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Since the Alma Ata Declaration of 1978, countries have varied in their progress towards establishing and sustaining comprehensive primary health care (PHC) and realizing its associated vision of ‘Health for All’. International health emergencies such as the coronavirus-19 (COVID-19) pandemic underscore the importance of PHC in underpinning health equity, including via access to routine essential services and emergency responsiveness. This review synthesizes the current state of knowledge about PHC impacts, implementation enablers and barriers, and knowledge gaps across the three main PHC components as conceptualized in the 2018 Astana Framework. A scoping review design was adopted to summarize evidence from a diverse body of literature with a modification to accommodate four discrete phases of searching, screening and eligibility assessment: a database search in PubMed for PHC-related literature reviews and multi-country analyses (Phase 1); a website search for key global PHC synthesis reports (Phase 2); targeted searches for peer-reviewed literature relating to specific components of PHC (Phase 3) and searches for emerging insights relating to PHC in the COVID-19 context (Phase 4). Evidence from 96 included papers were analysed across deductive themes corresponding to the three main components of PHC. Findings affirm that investments in PHC improve equity and access, healthcare performance, accountability of health systems and health outcomes. Key enablers of PHC implementation include equity-informed financing models, health system and governance frameworks that differentiate multi-sectoral PHC from more discrete service-focussed primary care, and governance mechanisms that strengthen linkages between policymakers, civil society, non-governmental organizations, community-based organizations and private sector entities. Although knowledge about, and experience in, PHC implementation continues to grow, critical knowledge gaps are evident, particularly relating to country-level, context-specific governance, financing, workforce, accountability and service coordination mechanisms. An agenda to guide future country-specific PHC research is outlined.

Realising renewed efforts to accelerate progress towards universal health coverage, manage health emergencies and create healthier populations requires integrated action on system-wide challenges. One of the best ways to do this is to focus on primary health care (PHC). Advancing PHC needs the support of a robust learning agenda—encompassing questions on how to improve both essential and emergency services, engage and empower communities and address the broader determinants of health through multisectoral action. Nowhere has the importance of learning been more compellingly exposed than during the ongoing COVID-19 pandemic, where the ability of countries to learn from experience has often determined the success or failure of their responses. How research informs policy and action is variable, and in low- and middle-income countries, the contribution of research to decision-making is often limited. Traditionally, PHC research priorities are determined by funders or researchers based in high-income countries.1 This has constrained the utility of this …

South Asia, home to 1.97 billion people (25% of the world’s population), is no stranger to conflict and confrontation. Longstanding border disputes (such as between India and China and the decades-old standoff between India and Pakistan), the forced displacement of Myanmar Muslims to Bangladesh, and the 2021 rise of the Taliban triggering a mass exodus of professionals and educated women from Afghanistan underscore the enormous volatility and unpredictability of the region. Climate change poses a further challenge, with the real risk of interstate “water wars.”1 Indeed, South Asia now faces a range of threats, with real risks of these spilling over into interstate conflict. The links between longstanding conflict, insecurity, and poverty are well recognised.23 Abject poverty, especially when associated with disparities, underlies many of the known conflicts worldwide, unsurprisingly given the drain conflict places on social sector spending. And although lack of social inclusion and ethnic inequalities have been shown to lead to domestic terrorism,4 economic inequalities and grievances are stronger drivers of rebellion,5 and are particularly relevant in South Asia. Despite robust economic growth and progress on many technological fronts, South Asia still has the world’s largest concentrations of poverty, illiteracy, malnutrition, and preventable maternal and child deaths outside sub-Saharan Africa.6 Widespread poverty is closely intertwined with social disparities, marginalisation on the basis of an egregious caste system, and vast inequities that perpetuate disillusionment, grassroot rebellion, and further conflict. We have previously described the disruptive effects of conflict and insecurity on health systems, with some long term consequences on maternal and child health outcomes.78 Conflict, insecurity, and uncertainty affect planning and stable investments in health systems, and the extreme distrust between India and Pakistan continues to jeopardise public health and social protection in South Asia. The two countries have fought …

The Paris Declaration defined five components of aid effectiveness: ownership, alignment, harmonisation, managing for results and mutual accountability. Afghanistan, which has received a high level of donor aid for health since 2002, has seen significant improvements in health indicators, expanded access to health services and an increased range of services. Do the impressive health outcomes in this fragile state mean that aid has been effectively utilised? The factors that contributed to the success of the Ministry of Public Health (MOPH)-donor partnership include as follows: Ownership: a realistic role for the MOPH as the steward of the health sector that was clearly articulated to all stakeholders; Donor alignment: donor coordination and collaboration initiated by the MOPH; Joint decisions: participatory decision-making by the MOPH and donors, such as the major decision to use contracts with nongovernmental organisations for health service delivery; Managing for results: basing programmes on available evidence, supplementing that evidence where possible and performance monitoring of health-sector activities using multiple data sources; Reliable aid flows: the availability of sufficient donor funding for more than 10 years for MOPH priorities, such as the Basic Package of Health Services, and other programmes that boosted system development and capacity building; Human factors: these include a critical mass of individuals with the right experience and expertise being deployed at the right time and able to look beyond agency mandates and priorities to support sector reform and results. These factors, which made aid to Afghanistan effective, can be applied in other countries.

Acute malnutrition affects more than 50 million under-five (U5) children, causing 8.0% of global child deaths annually. The prevalence of acute malnutrition (wasting) among U5 children in Afghanistan was 9.5% nationally and 3.7% in Faryab province in 2013. A cross-sectional study was conducted for 600 households in Faryab to find the prevalence and causes of acute malnutrition. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a logistic model. Demographic results of this study showed that 54.0% of the household heads and 92.3% of the mothers had no education. Three-fourths of households had a monthly income ≤ 250 USD. According to the measurement of weight for height Z-score (WHZ), 35.0% (210/600) of the children had acute malnutrition (wasting, WHZ < −2). In more than half of the households, water, sanitation, and hygiene (WASH) conditions were poor. When adjusted, a significant association of acute malnutrition among U5 children was found with the education level of household heads (OR=1.49; 95% CI, 1.02–2.17), age of household heads (OR=2.01; 95% CI, 1.21–3.35), income (OR=1.66; 95% CI, 1.04–2.27), education level of mothers (OR=2.21; 95% CI, 1.00–4.88), age of children (OR=1.99; 95% CI, 1.32–2.93), history of children with diarrhea in the last two weeks of data collection (OR=1.57; 95% CI, 1.10–2.27), feeding frequency (OR=3.01; 95% CI, 1.21–7.46), water sources (OR=1.89; 95% CI, 1.26–2.83), and iodized salt (OR=0.59; 95% CI, 0.39–0.88). The present study indicated that an increase in education level of parents, household income, and quality of WASH would result in a significant decrease in prevalence of wasting among U5 children.

Summary Background Maternal mortality in Afghanistan is uniformly identified as an issue of primary public-health importance. To guide the implementation of reproductive-health services, we examined the numbers, causes, and preventable factors for maternal deaths among women in four districts. Methods We did a retrospective cohort study of women of reproductive age (15–49 years) who died between March 21, 1999, and March 21, 2002, in four selected districts in four provinces: Kabul city, Kabul province (urban); Alisheng district, Laghman province (semirural); Maywand, Kandahar province (rural); and Ragh, Badakshan province (rural, most remote). Deaths among women of reproductive age were identified through a survey of all households in randomly selected villages and investigated through verbal-autopsy interviews of family members. Findings In a population of 90 816, 357 women of reproductive age died; 154 deaths were related to complications during pregnancy, childbirth, or the puerperal period. Most maternal deaths were caused by ante-partum haemorrhage, except in Ragh, where a greater proportion of women died of obstructed labour. All measures of maternal risk were high, especially in the more remote areas; the maternal mortality ratio (per 100 000 livebirths) was 418 (235–602) in Kabul, 774 (433–1115) in Alisheng, 2182 (1451–2913) in Maywand, and 6507 (5026–7988) in Ragh. In the two rural sites, no woman who died was assisted by a skilled birth attendant. Interpretation Maternal mortality in Afghanistan is high and becomes significantly greater with increasing remoteness. Deaths could be averted if complications were prevented through optimisation of general health status and if complications that occurred were treated to reduce their severity—efforts that require a multisectoral approach to increase availability and accessibility of health care.

Cover title. Spiral bound. “11 May 2002”. “Submitted to the Health and Nutrition section UNICEF/Afghanistan”—cover. Includes bibliographical references. Contents: Glossary of terms—Executive summary—General report—Region-specific reports and recommendations—Annexes.