Spatial analysis has become an increasingly used analytic approach to describe and analyze spatial characteristics of disease burden, but the depth and coverage of its usage for health surveys data in Sub-Saharan Africa are not well known. The objective of this scoping review was to conduct an evaluation of studies using spatial statistics approaches for national health survey data in the SSA region. An organized literature search for studies related to spatial statistics and national health surveys was conducted through PMC, PubMed/Medline, Scopus, NLM Catalog, and Science Direct electronic databases. Of the 4,193 unique articles identified, 153 were included in the final review. Spatial smoothing and prediction methods were predominant (n = 108), followed by spatial description aggregation (n = 25), and spatial autocorrelation and clustering (n = 19). Bayesian statistics methods and lattice data modelling were predominant (n = 108). Most studies focused on malaria and fever (n = 47) followed by health services coverage (n = 38). Only fifteen studies employed nonstandard spatial analyses . We recommend that for future spatial analysis using health survey data in the SSA region, there must be an improve recognition and awareness of the potential dangers of a naïve application of spatial statistical methods. We also recommend a wide range of applications using big health data and the future of data science for health systems to monitor and evaluate impacts that are not well understood at local levels. Spatial analysis concerns the use of statistical methods to analyze spatial data by accounting for location-specific information, elevation, distance, spatial relationships and association between the data ,2. TheseIn the context of the United Nation’s sustainable development goals (SDGs) to be achieved by 2030 ,5,6. To On the other hand, health surveys such as demographic and health surveys (DHS), Malaria Indicator Surveys (MIS), AIDs Indicator Surveys (AIS) and Multiple Indicator Cluster Surveys (MICS) cover a wide range of health topics. Analyses of data from nationally representative households and population health surveys have been done and the findings have provided enough evidence to track the progress of health and socio-demographic indicators to meet local, national and international goals. Even though these surveys are implemented at comparatively enormous costs, their usage has remained sub-optimal since such analyses demand advanced data management and often complicated statistical techniques . A comprEven though the application of spatial statistics to map health outcomes and processes have grown in Sub-Saharan Africa (SSA) over the past two decades, reviews summarizing a body of research studies that have employed spatial analysis methods based on nationally representative health survey data are scarce. One previous review on spatial analysis methods on health issues in Africa only applied to HIV research and was general in its coverage of data sources . We set Inclusion criteria: articles published in English during the period 1990–2018 employing spatial statistic methods in the SSA region to analyze nationally representative household and health survey data.Exclusion criteria: articles published outside the 1990–2018 period and all publications based on data from health surveys conducted outside the SSA region, systematic reviews and meta-analyses, publications that only referenced health surveys but did not analyze the data obtained, studies that used non-nationally representative local or regional health surveys data and those that had utilized non-spatial statistical methods such as multilevel/random-effects models. Spatial analyses that used surveillance data were also excluded.We conducted this scoping review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) guidelines . A CheckAll potential studies retrieved were first imported to Mendeley and duplicates were removed. The remaining articles were imported to Covidence, a web-based systematic review software-designed process of screening, data extraction and analysis  for screData extraction was performed using Microsoft Excel, which produced a master table with the following information extracted from each paper: spatial statistical methods and software; data source; public health outcomes and themes; and demographic focus groups. Spatial analysis techniques were categorized as spatial descriptive or aggregation method; spatial autocorrelation and clustering; spatial regression and interpolation and spatial modeling and prediction. The categories for health disciplines and themes were health service coverage; mortality; malaria and fever; diarrhea; malnutrition; non-communicable diseases; TB and HIV/AIDS; and others. Articles were permitted to be sorted into more than one methodological class and public health themes deemed appropriate. Counts and proportions were primarily used to summarize the study findings. The demographic focus groups were categorized into children (<15 years old) or adults (≥15 years of age) and gender. The study quality was not assessed.A total of 4193 unique articles were identified after excluding 4318 duplicates. Out of the remaining articles, 3992 were excluded because their abstracts and titles did not meet the eligibility requirements . From a In the set of articles chosen for review, the spatial methods that were used for disease mapping are shown in Most of the articles included in this review used data from DHS (n = 93). Country-specific surveys (n = 23), MIS (n = 17), MICS) (n = 5), AIDS Indictor Surveys (n = 4) were used in the other papers, and 11 articles used data from multiple surveys. All these surveys used multistage sampling designs that encamps stratification, cluster sampling, and unequal selection probabilities. These three complex sample design considerations have implications for statistical analyses of the survey data. There were 37 multicounty studies and country-specific articles, Malawi and Nigerian each contributed 17 studies, followed by South Africa with 11 studies, then Kenya with 10 studies.I, Local Moran’s I and Anselin Local Moran’s I that were each used in three studies. K-function (n = 1) was also used (Nineteen (19) studies used at least one spatial autocorrelation or clustering technique to assess non-random spatial patterns and quantify correlation of spatial observations . Kulldorlso used .Of the 153 studies included in this review, most—138(90.1%)—used a standard or routine application of spatial methods. These involved studies that used spatial analysis methods embedded in GIS or spatial statistics software to measure spatial clustering and cluster detection and perform spatial modelling and predictions. Numerous studies (122 articles) used spatial modelling to describe relationships between the spatial health data and contextual factors to model and predict health data in space . Out of I, Geary’s C and Getis’s G [I, Geary’s C and Getis’s G. However, the most commonly used hotspot analysis is based on Anselin’s local indicator of spatial association (LISA) [In this scoping review, several spatial statistical methods have been used in the extracted publications. These methods include descriptive spatial methods where features within a given area are simply summarized as totals or averages and then presented on that area (these are aggregation methods). These methods pose a challenge in the choice of the underlying population exposed, which may be problematic in SSA where data on population totals could be inadequate. Several forms of identifying specific observations or areas exhibiting spatial autocorrelation or clustering with their neighbors have been identified in the extracted articles. The spatial autocorrelation statistics methods employed included classic global statistics, such as Moran’s etis’s G ,169, whin (LISA)  and Kulln (LISA) .The widely used spatial statistics methods are the spatial regression ), spatial smoothing, and spatial interpolation, often employed by spatial epidemiologists to improve the estimation of health outcomes and burden. These methods have tools for deriving spatial surfaces from sampled data points or to smooth across polygons to create more robust estimates. Spatial interpolation or spatial prediction methods incorporate geographic information and values at a network of observed locations to estimate values at unobserved locations. In the traditional spatial analysis, the main spatial interpolation techniques include inverse distance weighting (IDW), Kriging, spline interpolation, and interpolating polynomials ,172. HowBefore reviewing the articles included in this review, a list of research topics reflecting major health problems or themes in the SSA region was drawn. Eight major research themes were identified . Some puMore than half (54.9%) of the articles focused on populations aged less than 15 years, about 34.6% were aged above or equal to 15 years and 10.5% of the articles included all age groups . We founThis scoping review has demonstrated a variety of applications of spatial analysis techniques to household and health survey data in the SSA region. Spatial smoothing and prediction using Bayesian spatial statistics were predominantly used. Spatial autocorrelation and cluster detection were mostly fitted using frequentist methods and routines in GIS software. The most frequently studied health disciplines were malaria and fever followed by health services coverage and HIV/AIDS and health-related to mother and child health.Despite the wide application of spatial methods in SSA, studies that only concentrated on men were scant (<1%). Additionally, there was a lack of studies concentrating on health program evaluation, possibly because data in this field might be sparse or not well captured in nationally representative health surveys. Most studies failed to account for complex survey design and data insufficiency, possibly due to data inadequacy about non-response, defective sampling frames, and missing information in addition to adjustments for clustering to ensure data representativeness and unbiased inferences. Few studies have developed and applied spatial statistics methods accounting for health survey design, but these were for data outside of SSA ,178,179.Though the review was conducted adhering to PRIMSA-ScR guidelines, the search strategy used strategy might have missed studies that focused on some countries in SSA because our research included the term SSA only. We excluded studies that analysed health survey data, but the surveys were not nationally representative. We also did not interrogate sufficiently the methods used and the resulting findings. Most of the studies failed to account for the complex sampling design, which could have influenced the findings and conclusions drawn because standard spatial analyses generally underestimate the estimated variance of spatial estimates. Indeed, blind usage of available packages may adversely affect the extent to which analyses follow PRIMSA-ScR guidelines, and our search strategy might have missed studies that deployed spatial analysis techniques because we excluded papers published in languages other than English. There might also have been a risk of publication bias, which we did not assess. This review also excluded published research work that used spatial analyses on sentinel surveillance data. For example, spatial autocorrelation and inverse distance-weighted interpolation were used in ,182,183 To the best of our knowledge, this is the first review to provide the range and depth of published studies using spatial analysis techniques to analyze the rich data obtained in nationally representative health surveys conducted in the SSA region. It includes health disciplines, themes and demographic information covering almost 30 years (1990–2018). Our findings demonstrate a wide range of applications of spatial analysis techniques dominated by modelling and prediction approaches based on Bayesian geostatistical and lattice data modelling.Sample survey software should be used, especially for estimation of population parameters, and for descriptive and analytical analyses. Under certain circumstances, standard statistical packages can be used to provide results approximately equal to the results obtained from sample survey software. However, recognition of prevailing circumstances and an awareness of the potential pitfalls of using standard statistical packages require detailed information about the characteristics of the survey dataset used  as well as a knowledge of the formulas and default options in standard software packages for weighted analyses. In the end, it seems easier and less time consuming to use a sample survey software package throughout.Advanced analytical, innovative, and adaptive skills in spatial statistics should be used to manage and analyze existing survey data to better inform policymakers and local health service implementers. Indeed, new spatial methods might need to be developed for applications. We recommend a wide range of implementation examples from big health data, data future science and health systems to monitor and evaluate health program impacts, which are not well understood at the local level. Gender-specific studies focusing on an assessment of health interventions need to be conducted in the SSA region to provide further insights and enable profoundly informed decisions to improve public health concerning new areas of direction and research in SSA. Other obstacles in the region include the financial costs to obtain new data, the prolonged time before data become available for public use due to slow publication and/or bureaucratic processes that hinder data access and use.Rigorous and coherent quality assessment of survey data is highly important, including design and coverage of sampling. Survey comparisons were often made when sample sizes, item measurement and context varied across years and were at times substantially and not necessarily congruent with national population numbers. Also, age ranges of respondents for the same data items differed across surveys, or across years within a survey. More could have been gained in studies had attempted to tackle key issues including data quality, data and methods triangulation and validation. A challenging, but potentially very fruitful undertaking could come from integrating household surveys with data from routine health information gathering, monitoring and surveillance systems. A focused agenda is recommended for data triangulation and contestability via linkage and validation studies that would allow drawing on complementary properties of different sources, assist in completeness estimations and improve our understanding of the accuracy attribution in the phenomena being studied. Such improved understanding holds clear gains for improved small area estimates, enhanced resource and service distribution, and, eventually, better meeting the health needs of the population.Refinements of spatial methods and mapping levels are needed, e.g., by updating accessibility layers to include more recent and detailed road networks and settlement layers. This could also involve modelling key driving factors of the phenomena under study, such as poverty or access to sanitation, and then using these as covariates themselves. The effect that a country-specific focus, tailored as much as possible to a specific indicator, can have on mapping accuracies rather than using globally consistent covariates should be explored. Also, many socio-economic factors, not captured by the suite of covariates used, and often available at aggregate levels such as administrative units, could be obtained and their ability to improve mapping accuracy tested. The rising international focus on inequalities in the SDG-era requires a detailed and strong evidence base with an explicit quantification of uncertainties. Some studies provided sufficiently accurate prediction at an administrative unit that is relevant for policymaking and the allocation of resources. However, none of the studies looked at the issue of the Modifiable Areal Unit Problem (MAUP) in spatial analyses where an analysis based on a grouping unit may accidentally misrepresent or overstate actual risk variations . Even ifFinally, we have already discussed at length how non-response, missing data, and self-reporting of health conditions pose statistical challenges when estimating small area spatial health variation. Missing data reduces the representativeness of the sample and can, therefore, distort the spatial inferences about a health measure. Perhaps a major feature of these survey data is their representativeness at national and regional levels, but not at the lower geographic level, which may not have been systemically covered sufficiently. Reliable estimates are highly associated with the number of observations falling into these lower levels. Conducting surveys that could generate representative data at the desired geographic level would be highly costly (due to an increase in sample sizes). Others have recommended choosing an appropriate spatial model after performing a systematic evaluation and validation of several spatial models for generating small area estimates ,4,5,6. YComparisons and assessments of public health interventions and control programs at the sub-national level based on health survey data should consider survey design aspects when undertaking spatial analyses. Additionally, future research should focus on developing and evaluating spatial methods that leverage survey data in providing local estimates of health burdens. Several recommendations are made in this scoping review but most of them require strong skills and analytic capacity. Thus, further expansion and strengthening of analytic capacity in the development and application of spatial analysis methods relating to health survey data constitute the main message of our critical and overarching recommendation.


In Pakistan, drug promotion practices, ethical or unethical, have rarely been in the spotlight. We aimed to assess the perception and barriers of medical representatives (MRs) and doctors (MDs) regarding ethical promotion of pharmaceuticals in Pakistan.A cross sectional survey was conducted in seven major cities of Pakistan for 6-months period. Self-administered questionnaire was used for data collection. Logistic regression and five-point Likert scale scoring was used to estimate the perceptions and barriers.p = 0.0005), International Federation of Pharmaceutical Manufacturers & Associations (IFPMA)  and national codes of ethics . MNCs trained their MRs , provide accurate and valid scientific data  with adequate system of accountability and controls on product samples , while, NCs sponsor social or entertainment activities, seminars and conferences, and all sort of facilitation in form of gifts of their choice and clinic renovation for medical doctors (MDs). MDs perceptions were similar to MRs mentioned above, yet strongly agreed that companies offer cash payments or equivalents to MDs. The MRs of NCs/MNCs and MDs agreed/strongly agreed that no external accountability, profiteering, pressure on sale targets, job insecurity, condoning unethical promotion by high-ups’ and business promotion by junior MDs were the predominant barriers.Compared to national companies (NCs), the medical representatives (MRs) of multinational companies (MNCs) strongly believed that their companies follow World Health Organization (WHO) (OR; 5.31, In conclusion, MRs of MNCs and MDs believed that MNCs follow certain codes of ethics in the promotion of pharmaceuticals, while NCs tend to be more profit oriented and even condone unethical promotion. All stakeholders, MRs, MDs and companies, might pose certain barriers, intentionally or unintentionally, in ethical promotion. In different parts of the world, the interpretation of the term “ethical” varies in societies, which pertains to or deals with the morals or principles of morality, while the term “promotion” refers to all the informational and persuasive activities by the companies. In line with this, the ethical criteria for drug promotion should be based on the proper behaviors that are consistent with the search for truthfulness and righteousness. According to World Health Organization (WHO) 2018 estimates, the global pharma market is worth $1.4 trillion per annum .Pharmaceutical drug promotion, a term used to entail all the communicative and persuasive efforts by pharmaceutical manufacturers and distributors to invoke pharmaceuticals demand . Drug prIn Pakistan, the term “unethical promotion” is a well-known practicing fact in the realm of pharmaceutical marketing, chiefly created and practiced by multinational companies (MNCs) because of adequate finances to afford and support these practices . Followiwww.dra.gov.pk, 2018)—357 in Punjab, 150 in Sindh, 89 in Khyber Pakhtunkhwa and 10 in Baluchistan. Only 554 registered companies were considered as rest of the companies were either of veterinary medicines or cotton/bandages. Out of 554, only 271 pharmaceutical companies accepted to participate in the study. Thus, for data collection, questionnaires were sent to 271 pharmaceutical companies, NCs = 217 and MNCs = 54, at their drug distribution setups, since MRs and the managers use these offices for official meetings. The final enrollments consisted of 205 MRs from NCs and 125 from MNCs. The province and city wise enrollments of pharmaceutical companies are mentioned in Fig. A cross-sectional survey base study was conducted in 7 major cities of all four provinces, Punjab , Khyber Pakhtunkhwa (Peshawar), Sindh (Karachi) and Baluchistan (Quetta) and federal capital city (Islamabad) of Pakistan from January 02, 2018 to July 30, 2018. Data was collected from both, medical representatives (MRs) of national companies (NCs) and multi-national companies (MNCs), along with medical doctors (MDs). List of 609 registered national and multi-national pharmaceutical companies were acquired from drug regulatory authority of Pakistan , the statutory, regulatory and registration authority for medical and dental education, and practitioners of Pakistan, registered database upon an official request and were approached via letters of request to participate in the study.http://www.raosoft.com/samplesize.html), assuming a population of 23,268 with a confidence interval of 95% and margin of error of 5%, the study sample was found out to be 378. For an estimated response rate of 70% a total of 542 medical representatives were targeted for the distribution of questionnaires. The number of MRs and MDs, province and city wise, included in final analysis based on consent to participate and completely filled questionnaires as summarized in Fig. Sample size of MRs was calculated by estimating total number of pharmaceutical companies and extracting data on average number of products assigned to each MR. On an average 3–6 products were assigned to each MR to promote in one specific zone of a city. Thus, we estimated an average of 6 MRs for one city  by one pharma company. This makes a workforce of almost 42 MRs, excluding managers, in 7 major cities of Pakistan by one pharma company. For 554 pharmaceutical companies, considering an average of 42 MRs per company, the estimated number of MRs working in 7 major cities of Pakistan were almost 23,268. Using Rao-soft sample size calculator (n = 271), 2 questionnaires per company to enroll MRs under the following criteria;A total of 542 questionnaires were distributed to pharmaceutical companies  and 3 general practitioners were enrolled—12 MDs from each city to make a total of 60 MDs from 5 major cities. For Islamabad and Baluchistan, 2 tertiary care public hospitals and 1–2 GP clinics were included from each city, thus, 3 specialist doctors from each tertiary care hospital (2 × 3 = 6) and 1–2 GPs were enrolled—7 MDs from each city to make a total of 15 MDs from these 2 cities. Thus, in total 75 questionnaires were distributed among MDs as per study inclusion and inclusion criteria.Inclusion criteria; the specified number of registered MDs of teaching hospital, medical specialist  is a postgraduate qualification awarded by the College of Physicians and Surgeons Pakistan upon completing specialized training in chosen area of specialization, almost 73; one has to complete part 1 before completing part 2), and GPs both having at least 10 years of practice and willing to participate in the study were included in the study.Exclusion criteria; non-registered MDs, those not registered with PMDC, registered MDs with working experience of less than 10 years and not willing to participate in the study were excluded from the study.All the returned questionnaires were completely scrutinized to exclude the partially filled questionnaires, thus, only 51 completely filled questionnaires were used for data analysis . Questionnaires were validated by expert academician for content validation and suggestions were incorporated to make it more objective driven. Face validation was done by conducting a pilot study on 25 enrollees. Questionnaire for MRs and MDs were comprised of demographics, perception about ethical promotion and self-perceived posed barriers in ethical promotion of pharmaceuticals in Pakistan. Self-administered questionnaires were distributed among both, MRs and MDs with empty envelops with postal stamps to ensure their confidentiality and timely return to the field administrators.Data was analyzed by using statistical software SPSS. The percentages and frequencies were estimated using descriptive statistics. Inferential data was analyzed by using cross-tabulation and associations were determined using Pearson’s chi-square. Bivariate logistic regression was used to determine the odd ratios. Data was presented in the form of tables. An alpha value of 0.05 or less was considered statistically significant.The demographics of MRs and MDs are summarized in Table Besides, most of the MDs were males (88.24%), working in public hospitals (80.03%), more than 80% had working experience of 10–20 years and had completed FCPS (80.03%) either part 1 or both . The MRs of MNCs were more likely to believe that their companies follow ethical guidelines , aware of IFPMA , WHO , national codes of ethics  and Pakistan Medical Research Council (PMRC) codes of ethics . Regarding promotional practices, MRs believed that MNCs were more likely to provide accurate and scientifically valid data on products , respect privacy of the data , trained their MRs on ethical promotion  and had adequate controls and accountability measures for the samples provided to MDs . Conversely, the MRs of NCs perceived that company obliged MDs by sending them to international conferences , sponsored social and entertainment activities of MDs in international conferences , always willing to bear the cost of accompanying individuals , offered cash or cash equivalents  and were fulfilling MD’s request for any facilitation or gifts  (Table As shown in Table p = 0.0001), follow ethical guidelines in promoting their products , provide accurate balanced and scientifically valid data on products , provide information and scientific data with valid references . Conversely, MDs agreed/strongly agreed to perceptions implying un-ethical promotion of pharmaceuticals by NCs, such as organize events for MDs outside Pakistan other than international congress , finance social or entertainment activities for MDs in international congress , pay cost of individuals accompanying MDs on conferences , fulfil MD’s request for any facilitation or gifts , emphasize more on doctor-company sales contracts rather than doctor-patient suitability as per patient’s needs , more focused on selling tactics rather than product usage in the right indication  and always looking for MDs who prefer to write company products at the expense of certain benefits  , company’s repute  and market position . When asked about the purpose of the symposia, congress and scientific meetings for MDs, the MRs of both companies believed that these were aimed at providing the scientific information , facilitate MDs  and promote sales  , price war , to maximize the profit , lack of research , low quality products need unethical push , job insecurity in case of below target sales , materialistic approach by the MDs lacking ethical and moral values , managers not only condone but also encourage unethical promotion  and low salaries compel MRs to opt unethical promotion for incentives on sales   or strongly agree (SA) that lack of external accountability , price war among pharmaceuticals , out of competition companies resort to unethical promotion to maximize the profits , lack of interests in research and study , company’s pressure to achieve sale targets , low quality products need unethical push , job insecurity if sales targets not met , non-existence of doctor-patient-pharmacist loop , sales managers not only condone unethical promotion by MRs but also encourage it  and low salaries but incentives on achieving sales targets  were the main barriers in ethical promotion  under statutory notification on June 2017, provided code of conduct for ethical marketing to health care professionals. To our knowledge, as of today, no real time implementation is perceptible at public or private health care facilities. As per the codes of ethics, pharma companies can provide modest meals and educational items to business discussions and MDs, respectively. Moreover, companies may engage health care professionals to provide services that support research and development to advance in medical science, develop new technologies, improve existing products and services, educate on the safe and effective use of company products or enhance the quality and efficacy of patient care. Companies may provide training and education of Healthcare Professional on the safe and effective use of Company products, including “hands-on” training sessions, cadaver workshops, wet lab sessions, live surgeries, lectures and presentations. However, pharma companies should not provide any gifts or sponsor entertainment activities of MDs. But according to this notification, not a government executive, rather a senior executive appointed by the company will oversee all these practices and warrant their compliance to these codes of ethics—purely against the spirit of ethical promotion. With regards to contravention and punishment, whosoever himself or by any other person on his behalf contravenes with the provisions of the DRAP Act 2012 and regulations made there under shall be punishable as provided for in Schedule II and III of the DRAP Act 2012. Under Schedule II, no person shall himself or by any other person on his behalf advertise, distribute therapeutic good as sample and print label for the therapeutic goods, failure to comply would result in imprisonment for a term up to five years and with fine up to five hundred thousand rupees (~ $3000). Nonetheless, to our knowledge, not a single individual has been penalized for misleading advertisement, yet there have been several reports where the culprit has been penalized for distributing doctor’s sample and for printing fake labels—suggesting poor implementation of this act with regards to unethical promotion of pharmaceuticals in Pakistan. While under Schedule III, whoever himself or by any other person on his behalf imports, export, manufacture or sale any spurious, counterfeit therapeutic good without a license shall be punishable with imprisonment for a term which may extend to seven years, or with fine which may extend to five hundred thousand rupees (~ $3000) or with both.In other countries of South Asian region, like India and Bangladesh, the situation is not much different. In India, the principal legislation that regulates the pharmaceutical industry, i-e., Drug and Cosmetic Act, 1940, does not cover much about the drug promotion regulations, i-e., do’s and don’ts of promotion to health care professionals (HCPs), thus, back in 2011 and later revised in 2014, Uniform Code of Pharmaceutical Marketing Practices (UCPMP) and Organization of Pharmaceutical Procedures of India (OPPI) was introduced with the intent to guide and to set standards of interactions between the pharma industry and HCPs. However, despite the regulations in place for the medical doctors by Medical Council of India and pharma industry by UCPMP, the former seems to be ambiguous, non-comprehensive and poorly implemented, while the latter seems to be self-regulatory codes lacking regulatory and legal binding , 29. LikIn Pakistan, it’s a matter of grave concern that majority of MRs working for NCs were oblivious of WHO, IFPMA and national codes of ethics regarding pharmaceutical promotion. This suggested that the pharmaceutical drug promotion practices are unattended and unaccountable for any misconduct affecting patient’s life and out of pocket finances. Thus, utmost attention should be paid to implement and maintain ethical standards of drug promotion by the health system regulators, health practitioners and professional organizations. The policy makers and regulators should ensure stricter legislation with regards to unethical promotion with mechanisms of policy implementation, regular monitoring, screening of printed promotional material and punitive fines for offenders. There should be written protocols on ethical marketing for awareness with training programs in place for all health workers. There should be courses, during undergraduate training, on ethical promotion of drugs dealing with the art of critical appraisal of drug promotion literature to confirm product claims. Importantly, Pakistan should adopt standard codes of ethics on pharmaceutical marketing, such as WHO or IFPMA with inhouse modifications in line with the needs of local health care and pharmaceutical market. However, critics of the way that pharmaceutical promotion is regulated believe that the WHO code is significantly stronger than the IFPMA one , 32. BesThe study has several limitations, the cross-sectional design of the study did not allow the documentation over an extended period of time. The response rate of MRs was not optimal because we were unable to visit them personally due to limited resources. Data obtained through self-administered questionnaires are self-reported and might be subject to bias. Besides, the gathered information is purely based on MDs and MRs self-sensed responses rather than the actual observation by an observer.Taken together, these data suggest that compared to MRs of NCs, majority of the MRs working in MNCs were more likely to follow and own adequate information about different codes of ethics in ethical promotion of pharmaceuticals. While, NCs tend to facilitate MDs in form of gifts, social and entertainment activities, local and abroad. Similar perception was upheld by the MDs regarding ethical promotion except one common tag that both MNCs and NCs offer cash payments or equivalents to MDs. Moreover, MRs of NCs and MNCs agreed or strongly agreed that pressure to achieve sales targets, incentivized MDs, sales linked job security, MD’s materialistic mindset, brand prescribing and junior doctor’s reliance on companies for their businesses were the predominant barriers. Likewise, majority of the MDs agree or strongly agree to the above-mentioned barriers in addition to lack of external accountability and blatant condonation of high-ups for such activities.Additional file 1: Table S1. Pharma companies’ priorities in promoting pharmaceuticals, medical representative’s perspectives.


In addition to healthcare entitlements, ‘migrant-friendly health services’ in Thailand include interpretation and cultural mediation services which aim to reduce language and cultural barriers between health personnel and migrants. Although the Thai Government started implementing these services in 2003, challenges in providing them still remain. This study aims to analyse the health system functions which support the interpretation and cultural mediation services of migrant health worker (MHW) and migrant health volunteer (MHV) programmes in Thailand.In-depth interviews were conducted in two migrant-populated provinces using purposive and snowball sampling. A total of fifty key informants were recruited, including MHWs, MHWs, health professionals, non-governmental organisation (NGO) staff and policy stakeholders. Data were triangulated using information from policy documents. The deductive thematic analysis was classified into three main themes of evolving structure of MHW and MHV programmes, roles and responsibilities of MHWs and MHVs, and supporting systems.The introduction of the MHW and MHV programmes was one of the most prominent steps taken to improve the migrant-friendliness of Thai health services. MHWs mainly served as interpreters in public facilities, while MHVs served as cultural mediators in migrant communities. Operational challenges in providing services included insufficient budgets for employment and training, diverse training curricula, and lack of legal provisions to sustain the MHW and MHV programmes.Interpretation and cultural mediation services are hugely beneficial in addressing the health needs of migrants. To ensure the sustainability of current service provision, clear policy regulation and standardised training courses should be in place, alongside adequate and sustainable financial support from central government, NGOs, employers and migrant workers themselves. Moreover, regular monitoring and evaluation of the quality of services are recommended. Finally, a lead agency should be mandated to collaborate with stakeholders in planning the overall structure and resource allocation for the programmes. The health of migrants is recognised as a global health issue in several international agreements , 2. InteThe Migrant Integration Policy Index (MIPEX) has carried out a benchmarking of migrant integration policy in 38 countries in Europe and beyond. The Health strand assesses four dimensions of policy: entitlements to health services; accessibility of services; responsiveness to migrants’ needs; and measures to achieve change . With rePolicies to improve the accessibility of health services include the provision of health education, health promotion, information about services and ‘cultural mediators’. Responsiveness to the needs of migrant patients includes providing qualified interpretation services and promoting ‘cultural competence’ or ‘diversity sensitivity’ . CulturaCulturally competent healthcare services enhance the accessibility and quality of services by reducing language and cultural barriers. Klemm et al. (2016) described the distinction between linguistic interpretation and cultural mediation. Interpretation involves conveying the meanings of language during interpersonal interactions as accurately as possible; it is a professional activity, with recognised standards and codes of conduct . CulturaSince 2003, ‘migrant-friendly health services’ have been implemented under a collaboration between the Thai MOPH and non-governmental organisations (NGO) in migrant-populated areas . ServiceAccording to the World Health Organization (WHO), health system building blocks are as follows: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership and governance (stewardship) . All of Previous studies evaluating the MHW and MHV programmes have outlined the following constraints: low numbers of MHWs and MHVs, limited interpretation skills, lack of training programmes and supervision, and lack of budgetary support , 19. Up A qualitative approach was employed using in-depth interviews triangulated with a policy document review. Purposive sampling was used to identify key informants in both public and non-governmental organisations. Additional informants were identified by snowball sampling. The study took place in the two most densely migrant-populated districts in Samut Sakhon and Ranong provinces, Thailand. Key informants included MHWs, MHVs, health professionals, NGO staff and policy stakeholders.Ethical approval to conduct the study was obtained from the Institute for Human Research Protection, Thailand (IHRP 530/2561). The interview topic guides consisted of three parts: a) background and structure of the interpretation and cultural mediation services in MHW and MHV programmes; b) health system support for these programmes focusing on human resources, financial management and inter-agency coordination; and c) strengths and weaknesses of the system and recommendations for the services. Each interview took about 30–45 min and was recorded with consent from the interviewees. All interviews took place in the households or workplaces of key informants from November 2018 to April 2019.The interviews were transcribed from the audio records and coded based on themes. A deductive thematic analysis was conducted to identify three main themes: 1) evolving structure of MHW and MHV programmes, 2) roles and responsibilities of MHWs and MHVs, and 3) supporting systems in need. The supporting systems were classified into three sub-themes of budget, human resource development, and inter-agency coordination and planning for MHW and MHV programmes.There were 50 key informants participating in this study (see Table We identified three main themes from the interviews: 1) evolving structure of MHW and MHV programmes, 2) roles and responsibilities of MHWs and MHVs, and 3) supporting systems in need.“Since 1995, our organisation [NGO] was involved in migrant health in province B. There was a language barrier because we did not have staff who could speak Burmese, so we had to hire Myanmar doctors in our team. The doctor salary was too high, so we could employ only one or two doctors which was not enough for our workload. Therefore, we tried to hire more staff called the ‘Frontline Social Network’ [MHWs] who networked with the target group [migrant workers] in this area.” [NGO-4].Originally, before 1995, interpretation services for migrant workers in Thailand were primarily provided by MHVs from NGOs; their voluntary work mainly involved interpretation and other kinds of help with overcoming language barriers experienced by migrants. Afterwards, they were employed as MHWs because there was a need for interpreters, especially in public health facilities and NGOs. These services were subsequently scaled up with technical and financial support from the IOM, the United States Agency for International Development (USAID) and the Thai MOPH . This ‘MMHWs are hired as staff in public health facilities and with NGOs in migrant communities, while MHVs work as volunteers within migrant communities. The MOPH training guidelines include content that emphasises differing roles and responsibilities of MHWs and MHVs . MHWs also have to help with disease screening (e.g. measuring blood pressure); coordinating interactions between and with health professionals; and educating MHVs and migrant workers about basic measures like personal hygiene and reproductive health , 16. At Various mechanisms are involved in the sustainability of MHW and MHV programmes in Thailand, such as laws and regulations supporting the formal status of MHWs, and budgets for employment and human resource development. Through system analysis, we identified several challenges in supporting these programmes: (i) budget, (ii) human resource development, and (iii) inter-agency coordination and planning for MHW and MHV programmes.“[In the past] jobs allowed for migrant workers were domestic workers and labourers, so in the work permit of MHWs, they were hired only in those two jobs. Nowadays, [we are] allowed to hire [them] as language coordinators.” [HP-9].In the past, according to the Alien Work Act 2008, migrants were not allowed to work in Thai health facilities. Accordingly, MHWs were employed as labourers or domestic workers to conform with the terms of their work permits. This situation changed in November 2016 with an announcement from the Prime Minister’s Office allowing migrant workers to be legally hired as migrant language coordinators (LCs) under the revised Alien Work Act  do not receive these benefits because [the hospital] hires with external contracts [temporary contract]” [HP-14].“The [MHW] salary was 6,900 Baht (US$230) then it was deducted for Social Security Scheme, approximately 300 Baht (10 US$). The remaining allowance was around 6,500 Baht which I had to pay for debts and living costs of the whole families, so it was not enough.” [MHW-7].“[When we announced MHW jobs], there were some unfilled posts because industries paid a higher salary than us [NGOs]. We had to compete with industries which offered minimal remuneration at 12,000-13,000 Baht (US$400). If they [MHWs] passed the probation, they would receive 15,000 Baht (US$500) which was sometimes higher than Thais” [NGO-1].In terms of source of funding, migrant workers who have passed the nationality verification processes under the OSS are obliged to be insured with the SSS if they work in the formal sector; while those who work in the informal sectors, including their dependants, are eligible for the HICS . SSS is “Luckily, we have a high number of migrant workers who enrolled in HICS, so we have enough money to hire MHWs and train both MHWs and MHVs. In some provinces, there is a small number of migrant workers, so it [negatively] affects the budget for MHVs and MHWs.” [HP-5].Local interviewees considered the financial support for hiring MHWs, as announced by the MOPH, was not adequate, and that the budget allocation had decreased over time due to a decline in the volume of HICS beneficiaries. Diminishing HICS enrolment was partly due to the implementation of the revised Working of Alien Act in 2017 , which sAlthough falling HICS revenues adversely affected budget support for MHW and MHV programmes, some policymakers addressed that the budget for hiring MHWs and training MHWs and MHVs was manageable in local contexts.“The local areas could manage themselves because we [MOPH] supported administrative costs [of HICS revenue]. Some provinces already used the earmarked revenue of the HICS to support health promotion and disease prevention activities, and to hire and train MHWs and MHVs. [POL-1].“For MHWs, we [health professionals] select migrant workers who have the potential [to be MHVs]. Firstly, they should pass the MHV training course. Secondly, they should speak and write both Thai and Burmese languages. Lastly, they are supposed to have a spirit of volunteerism and a service mind.” [HP-2].“For MHVs, firstly, they should have time to join training courses. Secondly, they should live in those areas, and be well-known persons in the communities. Thirdly, they are supposed to have fairly strong communication skills in Thai because the training programme is in the Thai language, and they have to assist health professionals in communicating with migrant workers.” [HP-16].Human resource development for interpretation and cultural mediation services comprised three elements: a) recruitment, b) training, and c) supervision of MHWs and MHVs. We found variations in the recruitment criteria of MHWs and MHVs in each organisation, related to differences in the responsibilities assigned, which in turn depended on the local context. However, there were some common criteria aligned with national guidelines , I would like to learn and know about it. In the emergency situation, it was unpredictable what we would confront, so I would like to help others.” [MHW-7].Some health staff considered that apart from assisting health professionals, MHWs  should only work as interpreters. In contrast, MHWs considered that they needed to expand their role beyond interpretation to offer health knowledge and skills to patients. Thus, there was a mismatch of expectations between MHWs and health workers.“I [MHV] do not have enough time [to join training courses]. For example, they [local organisations] set up a training programme this week, but I cannot join. When I learn intermittently, it influences our understanding of course contents.” [MHV-3].“Some MHWs cannot understand all the contents [in training courses]. MHWs who clearly understand more than others will sit nearby those who do not understand and explain things to them …” [MHW-4].Thai-Myanmar training materials and processes were supported by central MOPH and local organisations; however, local staff could adjust training to the local context. MHWs were trained in the Thai language by local staff from public health facilities and NGOs, while MHVs received bilingual training from both local staff and MHWs. However, some of the MHWs and MHVs interviewed said that they did not fully understand the course contents because of language barriers and time constraints.“For the supervision of MHWs, when they have activities such as training health knowledge, we [NGO staff] will observe their training. For example, we might ask MHVs whether they understand the training courses or not …” [NGO-3].MHWs and MHVs were supervised through direct observation by health staff at public facilities and NGOs. Some organizations also used exams to evaluate MHWs’ knowledge, but most were evaluated during on-the-job training. Compared with MHVs, MHWs tended to be more closely supervised during training, because they had longer contact time with staff in public facilities and NGOs during patient consultations.Coordination across organisations was another factor affecting the delivery of the MHW and MHV programmes. We identified a myriad of different mechanisms for collaboration between public health facilities and NGOs. For example, MHWs employed by NGOs served as interpreters in TB and HIV clinics in public hospitals; their services were also called on by public health officers in areas where there was no public provision of MHWs or MHVs. Moreover, MHWs and MHVs were able to join any training course provided by the public sector or NGOs. However, in some provinces, there was a lack of MHV registration data in local organisations. For example, some MHVs trained by the Provincial Health Office were neither registered in the public health facilities nor included in the NGO data. This created problems in human resources management as accurate data on the number and profiles of MHVs were not available.“We [Bureau of Health Administration] develop migrant service delivery … we have YouTube channel, posters in Thai, Myanmar and Laos languages and language manual [Manual Using Four Languages Thai-English-Myanmar-Cambodian For Health Personnel] … in the past, we could not hire [migrant workers as] MHWs, so we changed the laws then they [MHWs] could be hired [as LCs in the work permits]” [POL-3].At the national level, MHW and MHV programmes are one of the key activities in the National Action Plan for Public Health in Specific Areas (Migrant population) 2020–2024 [Overall, MHW and MHV programmes in migrant-friendly health services have received much attention from the Thai Government. The Thai healthcare system benefits hugely from the work of MHWs and MHVs, either as interpreters or as cultural mediators. Over the last two decades, there have been significant improvements to the MHW and MHV programmes, such as better training programmes and the provision of an appropriate legal framework for MHWs. However, some challenges still exist, such as the lack of standardisation of training curricula for interpretation services and cultural mediation, insufficient budget to hire MHWs, and a lack of inter-agency coordination and legal basis for overall services.The concept of health equity is vital in the health system . MigrantWe found much diversity in the way interpretation services and cultural mediation were provided. The MIPEX Health Strand classifies interpretation services as a way to improve the responsiveness of services to migrants’ needs, and cultural mediation as a way to make services more accessible . A studyThough MHWs were initially defined as interpreters and MHVs as cultural mediators, in practice, their roles intermingled. Although it is important to distinguish the roles for the purposes of training and supervision, some managerial flexibility should exist because of the limited number of MHWs and MHVs available. According to local need, MHWs may sometimes perform the function of MHVs and vice versa.Interpreters are usually classified into two types: formal and informal. Formal interpreters are specially trained for the job, particularly on the technicalities of medical interpretation, cultural sensitivities, and ethical considerations. Informal interpreters are usually ‘ad-hoc’ and may be family members, relatives or friends with knowledge of the language, or bilingual health staff who have other main duties . There aEvidence suggests that a contextual approach is advisable, paying attention to health providers’ and patients’ specific needs . For exaIn Thailand, MHWs have key roles as formal interpreters in health facilities, while MHVs take on this role when MHWs are not available. Accordingly, MHVs sometimes serve as interpreters for migrant patients; health professionals tend to prefer this to using ad-hoc interpreters like family members and friends. However, neither MHW and MHV curricula offer specific detail about developing interpretation skills such as guidelines for professional ethical conduct  or training for medical interpretation. Strictly speaking, MHVs are not supposed to work as formal interpreters, but in practice they do so when no MHW is available. The number of MHWs is limited, and it would be desirable to appoint more of them and develop their interpretation skills in order to increase the effectiveness of health services.Figure The roles of MHWs and MHVs combine interpretation and cultural mediation, but there are primary roles defined for each position (green boxes for MHWs and purple boxes for MHVs). However, the system faces many challenges in implementing the MHW and MHV programmes, and ideal resolutions are shown as grey lines in Fig. Challenges remain in sustaining these migrant health services; including budget constraints, non-standardized training methods and lack of legal provision to sustain the MHW and MHV programmes. Examples of some challenges follow below.Firstly, financing is of critical concern as these services can add significant cost to routine services. Each country has different budgetary sources to support interpreter services; for example, most of the intercultural mediators in hospitals in Belgium are funded by the federal government, while in Malaysia, an informal interpreter system is funded and implemented by NGOs , 13. CulEven though the cost of using a trained interpreter is higher than using an untrained one, formal interpretation has been claimed to be a more cost-effective and efficient way to improve service utilisation, compliance and health outcomes . More imAlthough the government and NGOs allocate budget to support the employment and training of MHW and MHV programmes, there are still challenges in terms of long-term planning. Owing to the decreasing number of HICS members, the budget available for these programmes has decreased. Moreover, unclear budget allocations and policies affect the remuneration and benefits for MHWs and MHVs, making their employment in the public sector less competitive compared to the private sector, which results in a high turnover of staff. The MOPH should clearly announce the budget allocated for MHW programming in terms of employment and training nationally in addition to the NGO budget. Migrants and employers can contribute to supporting these programmes by allocating funds from SSS to the MHW and MHV programmes.Secondly, Thailand recruits interpreters through an informal social network of migrants, while interpreters in other countries are recruited from interpretation agencies to ensure quality . AnotherGuidelines for selecting MHWs and MHVs have not been standardised to ensure the quality of interpreters, and therefore the recruitment process might directly affect the competence of interpreters. For example, there is a difference in quality when using interpreters recruited from the general pool of migrant workers as compared to interpreters who have health professional backgrounds. There is also room for improvement by standardising training programmes. Thailand has attempted to lay down standardised training guidelines for MHWs and MHVs, but these standards do not yet cover training guidelines for interpreters, while quality assurance of the interpretation services is not ensured.There is no formal state provision for interpreters in healthcare facilities in the other Southeast Asian migrant destination countries, Malaysia and Singapore. In Malaysia, NGOs have implemented informal interpreter systems in their own clinics. For example, refugees are usually hired as interpreters on stipends, as they cannot legally work in the country; the hiring NGO then provides training on professional ethics, patient confidentiality, and medical terminology. Health workers have adopted their own strategies including Google Translate, hand gestures and asking migrant patients to bring a companion as an interpreter. As reported in other settings, medical errors, inaccurate diagnosis and lack of informed consent can occur in the absence of trained interpreters , 33.In terms of training processes, the standard programmes should be clearly defined to ensure that the core capacities of interpreters and cultural mediators continue to improve. For interpreters, three main components exist in the standards of practice , which are addressed by the International Medical Interpreters Association . On the A study of an MHV programme by Sirilak et al. (2013) revealed that MHV programme management faced challenges including inadequate selection, training and supervision of MHVs, and argued that such programmes needed extra support from the MOPH and international donors. Since 2012, there has been some progress in developing standard guidelines for training MHWs and MHVs. However, problems remain, especially in training and supervision processes. For example, in the above-mentioned study one-third of MHVs did not understand or only partially understood the contents of the training programmes . SimilarMoreover, the earlier study found that the supervision system was unclear, resulting in inappropriate monitoring and supervision systems for evaluating the impact of the MHV programme. Although the present study found supervision processes in place in many organisations, they were not systematically conducted and integrated into training plans, representing an example of policy stagnation in MHV programming.Finally, there should be an element of obligation in the use of interpreters and cultural mediators with migrants . PatientMoreover, MHW and MHV programmes are based on MOPH policy pre-announcements, which have no legal authority to compel stakeholders to continue the programmes. Thai labour laws focus mostly on high-skilled foreign professionals. MHWs were not recognised as professional workers and MHVs were, in practice, volunteer-based. The lack of a legal basis to support the work of MHWs and MHVs hence undermines intersectoral coordination and leads to doubts about the sustainability of MHW and MHV programmes.Using the Hogwood and Gunn (1984) framework of factors affecting policy implementation, there are myriad challenges in MHW and MHV programme implementation, in terms of resources, processes and direction of programmes . There iOur recommendations for improving the implementation of MHW and MHV programmes are as follows: 1) The MOPH should be a key actor, building partnerships in close cooperation with stakeholders both inside and outside the health sector; 2) All relevant stakeholders should set the objectives and goals of the MHW and MHV programmes, differentiating the roles of MHWs and MHVs while aligning training programmes; 3) All relevant key actors should take part in the monitoring and evaluation of MHWs and MHVs and participate in the tracking of the impact of the programme, and; 4) All policies should be clearly communicated to stakeholders at all levels.This study provides a system analysis for MHW and MHV programmes, describing how these services are currently provided and resourced, with recommendations to support improvements in the implementation of these programmes. However, the study has some limitations. Firstly, a limited number of study sites means that findings showed only few aspects of service implementation in Thailand. Secondly, health professionals interviewed may be susceptible to social desirability bias in providing the answers that they thought the research team, comprised of health professionals, would like to hear. Nonetheless, these findings provide a necessary update to the 2013 evaluation of the MHV programme at a crucial time where Thailand’s migrant health policies are evolving .MHW and MHV initiatives are two of the most prominent applications of the concept of migrant-friendly health service policies, implemented as one of the measures to reduce language and cultural barriers between health personnel and migrant workers. MHWs mainly work as interpreters in public facilities and migrant communities, while MHVs work voluntarily as cultural mediators, bridging the gap between health services and their migrant users. Despite the huge merits of the programme in mitigating barriers to healthcare access among migrants, challenges remain in programme implementation. These include insufficient budget support, diverse and unstandardised training courses, and the lack of a legal basis to sustain these initiatives. To ensure the sustainability of MHW and MHV services, the following should be put in place: clear policy regulations on the different roles of MHW and MHV relative to health professionals, standardised training courses including recruitment, training and supervision processes, and efficient financial support from the central government. Moreover, it is important to institute regular monitoring and evaluation of the quality of interpretation services, as well as the entire MHW and MHV programmes. Finally, there should be a lead agency which has the authority to coordinate stakeholders and plan for the overall structure and resource allocation of the MHW and MHV programmes.


The relative global successes of strategies to control the COVID-19 pandemic, keep their economies afloat and avoid longer, harsh lockdown measures are markedly skewed towards the Asia–Pacific region. These successes are largely attributable to the urgent action taken by many Asia–Pacific jurisdictions to eliminate community transmission through a series of non-pharmaceutical interventions: a ‘zero-COVID’ strategy. In parts of western Europe and the Americas, premature easing of restrictions has preceded resurgences of SARS-CoV-2 infections. These countries are confronted with the challenge of devising new strategies that give precedence to the health of citizens, whilst minimising further economic damage, often in climates of reduced public compliance and government mistrust. The danger of reimposing restrictions on population movement, in the absence of policies that enable a zero-COVID strategy, are unsustainable lockdown–and–release cycles that compound the pervasive damage created by this syndemic. Aspiring towards the approaches observed in Taiwan and New Zealand, can considerably mitigate further devastation, at least until science permits a safe and effective vaccine.The Lancet Regional Health – Western Pacific, Jennifer Summers and colleagues examine the public health approaches employed by Taiwan and New Zealand, up to August 2020, and offer six recommendations for other high-income countries Given the marked international variance in epidemic responses, comparative analyses of the different approaches and experiences offer the opportunity for cross-country learning and facilitate important lessons to be shared. In Despite contrasting pre-pandemic preparedness and initial responses, both countries observed relatively few cases and low mortality up to August 2020: New Zealand (1 934 cases and 25 deaths), and Taiwan (550 cases and 7 deaths). The latest World Economic Outlook report––produced by the International Monetary Fund––reveal that up to October 2020, New Zealand experienced an annual contraction in real gross domestic product (GDP) of 6.1%, whereas Taiwan sustained a net GDP change of zero The responses in each nation  demonstrModelling studies suggest population-based interventions were instrumental in Taiwan's initial elimination efforts, and case-based interventions alone were not sufficient control measures Given the limitations of this analysis, caution is merited in the extent to which recommendations can be extrapolated to other nations. The evaluation did not identify direct associations between the specific interventions and their relative effect on epidemic control. The authors have attributed the combination of these strategic measures towards a successful outcome, but mandating these many not be as easily attainable in nations of different income levels and geographical location. Instituting strict border controls and quarantine facilities may also be viewed as less exacting in island nations. Further population-based epidemiological and modelling studies are needed to ascertain the true, independent effect of specific response measures.Taiwan were better prepared given the existing public health infrastructure from the SARS outbreak, but other nations also had established surveillance and warning systems to manage infectious disease threats. The proactive leadership style in Taiwan and New Zealand mobilised these impressively, in the context of SARS-CoV-2. There is an ongoing need to develop high-quality scientific data for efficient translation into evidence-based decision-making within the wider public health governance framework, especially if future waves of infection are to emerge.The Asia–Pacific region models to the rest of the world that a zero-COVID strategy works and should be prioritised as a highly effective strategic response.Jay Patel critically appraised the original review and drafted the manuscript. Devi Sridhar developed the comparative framework table and critically revised the manuscript.Professor Sridhar sits on the Scottish Government COVID-19 advisory group, has attended Scientific Advisory Group for Emergencies and UK Cabinet Office Advisory Group meetings, and sits on the Royal Society Data Evaluation and Learning for Viral Epidemics initiative that inputs into the Scientific Advisory Group for Emergencies.


Primary healthcare (PHC) principles provide a framework for strengthening the healthcare system to tackle increasing and diversifying health needs in low- and middle-income countries (LMICs). Currently, PHC systems in LMICs require expanded care capabilities in order to deal with noncommunicable diseases and injuries, including emergency conditions. In this article, we discuss the possibility of applying PHC principles to emergency care in LMICs and integrating emergency care into PHC; such principles include providing first points of contact with healthcare through nonprofessional providers close to communities in order to improve accessibility, providing high-quality  primary care, and addressing primary causes of ill-health through community empowerment. These principles are applicable to emergency care, which has the same attributes: it also requires increasing first points of contact through layperson first aid and the ambulance system, and it also provides comprehensive care for diverse diseases and injuries, with various facilities and personnel involved in its coordinated and continuous delivery; collective community actions also develop and strengthen the emergency care system, particularly through components outside the health sector . Integrating emergency care into PHC could enhance the general health system and is more efficient than having separate systems. While infectious diseases are gradually being brought under control, noncommunicable diseases, such as hypertension and diabetes, which may require acute care with severe symptoms , are increasing. Road traffic injuries are also increasing owing to rapid motorization. In addition, the possibility remains of maternal conditions and infectious diseases becoming critical.Recent epidemiological transitions in low- and middle-income countries (LMICs), along with the increase of diseases that potentially require emergency care, have required shifts in various healthcare capacities (6). The primary healthcare (PHC) principles that have provided a basic framework for strengthening the already existing healthcare system and helped achieve health equity in LMICs can also be applied to the development of emergency care capabilities in general healthcare systems. These principles assist in the response to diversifying health needs and address health inequities. In addition, there are commonalities between PHC and emergency care as both involve laypeople  as the first point of contact with the care and address a broad range of health problems (9).In order to respond to the increasingly diversifying healthcare demand, integrating emergency care would strengthen the entire healthcare system and would be more cost-effective than operating separate systems (10). Investment in tertiary care hospitals in urban areas was the predominant approach in newly independent countries before the Alma-Ata Declaration, but these investments did not improve access to health services or the health of the population, particularly in rural areas. In contrast, some successful community-based programs, in which basic health services were provided by nonprofessional personnel, such as community health workers (CHWs) or “barefoot doctors,” inspired the PHC principles (12).PHC principles originated in the Alma-Ata Declaration of 1978 and are based on the failures of facility-oriented healthcare programs and the successes of community-based healthcare programs (14). Instead, the use of community-based models with laypersons or nonprofessional providers can improve access to care and strengthen capacities in rural communities (13). In turn, emergency care skills, including the prompt arrangement of referrals, transportation, financing, and communication with other providers, when integrated into the community-based PHC system, can improve the quality of general health services.Likewise, high-income country (HIC) models of emergency care, which depend on an ambulance system with professional paramedics or physicians and emergency departments in tertiary care hospitals, do not adequately reach rural or underserved populations in LMICs (16). For each of these three components, we examined the definition by reviewing the existing literature and identified similarities between PHC and emergency care in terms of already existing problems and potential solutions. We then examined whether the integration of emergency care into PHC would strengthen the general healthcare system by enhancing the care quality and community participation.In this article, we discuss the extent to which PHC principles are applicable to the development of community-based emergency care, focusing on the health needs in LMICs, particularly in resource-constrained remote settings. Our discussion followed the three different meanings of “primary” in the key PHC principles, which are bringing the primary (first) points of contact with the healthcare system closer to the community, providing high-quality primary care, and addressing the primary (root) causes of ill-health (10). Increasing the points of contact with healthcare is expected to fill in the gaps in access to healthcare. The roles performed by the first points of contact include visiting communities to identify health problems and dealing with those who visit health facilities (17). In countries where there are insufficient professional medical personnel and facilities, these tasks have been shifted from medical professionals in hospitals to lay providers  (20). CHWs are based in village health centers and provide basic and preventive healthcare using simple techniques appropriate for nonprofessionals. Although rigorous evaluation studies are lacking, CHW programs have the potential to increase access to and utilization of health services and to improve health outcomes (21).The basic premise of PHC is that the healthcare system should bring care as close as possible to individuals by placing the first points of contact with the healthcare system in communities (23). EMSs also provide transport services, which can help address inequitable access to care. Without such services, severely ill or injured patients living far from healthcare facilities, particularly those who are poor, would face significant barriers to access services, causing a delay in treatment (24).Emergency medical services (EMSs), also referred to as ambulance services, including first aid provided by laypersons, are another strategy to bring points of contact with healthcare services to the community. Nonphysician and physician ambulance personnel provide care before reaching the hospital depending on their skill level. The first aid provided by laypersons is an important component of emergency care even in HICs, where they are an indispensable part of the chain of survival (6). Health center staffs and CHWs provide emergency care; in turn, emergency care providers may have the opportunity to contribute to general health services. In an example from HICs, paramedic practitioners make home visits to treat minor diseases, perform assessments of patients’ daily lives and social aspects, and communicate with family physicians (25).Integrating PHC with emergency care may strengthen the healthcare system as a whole, given that both systems require lay providers as the first points of contact in communities. Having points of contact provide both emergency and nonemergency care is more efficient than having separate service systems (14). This situation evokes the failure of facility-based medical models in the pre-Alma-Ata era. Investing in HIC models, despite being seemingly attractive to external donors seeking rapid outcomes, would concentrate limited resources in urban areas, only widening the gap (28).However, HIC models of emergency care systems consisting of hospital-based specialized care and formal EMS systems are too expensive for resource-constrained countries to provide adequate coverage to remote and dispersedly populated areas (29). In Ghana and Madagascar, taxi drivers who are likely to witness traffic injuries were trained to provide trauma first aid (31); in Uganda and South Africa, community residents, police, and commercial drivers were also trained in trauma first aid (32). A successful example of integrating PHC with emergency care has been reported in Iraq and Cambodia: emergency care training of CHWs (PHC personnel) and lay first responders improved the survival of patients with trauma (33). This example was expanded by including nurses and physicians of Iraqi hospitals and was replicated in Iran (36). Such informal programs may come to be accepted as part of a formal healthcare system, as was the case with the introduction of PHC (37).Instead, community-based care provided by nonprofessional personnel should be emphasized. Similar to the pre-Alma-Ata era, there have been successful community-based emergency care projects that have trained nonprofessional personnel to reach rural communities using appropriate technologies. Trauma first aid  administered by laypersons is an example of a promising project (7). Starfield (38) defined “primary care” as first-contact, continuous , comprehensive, coordinated care. This concept was envisaged in the Alma-Ata Declaration (10). In this section, we will discuss how integrating emergency services with primary care would enhance these aspects of high-quality primary care, except for first-contact care, which we have already discussed. As emergency care has a comprehensive nature and involves initial assessment and subsequent referral coordination, this would strengthen primary care management and result in increased user satisfaction and more effective use of services (42).Although PHC is not a version of primary care, high-quality primary care should be part of PHC in order to meet the various health needs of the whole population (15). Primary care should be the entry point to all types of services, whether those services are directly available at the point or whether users are connected to other providers as needed, which is key to user satisfaction. Selective approaches that provide limited services used to be the mainstay programs, as they were preferred by governments and donor agencies for their rapid results and easily measurable outcomes from short-term inputs (27). However, comprehensive approaches are more effective in addressing health issues than selective approaches are (43).Primary care should provide a comprehensive set of health services to respond to the increasing expectations in healthcare and to diversifying health problems due to epidemiological transition in LMICs  (45). Rather than having separate emergency care systems for different diseases, it is more efficient to have a single system that provides services for all diseases (46).Emergency medical care also has a comprehensive nature: it targets patients with acute conditions regardless of the type of disease, as any disease can become critical. Therefore, selective approaches do not fit emergency care systems well. When selective emergency service programs were implemented, they naturally expanded their target population. For example, programs providing transport for obstetric emergency cases focused on pregnant women but were also utilized by men and children with severe illnesses and injuries (42). Emergency care abilities in stabilizing, diagnosing, and triaging acute conditions would strengthen primary care, enabling it to deal with various healthcare needs. Instead of disease type, primary care personnel should be able to differentiate between emergency and nonemergency conditions and should have different protocols depending on the time sensitivity of conditions (40).Integrating emergency care into primary care would contribute to enhancing the comprehensiveness of primary care (9). With the current information technology, primary care can be easily connected with specialists  to obtain specialist advice or send the patient’s information before the referral (7). Good coordination abilities would also improve the gatekeeper function of primary care. User satisfaction with and trust in the coordination abilities of primary care staff would reduce the rate of self-referrals (40).When in need of specialized care, patients should be referred from primary care to secondary or tertiary care depending on their needs, with appropriate timing. This requires that primary care providers be aware of where and how to obtain the necessary resources for patients, be integrated in the healthcare network, and be able to arrange referral procedures and communicate with other providers (40).Emergency referrals require a wider range of resources and stronger coordination or negotiation abilities, such as responsiveness (available 24 h), appropriate decision-making regarding who should be referred and when, means and skills to communicate with other services, and transport and financing arrangements (risk sharing or fee exemption scheme). Integrating emergency care into primary care would streamline the overall referral process in primary care and district health systems. In fact, in areas with no formal ambulance system, primary care personnel are expected to coordinate referrals of emergency as well as nonemergency cases. For example, a study in Cambodia showed that the majority of patients with emergency conditions sought help at the nearest health centers (40). Successful examples in PHC settings include the following: motorcycle ambulances (45), tuk-tuk vehicles stationed in health centers (40), commercial driver mobilization(47), and solar-powered radio network and rudimentary vehicle stationed in a district hospital (48).Transport arrangements, whether in primary care facilities or the community, are particularly critical for emergency transfers and referrals in areas where there is no formal EMS system (40). Primary care should be able to directly manage risk sharing or cost exemption schemes or promptly contact community-based schemes. In addition to health service costs, long-distance transport costs and opportunity costs  are so high in emergency cases that patients and their families may go bankrupt (49). Such costs can be an immediate barrier to referrals that a risk-sharing system should preferably cover (54).Addressing financial barriers would facilitate the utilization of emergency services via primary care (38). In either case, patient information should be maintained and shared by all service providers. Temporal continuity refers to treating the patient with a consistent approach over time according to an understanding of the patient and his/her circumstances, usually by a regular provider in primary care (9). Interprovider continuity is required when patients need various types of specialized care and when all specialists involved in their care should take a consistent approach.The meaning of care continuity is twofold: temporal and interprovider continuity (24). In upward referral of emergency cases, primary care providers send information on the patients’ history and conditions or may request specialists’ advice regarding first aid and referral necessity. In downward referral of emergency cases, patients return from tertiary to primary care after receiving definitive acute care, with information on the acute treatment received and necessity of rehabilitation and aftercare. Some patients may require welfare services to return to the community. In practice, interprovider communication, key to information sharing, has room for improvement. For instance, information is not appropriately conveyed via referral letters or telephone when patients are referred (56). However, new information technologies have enabled easier interprovider communication. For example, by utilizing social networking services, images can be shared with no effort and expert advice can be easily obtained.Emergency referrals require interprovider communication to share patient information promptly and accurately; the integration of emergency care would strengthen this aspect of primary care. Referral communication functions in various ways (57). Health status is determined not only by biological factors but also by social factors, such as poverty, personal behaviors, lifestyle, interaction with family members and neighbors, support from the community, access to social and health services, living environments, and social and cultural environments (58). The social determinants of health (SDHs) are usually unevenly distributed in the society and are potentially modifiable (58). Modifying SDHs that are outside the health sector is a component of PHC actions, which requires sector-wide public policies and input from outside the health sector. In contrast, primary care focuses on health service delivery and can be fulfilled within the health sector.Addressing the primary (root) causes of ill-health to achieve health equity is the core value of PHC and differentiates it from “primary care.” Health equity is an aspect of social justice, given that everyone has the right to attain the highest possible level of health (59). Similarly, socioeconomic status, ethnicity, and gender are associated with access to care and outcomes of myocardial infarction (60). Low socioeconomic status is also associated with a higher risk of trauma (62). Studies in LMICs also show an association of socioeconomic status with risk behaviors and incidence of myocardial infarction (64).SDHs also influence the incidence of emergency conditions , access to emergency care, and outcomes, although most of the evidence comes from HICs. Access to healthcare is also an SDH, as poor access to care directly affects the prognosis of severely ill and injured patients. For example, ethnic disparities in stroke incidence and access to care are prevalent and result from modifiable social factors, although genetic factors also contribute to the differences in incidence (65). The most underserved populations should be prioritized to minimize the inequalities, because starting from the “easiest to reach” populations, who already have good access to services, would simply widen the gap (66). This approach is relevant to both primary and emergency care, and their integration would be promising in minimizing the gap (33). For example, investment in lay providers increases service access points in underserved areas.Therefore, public policies, as well as public health policies, should aim to address the uneven distribution of SDHs including healthcare resources (68).In addition to increasing the first points of contact to healthcare, strengthening district- or provincial-level health systems should also put a special emphasis on remote areas to address uneven access to health services. District or provincial hospitals need to have capabilities to provide appropriate definitive or specialized care to severely ill and injured patients coming to the hospitals referred from primary care. Otherwise, patients referred to a district or provincial hospital find that the care that they require is not available there and must travel to a national hospital in the capital city, causing further delay (69). Community participation is a key feature of PHC but has been defined in various ways. The fundamental factor is that community residents contribute to delivering health services as part of the service system and are not simply its beneficiaries (70). More importantly, their active participation and decision-making power would foster collective action by the community that contributes to change  (70). In turn, this community action will help individuals act with confidence to improve their lives and environments (70).Community-level leadership, termed “community participation” in the Alma-Ata Declaration, is crucial for dealing with local health issues and uneven distribution of SDHs (24). Fortunately, it is easy to set clear targets regarding these elements  so that residents can plan and manage them. There have been successful innovative attempts in communities to mobilize laypersons as first responders or to establish mutual aid systems to arrange transportation and money for emergencies (72).Community-level collective actions are even more critical when providing emergency care in resource-constrained settings in remote areas that HIC models of ambulance systems cannot reach. Community residents should play a central role and serve as first responders and managers of the various systems outside the health services, such as transportation, communication, and financial protection (33) or inclusive by nature  (72). If various providers are involved in different actions , they are coordinated under the community leadership.Such community-level actions show commonalities that are favorable to the integration of emergency care with PHC, although organization structures may differ from community to community. The above-mentioned examples are a simple expansion of already existing PHC programs (training of PHC personnel) (73). For example, training of lay community volunteers in trauma first aid has been found to change their perceptions of their abilities (73). Before the training, they did not know how to help severely injured patients, feared doing something wrong, and often did nothing; after the training, they had the confidence to help injured patients. Establishing mutual aid or transport arrangement systems may also foster community stewardship of such systems.Attempts to develop community-level collective actions to improve the healthcare system, in turn, may enhance community empowerment and solidarity Here, we examined the similarities between PHC and emergency care through a literature review and explored the possibility of integrating these services to strengthen the general healthcare system. Nonprofessional community healthcare providers, such as CHWs and health volunteers (primary points of contact for PHC), who provide preventive care and simple curative care, can also serve as the first points of contact for emergency care, if they have first-aid training and the ability to communicate with the EMS or hospitals. Primary care providers can improve their ability to provide care by learning emergency care skills and streamlining their referral network, which would increase user satisfaction with their services. Community-level collective actions, such as mutual aid and transport arrangements, can contribute to minimizing inequitable access to healthcare (primary cause), which would lead to community empowerment and improved general healthcare.(9). First, nationwide training should be conducted hierarchically by restructuring the training systems. For example, CHWs or primary-care-level personnel should train lay personnel , district hospital personnel should train CHWs and primary care personnel, and provincial or national hospital personnel should train district-level personnel (36). Second, many factors of emergency care, particularly prehospital care, are beyond the control of the health sector . Prevention strategies aimed at addressing the uneven distribution of SDHs also require input from outside the health sector. However, health policymakers may have concerns and hesitance about dealing with political and social issues that are beyond the realm of the health sector (74). Superordinate government bodies that supervise and control related sectors may be needed.Meanwhile, integrating enhanced emergency care into the general healthcare systems requires strong national-level leadership with a broader vision to organize actions that can integrate stakeholders external to the health sector (75). For example, community initiatives to develop a lay first-responder system cannot work without legislation that enables laypersons to provide emergency care and a protection mechanism in the case of adverse events (both to beneficiaries and to providers).Local activities can only be exercised or activated within legal or institutional frameworks; national-level plans could offer a guide, and safeguard systems may be needed to protect those who participate in the activities (21). Identifying and examining the distribution of risk factors of ill-health, including emergency conditions, is an important research agenda contributing to public health strategies to prevent ill-health and decrease health inequities in LMICs (64).More research and evaluation activities based on high-quality data need to be conducted, as the health system should be improved according to evidence-based evaluations and recommendations. Currently, there is only weak evidence supporting the integration of community-based emergency and primary care, or even the PHC programs targeting maternal and child health, infectious diseases, and nutritional conditions Lessons learned from PHC experiences can be applied to the development of emergency care in LMICs; in turn, the capabilities required in emergency care may enhance the whole healthcare system. Epidemiological transitions in LMICs require care capacities in the healthcare system to deal with noncommunicable diseases and injuries, which should include emergency care abilities. It may be more efficient to have the same points of contact with healthcare for emergency and nonemergency cases than to have separate systems, and this can be achieved by providing emergency care training to primary care providers. This can also enhance the comprehensiveness of care and coordination abilities. The emergency care system requires components outside the health service, such as transportation and mutual aid systems that have clear targets. Entitling community residents to develop community-based management schemes would foster stewardship and empowerment.NoneThis work was supported by JSPS KAKENHI grant number [16K11422].All authors contributed to the concept of the manuscript, interpretation of the literature, and critical review of the manuscript and approved the final version. SN reviewed the literature and drafted the manuscript.Not applicable for review articles.