Skip to main content
NCBI home page
Bulletin of the World Health Organization logoLink to Bulletin of the World Health Organization
. 2020 Sep 3;98(11):792–800. doi: 10.2471/BLT.19.245613

Primary health care and sustainable development goals

Soins de santé primaires et objectifs de développement durable

Atención primaria de salud y objetivos de desarrollo sostenible

الرعاية الصحية الأولية وأهداف التنمية المستدامة

初级卫生保健和可持续发展目标

Первичная медико-санитарная помощь и цели устойчивого развития

Somtanuek Chotchoungchatchai a, Aniqa Islam Marshall a, Woranan Witthayapipopsakul a, Warisa Panichkriangkrai a, Walaiporn Patcharanarumol a, Viroj Tangcharoensathien a,✉
PMCID: PMC7607463  PMID: 33177776

Abstract

We examine the potential and limitations of primary health care in contributing to the achievement of the health-related sustainable development goals (SDGs), and recommend policies to enable a functioning primary health-care system. Governments have recently reaffirmed their commitment to the SDGs through the 2018 Declaration of Astana, which redefines the three functions of primary health care as: service provision, multisectoral actions and the empowerment of citizens. In other words, the health-related SDGs cannot be achieved by the provision of health-care services alone. Some health issues are related to environment, necessitating joint efforts between local, national and international partners; other issues require public awareness (health literacy) of preventable illnesses. However, the provision of primary health care, and hence achievement of the SDGs, is hampered by several issues. First, inadequate government spending on health is exacerbated by the small proportions allocated to primary health care. Second, the shortage and maldistribution of the health workforce, and chronic absenteeism in some countries, has led to a situation in which staffing levels are inversely related to poverty and need. Third, the health workforce is not trained in multisectoral actions, and already experiences workloads of an overwhelming nature. Finally, health illiteracy is common among the population, even in developed countries. We recommend that governments increase spending on health and primary health care, implement interventions to retain the rural health workforce, and update the pre-service training curricula of personnel to include skills in multisectoral collaboration and enhanced community engagement.

Introduction

The concept of primary health care has been at the centre of the health development agenda for many decades, originally inspired by the 1948 World Health Organization (WHO) constitution1 and later the focus of the Alma-Ata International Conference on Primary Health Care in September 1978.2,3 Primary health care is a whole-society approach to health, and aims to attain the highest possible level and distribution of health and well-being by providing an accessible and wide range of services, including: health promotion; disease prevention, treatment and rehabilitation; and palliative care.4 As the first contact between the population and the health-care system, primary care is essential for integrated personal health care, public health function and ongoing referrals to hospital services. However, the provision of primary care services is only one part of the broader primary health-care concept;5 to address the determinants of health, the implementation of a primary health-care concept must be accompanied by multisectoral actions and the empowerment of the population.6

Of the 17 sustainable development goals (SDGs) adopted at the Seventieth session of the United Nations (UN) General Assembly in 2015,7 to be achieved by 2030,8 the third (SDG 3, to “ensure healthy lives and promote well-being for all at all ages”) is specific to health. SDG 3 includes the provision of universal health coverage (UHC; SDG 3.8), which aims to provide access to good-quality health services for all, without financial hardship. Other SDGs (e.g. on hunger; gender equality; clean water and sanitation; affordable and clean energy; sustainable cities and communities; climate action; and peace, justice and strong institutions) also contribute indirectly to the attainment of health.

To maintain momentum in the provision of primary health care and UHC, governments have recently reaffirmed their commitments to the SDGs through the 2018 Astana Declaration9 and the 2019 UN High-Level Meeting on UHC.10 The Astana Declaration redefined the three main functions of primary health care as: (i) meeting the health needs of a population through the provision of a comprehensive range of promotive, protective, preventive, curative, rehabilitative and palliative health-care services throughout the life course; (ii) systematically addressing the broader determinants of health including social, economic and environmental contexts through evidence-informed public policies and multisectoral action; and (iii) empowering individuals, families and communities to optimize their health, and supporting people such as self-carers and caregivers as co-developers of health and social services.11

We examine the potential and limitations of primary health care in contributing to health-related SDGs, identify barriers to the provision of primary health care, and recommend policies for implementation to enable a fully functioning primary health-care service.

Comparison with UHC

The provision of a health service is the main function of both primary health care and UHC;12 we indicate in Fig. 1 where these two systems overlap in terms of achieving the SDGs. Both primary health care and UHC advocate for the whole continuum of required health services, and not just for first-contact or ambulatory health services. For example, the provision of antiretroviral, anti-tuberculosis and antimalarial drugs (SDG 3.3) requires a higher level of clinical competency, that is, as provided by secondary- or tertiary-level facilities, beyond the scope of first-contact primary care. Finally, while the primary-care system is focused on the provision of good-quality and coverage of essential health services (SDG 3.8.1), it does not address the avoidance of financial hardship in using these services; however, UHC includes protection from financial risk (SDG 3.8.2).

Fig. 1.

The contribution of primary health care and universal health coverage to the achievement of health-related sustainable development goals

AIDS: acquired immunodeficiency syndrome; FCTC: Framework Convention on Tobacco Control; SDG: sustainable development goal; WHO: World Health Organization.

Note: The SDGs in the intersection of the two circles can be addressed by the synergies of universal health coverage and primary health care, while SDGs lying outside the two circles require multisectoral action and citizen empowerment.

Fig. 1

Open in a new tab

Potential

The health-related SDGs cannot be achieved by the provision of high-quality primary health-care services alone. Some health issues are related to a person’s environment, necessitating joint efforts between sectors from local to national and international development partners; other issues require public awareness (health literacy) of preventable illnesses and the provision of supportive environments. We describe in the following, and depict in Fig. 1, how primary health care as defined by the Astana Declaration (i.e. advocating for multisectoral actions and the empowerment of citizens) contributes to the achievement of both health-specific SDG 3 and the other health-related SDGs.

SDG 3

The goal of ending the prevalence of neglected tropical diseases (SDG 3.3) is an example of where collective efforts are required. Cost-effective interventions are available for as little as 3 United States dollars (US$) per disability-adjusted life year (DALY) averted.13 However, multisectoral actions to address poverty, control disease vectors and the environment, and improve access to clean water and sanitation are key components of neglected tropical disease programmes. For example, the elimination of trachoma has been a collective effort beyond national boundaries between development partners, the private sector and governments.14

The achievement of SDG 3.4 on noncommunicable diseases also requires multisectoral actions to address the determinants of health. To some extent, primary health care and UHC can secure the availability and affordability of essential medicines for the treatment of noncommunicable diseases, such as insulin and metformin for diabetes, diuretics for hypertension and statins for hyperlipidaemia. However, the provision of access to essential medicines also requires multisectoral collaborations at the national level to exercise Trade-Related Aspects of Intellectual Property Rights flexibilities,15,16 as envisioned by the Doha Declaration. In addition, empowering individuals and families by improving health literacy can encourage lifestyle changes and the subsequent prevention of noncommunicable diseases. Population-based interventions addressing the distal determinants of health risk (e.g. increasing taxation on tobacco, alcohol and unhealthy foods; improving physical and social environments, conducive to active lifestyles) yield higher health gains than addressing the proximal determinants through the screening and treatment of individual patients at the primary-care level.17 In terms of addressing tobacco use, Table 1 demonstrates the higher potential and capacity of multisectoral actions compared with those of the primary health-care system.

Table 1. Interventions to address tobacco use: what multisectoral actions can achieve compared with primary health care.

Interventions17 Multisectoral actions Primary health care
Best buys: effective interventionsa
Increase excise taxes and prices on tobacco products Legislative and regulatory measures by ministry of finance; high-level political leadership in the context of political interference by tobacco industry;18 addressing the legal threats of the tobacco industry;19 civil society role in monitoring interference;20 and government application of tobacco strategic litigation19 Very limited role and capacity
Implement plain, standardized packaging and/or large graphic health warnings on all tobacco packages Legislative and regulatory measures, with penalty for non-adherence Very limited role and capacity
Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship Legislative measures, surveillance and legal sanction of non-adherence Very limited role and capacity
Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places and on public transport Public and private sector (including civil society organizations) support of smoke-free indoor workplaces and public transport, and monitor non-adherence Create public awareness and social demand for tobacco-free environment; surveillance of non-adherence
Implement effective mass media campaigns that educate the public about the harms of tobacco use and second-hand smoke Public and private sector support of media campaigns Support community-based public awareness campaigns
Effective interventionsb
Provide support, advice and national toll-free helpline services for tobacco cessation Ministry of health and civil society organizations support tobacco cessation services Key role in providing counselling service
WHO-recommended interventionsc
Implement measures to minimize illicit trade in tobacco products Active surveillance and law enforcement by customs departments No role
Ban cross-border advertising, including using modern means of communication Active monitoring by departments of information and communication technology, and by digital experts Support regulatory bodies in surveillance of non-adherence
Provide mobile-phone-based tobacco cessation services Ministry of health and civil society organizations support tobacco cessation services Key role in providing counselling service
Open in a new tab

WHO: World Health Organization.

a The cost was less than 100 international dollars per disability-adjusted life year (DALY) averted in low- and middle-income countries.

b Cost–effectiveness ratio of more than 100 international dollars per DALY averted in low- and middle-income countries.

c No cost–effectiveness data available.

Preventing the harmful use of alcohol (SDG 3.5) also requires best-buy interventions, defined as interventions costing at most 100 international dollars per DALY averted in low- and middle-income countries.17 Such interventions include controlling availability through legal age limits, service hours and number of sales outlets, increasing tax and retail price, and prohibiting advertisements and market promotion. Effective control of substances requires a strong collaboration between health and law enforcement officers, framed by good governance. These actions require policy coherence across government sectors and are the remit of national-level actors, notably finance ministries and regulatory bodies for sales and promotion of these harmful products.

Finally, the provision of good-quality health care on its own makes a minimal contribution to achieving SDG 3.6, halving the number of global deaths and injuries from road traffic accidents. Primary health care does have a role in pre-hospital service, referral to a hospital-based accident and emergency unit, and post-crash responses such as minimizing time between road traffic incidents and the provision of first response emergency care. However, other primary prevention methods, such as (i) technical standards of new and existing roads, taking into account international safety standards; (ii) the adherence of new and used vehicles to safety standards; (iii) the use of seat belts, child restraint systems and helmets; (iv) the designation and regulation of speed limits; (v) legislation and enforcement of blood alcohol content and use of mobile phones while driving; and (vi) driving time and rest periods for professional public transport drivers, are the responsibility of other sectors and regulatory bodies.21

Other health-related SDGs

Progress towards other health-related SDGs also requires a multisectoral approach. Strong governance is required, as all actors must articulate their interests, exercise their rights and obligations, and mediate their differences.22

For example, to end hunger (SDG 2), primary health care can support community-based therapeutic care using ready-to-use, therapeutic foods for severe acute malnutrition;23 however, a more sustainable solution lies in the adoption of agricultural policies that aim to double the productivity and income of small-scale food producers.

To achieve SDG 11 on the creation of sustainable cities, primary health care can support the monitoring of air pollution, issue health warnings when particulate matter of diameter less than 2.5 μm in the air exceeds limits, and advocate for the reduction of indoor pollution through the use of clean energy.24 However, sustainable solutions can only be achieved through policies that address industrial, residential and vehicular sources of pollution.

Limitations

We have identified four underlying factors currently impeding the full implementation of the three primary health-care functions, and hence achievement of the SDGs. The factors reviewed here, in particular inadequate funding, primary health-care workforce shortage and insufficient multisectoral actions, were also highlighted in an online survey of 50 WHO Member States conducted by the WHO Evaluation Office.25

Inadequate funding

Inadequate spending on primary health care undermines the development of related infrastructure, including the capacity for disease prevention and health promotion. The average government health expenditure per capita increased from US$ 4.1 to US$ 7.9 in low-income countries, and from US$ 6.5 to US$ 25.6 in lower-middle-income countries, between 2000 and 2016.26 However, a minimum government health spending of US$ 91 and US$ 89 per capita per year, in low-income and lower-middle-income countries, respectively, is required by 2030 to achieve SDG 3 (Fig. 2).27

Fig. 2.

Domestic general government health expenditure per capita, 2000–2016

US$: United States dollars.

Source: World Bank.26

Fig. 2

Open in a new tab

As well as spending levels on health being too low, they can also be biased towards curative services and hospital care; any rise in health spending is often driven by medical technologies, particularly in the hospital sector.28 In high income countries, the hospital sector consumed 38% of total current health spending in 2016 (average of 28 European Member States)29 while spending on primary care was only 14% of total health spending (average of 22 Organisation for Economic Co-operation and Development, OECD, Member States).30

This problem of underfunding is impounded by the lack of a credible system to properly monitor primary health-care expenditure. The National Health Account, guided by the 2011 OECD Systems of Health Account, does not provide an estimate of the total spending on primary health care as a percentage of current health expenditure;31 however, a study in 36 low- and middle-income countries showed an interquartile range of primary health-care expenditure of US$ 15–60 per capita, or 31–88% of current health expenditure.32 These insufficient data hamper national and global monitoring of adherence to the 2019 UN General Assembly resolution 74/2, for which an additional investment in primary health care of 1% of gross domestic product was agreed to by UN Member States.10

Workforce shortage

Provision of a comprehensive range of health services is hampered by a health workforce shortage and maldistribution, something that has always been a chronic problem for low- and middle-income countries. In 2006, the World Health Report identified 57 Member States with a density of health workers below the benchmark of 22.8 doctors, nurses and midwives per 10 000 population (the minimum required for 80% of births to be attended by a skilled health professional); the most significant shortfalls occurred in sub-Saharan Africa.33 Our primary analysis revealed no improvement since 2006; in 2019, 62 of 194 WHO Member States (32%) reported a health worker density of less than the above-mentioned benchmark.34

Analysis by World Health Statistics, depicted in Fig. 3, indicates a gloomy and unchanging situation in health workforce density from 2010 to 2019; of the 67 countries that fell below the benchmark in 2010, 21 countries (31%) showed no progress by 2019, while 35 countries (52%) had progressed but remained below the threshold. Only 11 countries (16%) had progressed to an adequate density of health workers.

Fig. 3.

Changes in health workforce density in 67 countries, 2010–2019

Note: We included countries with less than 22.8 doctors, nurses and midwives per 10 000 population in 2010: no data were available for some countries for the year 2015.

Source: World Health Statistics 2010,35 201536 and 2019.34

Fig. 3

Open in a new tab

The basic health worker density needed to achieve the SDGs has been reported by the WHO as 44.5 per 10 000 population,37 meaning that almost half of the Member States (96/194; 49%) had an insufficient health workforce in 2019. With this critical shortage, exacerbated by poor distribution of rural primary care and a lack of necessary skills, the commitments of the Astana Declaration appear to be out of reach for the immediate future.

Absenteeism of frontline health workers is not uncommon in many Asian and African countries, and the root cause of a poorly functioning primary care system and the lack of population trust in service quality. A survey of Indonesian community health centre staff, including 20 doctors, 61 midwives and 76 paramedics, reported an overall absenteeism rate of 23%.38 A multicountry study in developing countries reported higher rates of absenteeism in higher-level cadres, including those with more opportunity for private practice.39

A multicountry study in five African countries highlighted that the minority of the health workforce are employed in primary health care, with greatest shortages in rural areas.40 This finding illustrates what is referred to as the “inverse primary health care law,” where staffing levels are inversely related to poverty and level of need. According to 66 migrant health personnel from sub-Saharan African countries, this inverse primary health care law is explained by poor working environments, difficult living conditions and a perceived inferior career path, leading to high levels of out-migration.41 In the United Kingdom of Great Britain and Northern Ireland, a high-income country, the inverse primary health care law also exist; citizens in the most deprived areas have higher levels of multimorbidity and are deprived access to high-quality primary health care.42

Limited multisectoral action

The capacity for multisectoral action at local communities as demanded by the Astana Declaration is often limited. Despite its potential to significantly address many social and economic determinants of health, multisectoral collaboration is not generally or adequately practised. Health personnel, particularly at the primary-care level, are not trained in multisectoral skills.43 The workload of public health and curative services is often overwhelming, reducing the likelihood of interaction with actors outside the health sector. Multisectoral collaborations also require social credibility and convening power, which is too demanding for facilities with few or young primary health-care staff and a high turnover rate.

Another problem is that multisectoral actions at the community level, such as legislative and regulatory tools to apply and scale-up best-buy interventions, have limited impact on the distal determinants of health.17 While proximal determinants of health (e.g. lifestyle and socioeconomic status) can be addressed by the primary health-care system, distal determinants (e.g. legal and cultural) can be tackled more effectively through national-level mechanisms including legislation, regulation and enforcement. Effective multisectoral action therefore requires political commitment, as well as a balance between competition and collaboration among government agencies.44

Inadequate empowerment

Finally, the primary health-care function of empowering citizens provides another challenge. Although the primary health-care setting has the comparative advantage of its proximity to the people and community, strengthening health literacy requires actions beyond the microlevel. The experience of high-income countries has shown that health literacy education or partnerships between adult education programmes and primary health care providers can support a wide range of actions that improve health and well-being.45

The importance and benefits of health literacy are clear; however, the WHO Regional Office for Europe provided evidence of limited health literacy as recently as 2013. In the European Health Literacy Survey of 7795 people from eight countries, an average of 12% of the respondents demonstrated an inadequate general health literacy (ranging from 2% out of 993 respondents in the Netherlands and 27% out of 925 respondents in Bulgaria), and an average of 35% with a limited health literacy (as measured by those with inadequate literacy plus those with problematic literacy; ranging from 29% for the Netherlands to 62% in Bulgaria).46,47

A recent systematic review reported a lack of institutional support, data and resources required for community and citizen empowerment and for participatory and deliberative approaches in health policy-making processes in sub-Saharan Africa.48 Despite the existence of participatory health councils in 99% (1972/2000) of all Brazilian cities, there still exists a lack of full citizen and community empowerment in health policy decision-making.49,50

Recommendations

To overcome the issues affecting the successful implementation of the primary health-care functions, and hence achievement of UHC and other health-related SDGs, we recommend that governments in low- and middle-income countries take the following actions.

First, governments must significantly increase their financial commitment to the health sector, but also increase the proportion of this spending in the area of primary health care by streamlining hospital spending.

Second, we recommend that governments implement programmes focused on the effective retention of the health workforce in rural primary care services.51 Bundle interventions, such as providing integrated training and career pathways, financial and non-financial incentives, and safe and supportive work environments, as well as meeting the needs of both individual health-care workers and those of their families, can be more effective than any single intervention.52

Third, we recommend that pre-service training curricula of primary health-care personnel are updated to ensure that, as well as skills in delivering clinical services, staff have the opportunity to acquire (i) awareness of the importance of public health interventions and (ii) competence in collaborating with communities and other sectors. Further, local- and national-level multisectoral actions should be synergized to address the determinants of health through the application of best-buy interventions. For example, the local-level law enforcement of smoke-free public spaces, alcohol breath testing53 and maximum driving speeds54 can be synergized with national-level interventions such as increased tax, controlled tobacco marketing, and legislation on alcohol and vehicle speed limits.

Finally, to improve the health literacy of populations, we recommend that the skills of primary health-care workers be enhanced to include the establishment of official platforms that could support community engagement in multilevel decision-making in health care.

Funding:

The Thailand Science Research and Innovation (TSRI) under the Senior Research Scholar on Health Policy and System Research [Contract No. RTA6280007] funded this article.

Competing interests:

None declared.

References

  • 1.Constitution of the World Health Organization. Geneva: World Health Organization; 1948. Available from: https://apps.who.int/gb/bd/pdf_files/BD_49th-en.pdf#page=7 [cited 2020 Aug 17].
  • 2.Tangcharoensathien V, Mills A, Palu T. Accelerating health equity: the key role of universal health coverage in the Sustainable Development Goals. BMC Med. 2015. April 29;13(1):101. 10.1186/s12916-015-0342-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.International Conference on Primary Health Care. Declaration of Alma-Ata. WHO Chron. 1978. November;32(11):428–30. [PubMed] [Google Scholar]
  • 4.A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. Geneva: World Health Organization, United Nations Children’s Fund; 2018. Available from: https://apps.who.int/iris/handle/10665/328065 [cited 2020 Aug 12].
  • 5.Hone T, Macinko J, Millett C. Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals? Lancet. 2018. October 20;392(10156):1461–72. 10.1016/S0140-6736(18)31829-4 [DOI] [PubMed] [Google Scholar]
  • 6.Starfield B. Politics, primary healthcare and health: was Virchow right? J Epidemiol Community Health. 2011. August;65(8):653–5. 10.1136/jech.2009.102780 [DOI] [PubMed] [Google Scholar]
  • 7.A/RES/70/1. Transforming our world: the 2030 Agenda for Sustainable Development. In: Seventieth United Nations General Assembly, New York, 25 Sep 2015. New York: United Nations; 2015. Available from: https://undocs.org/en/A/RES/70/1 [cited 2020 Aug 12].
  • 8.Global indicator framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development. New York: United Nations; 2018. Available from: https://unstats.un.org/sdgs/indicators/Global%20Indicator%20Framework%20after%202019%20refinement_Eng.pdf [cited 2020 Aug 12].
  • 9.Declaration of Astana. Global Conference on Primary Health Care. Geneva: World Health Organization; 2018. Available from: https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf [cited 2020 Aug 12].
  • 10.A/RES/74/2. Political declaration of the high-level meeting on universal health coverage. In: Seventy-fourth United Nations General Assembly, New York, 10 Oct 2019. New York: United Nations; 2019. Available from: https://undocs.org/en/A/RES/74/2 [cited 2020 Aug 17].
  • 11.A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF); 2018. Available from: https://apps.who.int/iris/handle/10665/328065 [cited 2020 Aug 18].
  • 12.Primary Health Care on the Road to Universal Health Coverage. 2019 Monitoring Report. Geneva: World Health Organization; 2019. Available from: https://www.who.int/healthinfo/universal_health_coverage/report/uhc_report_2019.pdf?ua=1 [cited 2020 Aug 12].
  • 13.Holmes KK, Bertozzi S, Bloom BR, Jha P, Gelband H, DeMaria LM, et al. Major infectious diseases: key messages from disease control priorities. In: Holmes KK, Bertozzi S, Bloom BR, Jha P, editors. Major infectious diseases. 3rd ed. Washington, DC: The International Bank for Reconstruction and Development/The World Bank; 2017. 10.1596/978-1-4648-0524-0_ch1 [DOI] [PubMed] [Google Scholar]
  • 14.Bartlett S, Haslam D, Bush S, Haddad D. Elimination through collaboration: success factors in a global consortium. Int Health. 2019. January 1;11(1):24–9. 10.1093/inthealth/ihy054 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Declaration on the TRIPS agreement and public health. Geneva: World Trade Organization; 2001. Available from: https://www.who.int/medicines/areas/policy/tripshealth.pdf [cited 2020 Aug 12].
  • 16.Nicol D, Owoeye O. Using TRIPS flexibilities to facilitate access to medicines. Bull World Health Organ. 2013. July 1;91(7):533–9. 10.2471/BLT.12.115865 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2017. Available from: https://apps.who.int/iris/handle/10665/259232 [cited 2020 Aug 12].
  • 18.Tangcharoensathien V, Chandrasiri O, Kunpeuk W, Markchang K, Pangkariya N. Addressing NCDs: challenges from industry market promotion and interferences. Int J Health Policy Manag. 2019. May 1;8(5):256–60. 10.15171/ijhpm.2019.02 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Gostin LO, Monahan JT, Kaldor J, DeBartolo M, Friedman EA, Gottschalk K, et al. The legal determinants of health: harnessing the power of law for global health and sustainable development. Lancet. 2019. May 4;393(10183):1857–910. 10.1016/S0140-6736(19)30233-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Kolandai MA, Reyes JL. South East Asia Tobacco Industry Interference Index. Bangkok: South-east Asia Tobacco Control Alliance (SEATCA); 2019. Available from: https://www.who.int/docs/default-source/searo/tobacco/south-east-asia-tobacco-control-alliance-2019.pdf?sfvrsn=bf1b72d6_2 [cited 2020 Aug 12].
  • 21.A/RES/72/271. Improving global road safety. In: Seventy-second United Nations General Assembly, New York, 18 Apr 2018. New York: United Nations; 2018. Available from: https://www.unece.org/fileadmin/DAM/road_Safety/Documents/UN_Road_Safety_Trust_Fund_launch_event_April_2018/GA_resolution_A_RES_72_271_N1810643.pdf [cited 2020 Aug 12].
  • 22.Bennett S, Glandon D, Rasanathan K. Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge. BMJ Glob Health. 2018. October 10;3(4) Suppl 4:e000880. 10.1136/bmjgh-2018-000880 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A. Management of severe acute malnutrition in children. Lancet. 2006. December 2;368(9551):1992–2000. 10.1016/S0140-6736(06)69443-9 [DOI] [PubMed] [Google Scholar]
  • 24.Kunzli N, Rapp R, Perez L. “Breathe Clean Air”: the role of physicians and healthcare professionals. Breathe (Sheff). 2014;10(3):214–9. 10.1183/20734735.103114 [DOI] [Google Scholar]
  • 25.Review of 40 years of primary health care implementation at country level. Geneva: World Health Organization; 2019. Available from: https://www.who.int/docs/default-source/documents/about-us/evaluation/phc-final-report.pdf?sfvrsn=109b2731_4 [cited 2020 Aug 12].
  • 26.Data: Domestic general government health expenditure per capita (current US$) - Low income, Lower middle income. Washington, DC: World Bank; 2020. Available from: https://data.worldbank.org/indicator/SH.XPD.GHED.PC.CD?locations=XM-XN [cited 2020 Aug 12].
  • 27.Stenberg K, Hanssen O, Edejer TT-T, Bertram M, Brindley C, Meshreky A, et al. Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries. Lancet Glob Health. 2017. September;5(9):e875–87. 10.1016/S2214-109X(17)30263-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Sorenson C, Drummond M, Bhuiyan Khan B. Medical technology as a key driver of rising health expenditure: disentangling the relationship. Clinicoecon Outcomes Res. 2013. May 30;5:223–34. 10.2147/CEOR.S39634 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Health expenditure in hospitals. In: Health at a Glance: Europe 2018. Paris: OECD Publishing; 2018. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2018/health-expenditure-in-hospitals_health_glance_eur-2018-32-en [cited 2020 Aug 12].
  • 30.Spending on primary care: first estimates. Paris: OECD; 2019. Available from: https://www.oecd.org/health/health-systems/Spending-on-Primary-Care-Policy-Brief-December-2018.pdf [cited 2020 Aug 12].
  • 31.A System of Health Accounts 2011. Revised edition Paris: Organisation for Economic Co-operation and Development, Eurostat, World Health Organization; 2017. 10.1787/9789264270985-en [DOI] [Google Scholar]
  • 32.Vande Maele N, Xu K, Soucat A, Fleisher L, Aranguren M, Wang H. Measuring primary healthcare expenditure in low-income and lower middle-income countries. BMJ Glob Health. 2019. February 21;4(1):e001497. 10.1136/bmjgh-2019-001497 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.The World Health Report 2006 - working together for health. Geneva: World Health Organization; 2006. Available from: https://www.who.int/whr/2006/en/ [cited 2020 Aug 12].
  • 34.World Health Statistics 2019: monitoring health for the SGDs. Geneva: World Health Organization; 2019. Available from: https://www.who.int/gho/publications/world_health_statistics/2019/en/ [cited 2020 Aug 12].
  • 35.World Health Statistics 2010. Geneva: World Health Organization; 2010. Available from: https://www.who.int/whosis/whostat/EN_WHS10_Full.pdf?ua=1 [cited 2020 Aug 17].
  • 36.World Health Statistics 2015. Geneva: World Health Organization; 2015. Available from: https://bit.ly/2PWnC96 [cited 2020 Aug 17].
  • 37.Global strategy on human resources for health: Workforce 2030. Geneva: World Health Organization; 2016. Available from: https://www.who.int/hrh/resources/global_strategy_workforce2030_14_print.pdf?ua=1 [cited 2020 Aug 16].
  • 38.Ramadhan AP, Santoso D. Health workers absenteeism: Indonesia urban public health centres. J Public Health. 2015. June;23(3):165–73. 10.1007/s10389-015-0667-6 [DOI] [Google Scholar]
  • 39.Chaudhury N, Hammer J, Kremer M, Muralidharan K, Rogers FH. Missing in action: teacher and health worker absence in developing countries. J Econ Perspect. 2006. Winter;20(1):91–116. 10.1257/089533006776526058 [DOI] [PubMed] [Google Scholar]
  • 40.Willcox ML, Peersman W, Daou P, Diakité C, Bajunirwe F, Mubangizi V, et al. Human resources for primary health care in sub-Saharan Africa: progress or stagnation? Hum Resour Health. 2015. September 10;13(1):76. 10.1186/s12960-015-0073-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Moosa S, Wojczewski S, Hoffmann K, Poppe A, Nkomazana O, Peersman W, et al. The inverse primary care law in sub-Saharan Africa: a qualitative study of the views of migrant health workers. Br J Gen Pract. 2014. June;64(623):e321–8. 10.3399/bjgp14X680089 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Mercer SW, Guthrie B, Furler J, Watt GCM, Hart JT. Multimorbidity and the inverse care law in primary care. BMJ. 2012. June 19;344:e4152. 10.1136/bmj.e4152 [DOI] [PubMed] [Google Scholar]
  • 43.Bennett S, Glandon D, Rasanathan K. Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge. BMJ Glob Health. 2018. October 10;3 Suppl 4:e000880. 10.1136/bmjgh-2018-000880 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.The World Health Report 2002. Reducing risks, promoting healthy life. Geneva: World Health Organization; 2002. Available from: https://apps.who.int/iris/bitstream/handle/10665/42510/WHR_2002.pdf?sequence=1 [cited 2020 Aug 12].
  • 45.Vamos S, Okan O, Sentell T, Rootman I. Making a case for “Education for Health Literacy”: an international perspective. Int J Environ Res Public Health. 2020. February 24;17(4):1436. 10.3390/ijerph17041436 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Health literacy: the solid facts. Regional Office for Europe: World Health Organization. 2013. Available from: https://apps.who.int/iris/bitstream/handle/10665/128703/e96854.pdf [cited 2020 Aug 17].
  • 47.Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, et al. ; HLS-EU Consortium. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Public Health. 2015. December;25(6):1053–8. 10.1093/eurpub/ckv043 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Danhoundo G, Nasiri K, Wiktorowicz ME. Improving social accountability processes in the health sector in sub-Saharan Africa: a systematic review. BMC Public Health. 2018. April 13;18(1):497. 10.1186/s12889-018-5407-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Kohler JC, Martinez MG. Participatory health councils and good governance: healthy democracy in Brazil? Int J Equity Health. 2015. February 19;14(1):21. 10.1186/s12939-015-0151-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Avritzer L. Participatory institutions in democratic Brazil. Washington, DC: Woodrow Wilson Center Press; 2009. [Google Scholar]
  • 51.Dolea C. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: https://www.who.int/hrh/retention/guidelines/en/ [cited 2020 Aug 12]. [PubMed] [Google Scholar]
  • 52.Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Hum Resour Health. 2019. December 16;17(1):99. 10.1186/s12960-019-0432-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Brady JE, Baker SP, Dimaggio C, McCarthy ML, Rebok GW, Li G. Effectiveness of mandatory alcohol testing programs in reducing alcohol involvement in fatal motor carrier crashes. Am J Epidemiol. 2009. September 15;170(6):775–82. 10.1093/aje/kwp202 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Vecino-Ortiz AI, Jafri A, Hyder AA. Effective interventions for unintentional injuries: a systematic review and mortality impact assessment among the poorest billion. Lancet Glob Health. 2018. May;6(5):e523–34. 10.1016/S2214-109X(18)30107-4 [DOI] [PubMed] [Google Scholar]

Articles from Bulletin of the World Health Organization are provided here courtesy of World Health Organization

RESOURCES