAN methodology, VSM was added to identify non-value added processes contributing to wait times. Results The care team successfully reduced wait times to 2 months in 2014 with no wait times for care anticipated in 2015. Increased patient engagement and satisfaction are also outcomes of this innovative initiative. In addition, successful transformations and implementation have resulted in resource efficiencies without increase in costs. Patients have shown significant improvements in functional health following Integrated Chronic Care Service (ICCS) intervention. The methodology will be applied to other chronic disease management areas in Capital Health and the province. Conclusion Wait times to care in the management of multimoribidities and other complex conditions can add a significant burden not only on the affected individuals but also on the healthcare system. In this study, a novel and modified LEAN methodology has been applied to embed the voice of the patient in care delivery processes and to reduce wait times to care in the management of complex chronic conditions.

Background Scholars describe poor health literacy as a “silent epidemic,” which is challenging the functioning of healthcare systems all over the world. Health literacy is mainly meant as an individual trait which concerns the ability to obtain, process, and understand basic health information in order to effectively navigate the health system. Low health literate patients perceive poor self-efficacy dealing with their health conditions, are not willing to be involved in the provision of care, show larger risks of hospitalization and mortality, and are not aware about the determinants of well-being. Hence, limited health literacy has been associated with inadequate management of long-term conditions; nonetheless, several authors argue that health literacy has been an overlooked factor dealing with HIV. Methods This study is aimed at discussing the effects of poor health literacy on people living with HIV, drawing from the findings of a narrative literature review which involved 41 papers retrieved from the databases “Scopus-Elsevier” and “PubMed.” Results The scientific literature is not consistent dealing with the relationship between health literacy and HIV treatment. For example, health literate patients seem to better understand their health conditions; on the other hand, people living with poor health literacy are likely to report higher compliance with providers’ prescriptions, blindly trusting healthcare professionals. Conclusions Poor health literacy is a social barrier to access healthcare services and to appropriate health treatment among patients living with HIV. Tailored interventions should be aimed at enhancing the health skills of patients affected by HIV infection to improve their ability to navigate the health system.

Lunt (1) and Mainil (2) emphasize the importance of continued research into the scope, nature and motivations for cross border care within Europe. Understanding patient mobility in the rapidly changing environment and turbulent movements is crucial in the consideration of accessible healthcare provision.

This is a short piece in response to the “Heterogeneity of European DRG systems and potentials for a common EuroDRG system”1 by Alexander Geissler, Wilm Quentin and Reinhard Busse from the EuroDRG team. We would like to thank them for taking the time to read our article and offer excellent suggestions to the diagnosis-related group (DRG) systems for further development.

Background The current distribution of and access to health services along with the future health needs of the population have prompted wide application of Geographic Information Systems (GISs). During recent years, GIS has been used in public health management for planning and organization of healthcare services. This study investigates geographical accessibility of residential areas in Bandar Abbas, Iran to healthcare services. Methods Accessibility was evaluated by using Floating Catchment Area (FCA), minimum distance methods and Response Time (RT) accessibility technique. Results More accurate measures of distances in Bandar Abbas, illustrated that Euclidean distances were not strongly correlated with network distances. The RT accessibility technique that utilizes shortest network path and time distances, presented detailed information about all the possible positions of the patients with respect to available healthcare services based on optimum and critical response times. Conclusion Locations of public health services in Bandar Abbas were not related to the sites of populations. The RT accessibility technique provides a reasonably sensitive and robust evaluation of accessibility

Background India’s economic growth rate in recent years has been fairly impressive. But, it has been consistently failing to make considerable progress in achieving health related Millennium Development Goal (MDG) targets. Lack of coherence between provisions and utilization becomes the face of the problem. Inadequacies in outreach, access and affordability coupled with escalating healthcare costs have aggravated the problem. Here the application of PublicPrivate Partnership (PPP) model seems to have enormous potential to ease the impasse. Methods This paper tries to find the gap between the provisions and access in healthcare. The paper attempts to construct a Health Infrastructure Index (HII) and Health Attainment Index (HAI) for different states of India. Considering the presence of regional variations found in health infrastructure and attainment among the states, two states, viz. Maharashtra (MAH) and West Bengal (WB) have been chosen. Then contributions of health programs like Rashtriya Swasthya Bima Yojana (RSBY), National Rural Telemedicine Network (NRTN) and Fair Price Shops (FPS), all PPP initiatives, have been assessed for both the states by carrying out comprehensive benefit-cost analysis. Results The health infrastructure for population per unit area captures the outreach/delivery issue and the health attainment reveals the true scenario about how far the infrastructure has been accessed by the people; and the gap between the two, as the paper finds, is the root of the problem. The combined effect of RSBY and NRTN will leave both MAH and WB higher benefits in terms of health attainment. The contributions of RSBY and NRTN have been assessed for both the states by carrying out comprehensive benefit-cost analysis. FPS comes up with immense benefits for WB. It is yet to be implemented in MAH. Conclusion The outreach and access problems arising from deficiencies in infrastructure, human resources and financial ability are expected to be well-addressed by the spread of RSBY and NRTN jointly. The FPS mechanism under PPP initiative can be an effective tool in solving affordability problem by reducing the cost of treatment.

The decline in Avoidable Mortality (AM) and increase in life expectancy in Shanghai is impressive. Gusmano and colleagues suggested that Shanghai’s improved health system has contributed significantly to this decline in AM. However, when compared to other global cities, Shanghai’s life expectancy at birth is improving as London and New York City, but has yet to surpass that of Hong Kong, Tokyo, and Paris. Over the past decade, the reduction in AM of Shanghai is just in line with the international experience in reducing avoidable premature deaths. We suggest that a more elaborate research design is needed to examine the impact of the improvement in Shanghai’s health system on its population health status.