Canadian Journal of Cardiology

A Global Perspective on Cardiovascular Disease in Vulnerable Populations


      Cardiovascular disease (CVD) is a major contributor to the growing public health epidemic in chronic diseases. Much of the disease and disability burden from CVDs are in people younger than the age of 70 years in low- and middle-income countries, formerly “the developing world.” The risk of CVD is heavily influenced by environmental conditions and lifestyle variables. In this article we review the scope of the CVD problem in low- and middle-income countries, including economic factors, risk factors, at-risk groups, and explanatory frameworks that hypothesize the multifactorial drivers. Finally, we discuss current and potential interventions to reduce the burden of CVD in vulnerable populations including research needed to evaluate and implement promising solutions for those most at risk.


      La maladie cardiovasculaire (MCV) contribue de manière importante au problème de santé publique croissant que représente l’épidémie de maladies chroniques. La majeure partie du fardeau de la MCV et de l’incapacité qu’elle occasionne touche les personnes âgées de moins de 70 ans vivant dans les pays à revenu faible ou intermédiaire, anciennement appelés « les pays en voie de développement ». Le risque de MCV est fortement déterminé par les conditions environnementales et le mode de vie. Dans cet article, nous nous penchons sur l’ampleur du problème posé par la MCV dans les pays à revenu faible ou intermédiaire, en examinant notamment les facteurs économiques, les facteurs de risque et les groupes à risque ainsi que les cadres explicatifs des hypothèses sur les multiples variables en cause. Enfin, nous analysons les interventions déjà en cours et les mesures susceptibles de réduire le fardeau de la MCV dans les populations vulnérables, y compris la réalisation des études requises pour pouvoir évaluer et mettre en place des solutions prometteuses ciblant les personnes les plus à risque.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. World Health Organization. Noncommunicable diseases. Available at: Accessed April 15, 2015.

        • United Nations
        Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases - Resolution adopted by the General Assembly.
        United Nations, New York2011
        • Hunter D.J.
        • Reddy K.S.
        Noncommunicable diseases.
        N Engl J Med. 2013; 369: 1336-1343
        • Beaglehole R.
        • Bonita R.
        • Horton R.
        • et al.
        Priority actions for the non-communicable disease crisis.
        Lancet. 2011; 377: 1438-1447
        • Lozano R.
        • Naghavi M.
        • Foreman K.
        • et al.
        Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2095-2128
        • Murray C.J.
        • Vos T.
        • Lozano R.
        • et al.
        Disability-adjusted life-years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2197-2223
        • World Health Organization
        The global burden of disease: 2004 update.
        World Health Organization, Geneva2008
        • Mendis S.
        • Banerjee A.
        Cardiovascular disease: equity and social determinants.
        in: Blas E. Kurup A.S. Equity, Social Determinants and Public Health Programmes. WHO, Geneva2010: 31-48
        • Lynch J.W.
        • Kaplan G.A.
        • Salonen J.T.
        Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse.
        Soc Sci Med. 1997; 44: 809-819
        • Mackenbach J.P.
        • Stirbu I.
        • Roskam A.J.
        • Schaap M.M.
        • Menvielle G.
        Socioeconomic inequalities in health in 22 European countries.
        N Engl J Med. 2008; 358: 2468-2481
        • Bovet P.
        • Paccaud F.
        Cardiovascular disease and the changing face of global public health: a focus on low and middle income countries.
        Public Health Rev. 2012; 33: 397-415
        • World Health Organization
        2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases.
        WHO, Geneva2008
        • The World Bank
        The Growing Danger of Non-Communicable Diseases - Acting Now to Reverse Course.
        The World Bank, Washington DC2011
        • World Health Organization and World Economic Forum
        From Burden to “Best Buys”: Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income Countries.
        WHO and World Economic Forum, Geneva2011
        • The NCD Alliance
        Non-Communicable Diseases: a Priority For Women’s Health and Development.
        World Heart Federation (with the International Diabetes Federation, the International Union Against Cancer, and the Framework Convention Alliance), 2011
        • McGill Jr., H.C.
        • McMahan C.A.
        • Gidding S.S.
        Preventing heart disease in the 21st century: implications of the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study.
        Circulation. 2008; 117: 1216-1227
        • Wandera S.O.
        • Kwagala B.
        • Ntozi J.
        Prevalence and risk factors for self-reported non-communicable diseases among older Ugandans: a cross-sectional study.
        Glob Health Action. 2015; 8: 27923
        • Hayes D.K.
        • Denny C.H.
        • Keenan N.L.
        • et al.
        Racial/ethnic and socioeconomic differences in multiple risk factors for heart disease and stroke in women: behavioral risk factor surveillance system, 2003.
        J Womens Health (Larchmt). 2006; 15: 1000-1008
        • Martikainen P.
        • Mäkelä P.
        • Koskinen S.
        • Valkonen T.
        Income differences in mortality: a register-based follow-up study of three million men and women.
        Int J Epidemiol. 2001; 30: 1397-1405
        • Marmot M.
        Economic and social determinants of disease.
        Bull World Health Organ. 2001; 79: 988-989
        • Kuper H.
        • Adami H.O.
        • Theorell T.
        • Weiderpass E.
        The socioeconomic gradient in the incidence of stroke: a prospective study in middle-aged women in Sweden.
        Stroke. 2007; 38: 27-33
        • Morgenstern H.
        The changing association between social status and coronary heart disease in a rural population.
        Soc Sci Med Med Psychol Med Sociol. 1980; 14A: 191-201
        • Kunst A.E.
        • del Rios M.
        • Groenhof F.
        • Mackenbach J.P.
        Socioeconomic inequalities in stroke mortality among middle-aged men: an international overview. European Union Working Group on Socioeconomic Inequalities in Health.
        Stroke. 1998; 29: 2285-2291
        • Stringhini S.
        • Viswanathan B.
        • Gedeon J.
        • Paccaud F.
        • Bovet P.
        The social transition of risk factors for cardiovascular disease in the African region: evidence from three cross-sectional surveys in the Seychelles.
        Int J Cardiol. 2013; 168: 1201-1206
        • Ziraba A.K.
        • Fotso J.C.
        • Ochako R.
        Overweight and obesity in urban Africa: a problem of the rich or the poor?.
        BMC Public Health. 2009; 9: 465
        • Jones-Smith J.C.
        • Gordon-Larsen P.
        • Siddiqi A.
        • Popkin B.M.
        Is the burden of overweight shifting to the poor across the globe? Time trends among women in 39 low- and middle-income countries (1991-2008).
        Int J Obes (Lond). 2012; 36: 1114-1120
        • World Health Assembly
        Global Strategy for the Prevention and Control of Noncommunicable Diseases (NCDs) (WHA A53/14).
        World Health Organization, Geneva2000
        • Hosseinpoor A.R.
        • Parker L.A.
        • Tursan d'Espaignet E.
        • Chatterji S.
        Social determinants of smoking in low- and middle-income countries: results from the World Health Survey.
        PLoS One. 2011; 6: e20331
        • Dodani S.
        • Mistry R.
        • Khwaja A.
        • et al.
        Prevalence and awareness of risk factors and behaviours of coronary heart disease in an urban population of Karachi, the largest city of Pakistan: a community survey.
        J Public Health (Oxf). 2004; 26: 245-249
        • Dubowitz T.
        • Heron M.
        • Bird C.E.
        • et al.
        Neighborhood socioeconomic status and fruit and vegetable intake among whites, blacks, and Mexican Americans in the United States.
        Am J Clin Nutr. 2008; 87: 1883-1891
        • World Health Organization
        The World Health Report - Health System Financing.
        WHO, Geneva2010
        • World Health Organization
        Commission on the Social Determinants of Health.
        WHO, Geneva2008
        • The World Bank
        How we classify countries?.
        The World Bank, Washington, DC2011
      2. The World Bank. World Development Indicators Database. Available at: Accessed July 30, 2015.

      3. World Bank. New Country Classifications. Available at: Accessed July 30, 2015.

        • Ebrahim S.
        • Pearce N.
        • Smeeth L.
        • et al.
        Tackling non-communicable diseases in low- and middle-income countries: is the evidence from high-income countries all we need?.
        PLoS Med. 2013; 10: e1001377
        • World Health Organization
        Prevention of Cardiovascular Disease: Guidelines for Assessment and Management of Total Cardiovascular Risk.
        World Health Organization, Geneva2007
      4. Leeder S, Raymond S, Greenberg H. A race against time. The challenge of cardiovascular diseases in developing economies. Available at: Accessed July 30, 2015.

      5. World Health Organization. Projections of mortality and burden of disease, 2004-2030. Available at: Accessed July 30, 2015.

      6. World Health Organization. Preventing chronic disease: a vital assessment. Available at: Accessed July 30, 2015.

        • Bygbjerg I.C.
        Double burden of noncommunicable and infectious diseases in developing countries.
        Science. 2012; 337: 1499-1500
        • GBD 2013 Mortality and Causes of Death Collaborators
        Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.
        Lancet. 2015; 385: 117-171
        • Beaglehole R.
        • Yach D.
        Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults.
        Lancet. 2003; 362: 903-908
        • Danaei G.
        • Finucane M.M.
        • Lu Y.
        • et al.
        National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants.
        Lancet. 2011; 378: 31-40
        • Farzadfar F.
        • Finucane M.M.
        • Danaei G.
        • et al.
        National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3.0 million participants.
        Lancet. 2011; 377: 578-586
        • Finucane M.M.
        • Stevens G.A.
        • Cowan M.J.
        • et al.
        National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants.
        Lancet. 2011; 377: 557-567
        • Danaei G.
        • Finucane M.M.
        • Lin J.K.
        • et al.
        National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants.
        Lancet. 2011; 377: 568-577
        • Anand S.S.
        • Yusuf S.
        Stemming the global tsunami of cardiovascular disease.
        Lancet. 2011; 377: 529-532
        • Nikolic I.A.
        • Stanciole A.E.
        • Zaydman M.
        Chronic emergency: why NCDs matter.
        The International Bank for Reconstruction and Development - The World Bank, Washington DC2011
        • Mendis S.
        Epidemiology, global public health; the need for equitable action to address cardiovascular diseases.
        in: Estol C.J. Sorondo M.S. Atherosclerosis: The 21st Century Epidemic. The Pontifical Academy of Sciences, Vatican City2011
        • Bobadilla J.L.
        • Frenk J.
        • Lozano R.
        • et al.
        The epidemiologic transition and health priorities.
        in: Jamison D.T. Disease Control Priorities in Developing Countries. Oxford University Press, New York, NY1993: 351-356
        • Kaplan G.A.
        • Keil J.E.
        Socioeconomic factors and cardiovascular disease: a review of the literature.
        Circulation. 1993; 88: 1973-1998
        • Yusuf S.
        • Reddy S.
        • Ôunpuu S.
        • Anand S.
        Global burden of cardiovascular diseases. Part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization.
        Circulation. 2001; 104: 2746-2753
        • Okpechi I.G.
        • Swanepoel C.R.
        • Venter F.
        Access to medications and conducting clinical trials in LMICs.
        Nat Rev Nephrol. 2015; 11: 189-194
        • Lucero A.A.
        • Lambrick D.M.
        • Faulkner J.A.
        • et al.
        Modifiable cardiovascular disease risk factors among indigenous populations.
        Adv Prev Med. 2014; 2014: 547018
      7. Statistics Canada. Aboriginal peoples in Canada: First Nations People, Metis and Inuit. Analytical Document 99-011-x. Available at: Accessed July 30, 2015.

        • Atzema C.L.
        • Gravelle M.R.
        • Kapral M.
        • et al.
        Cardiovascular Disease in the Métis Nation of Ontario.
        Institute for Clinical Evaluative Sciences (Technical Report), 2010 (Available at: Accessed July 30, 2015.)
        • Garner R.
        • Carriere G.
        • Sanmartin C.
        The health of First Nations living off-reserve, Inuit, and Métis adults in Canada: the impact of socio-economic status on inequalities in health.
        Statistics Canada (working paper), 2010 (82-622-X no. 004)
        • Beiser M.
        • Stewart M.
        Reducing health disparities, a priority for Canada.
        Can J Public Health. 2005; 96: S4-S5
        • Shah B.R.
        • Cauch-Dudek K.
        • Fangyun Wu C.
        Diabetes in the Métis Nation of Ontario (Technical Report).
        Institute for Clinical Evaluative Sciences, 2010
        • Anand S.S.
        • Tookenay V.
        Cardiovascular diseases in Aboriginal Canadians. Canadian Cardiovascular Society Consensus Paper.
        Can J Cardiol. 1999; 15: 44G-46G
        • Howard B.V.
        • Lee E.
        • Cowan L.
        • et al.
        Rising tide of cardiovascular disease in American Indians: the Strong Heart Study.
        Circulation. 1999; 99: 2389-2395
        • Shah B.R.
        • Hux J.E.
        • Zinman B.
        Increasing rates of ischemic heart disease in the native population of Ontario, Canada.
        Arch Intern Med. 2000; 160: 1862-1866
        • Anand S.S.
        • Yusuf S.
        • Jacobs R.
        • et al.
        Risk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: the Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE-AP).
        Lancet. 2001; 358: 1147-1153
        • Global Youth Tobacco Survey Collaborative Group
        Tobacco use among youth: a cross country comparison.
        Tob Control. 2002; 11: 252-270
        • Deslisle H.F.
        • Ekoe J.M.
        Prevalence of non-insulin dependent diabetes mellitus and impaired glucose intolerance in two Algonquin communities in Quebec.
        CMAJ. 1993; 148: 41-47
        • Harris S.B.
        • Gittelsohn J.
        • Hanley A.J.
        • et al.
        The prevalence of NIDDM and associated risk factors in Native Canadians.
        Diabetes Care. 1997; 20: 185-187
        • Lee E.
        • Howard B.
        • Savage P.J.
        • et al.
        Diabetes and impaired glucose tolerance in three American Indian populations age 45-74 years: The Strong Heart Study.
        Diabetes Care. 1995; 18: 599-610
        • Gittelsohn J.
        • Wolever T.M.
        • Harris S.B.
        • et al.
        Specific patterns of food consumption and preparation are associated with diabetes and obesity in a native Canadian population with high rates of NIDDM.
        J Nutr. 1998; 128: 541-546
        • Harris S.B.
        • Zinman B.
        • Hanley A.J.
        • et al.
        The impact of diabetes on cardiovascular risk factors and outcomes in a Native Canadian population.
        Diabetes Res Clin Pract. 2002; 55: 165-173
        • Katzmarzyk P.T.
        Obesity and physical activity among Aboriginal Canadians.
        Obesity. 2008; 16: 184-190
        • Sharma S.
        • Malarcher A.M.
        • Giles W.H.
        • Myers G.
        Racial, ethnic and socioeconomic disparities in the clustering of cardiovascular disease risk factors.
        Ethn Dis. 2004; 14: 43-48
        • Herbert K.
        • Plugge E.
        • Foster C.
        • Doll H.
        Prevalence of risk factors for non-communicable diseases in prison populations worldwide: a systematic review.
        Lancet. 2012; 379: 1975-1982
        • Møller L.
        • Stöver H.
        • Jürgens R.
        • Gatherer A.
        • Nikogosian H.
        Health in prisons: a WHO guide to the essentials in prison health.
        World Health Organization, Geneva2007
        • Lee R.
        The demographic transition: three centuries of fundamental change.
        J Econ Perspect. 2003; 17: 167-190
        • Omran A.R.
        The epidemiologic transition: a theory of the epidemiology of population change. 1971.
        Milbank Q. 2005; 83: 731-757
        • Sen K.
        • Bonita R.
        Global health status: two steps forward, one step back.
        Lancet. 2000; 356: 577-582
        • Leon D.
        • Chenet L.
        • Shkolnikov V.M.
        • et al.
        Huge variation in Russian mortality rates 1984-1994: artefact, alcohol, or what?.
        Lancet. 1997; 350: 383-388
        • King M.
        • Smith A.
        • Gracey M.
        Indigenous health part 2: the underlying causes of the health gap.
        Lancet. 2009; 374: 76-85
        • Guindond G.E.
        • Boisclaire D.
        HNP Discussion Paper Economics of Tobacco Control Paper No. 6 Past, Current and Future Trends in Tobacco use.
        The World Bank, Washington DC2003
        • Toll B.A.
        • Ling P.M.
        The Virginia Slims identity crisis: an inside look at tobacco industry marketing to women.
        Tob Control. 2005; 14: 172-180
        • Moussavi S.
        • Chatterji S.
        • Verdes E.
        • Tandon A.
        • Patel V.
        Depression, chronic diseases, and decrements in health: results from the World Health Surveys.
        Lancet. 2007; 370: 851-858
        • Kanjilal S.
        • Gregg E.W.
        • Cheng Y.J.
        • et al.
        Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971-2002.
        Arch Intern Med. 2006; 166: 2348-2355
        • World Economic Forum (WEF)
        Global Risks 2010: A Global Risk Network Report.
        World Economic Forum, Geneva2010
        • Stuckler D.
        • Basu S.
        • McKee M.
        Drivers of inequality in millennium development goal progress: a statistical analysis.
        PLoS Med. 2010; 7: e1000241
        • Galobardes B.
        • Smith G.D.
        • Lynch J.W.
        Systematic review of the influence of childhood socioeconomic circumstances on risk for cardiovascular disease in adulthood.
        Ann Epidemiol. 2006; 16: 91-104
        • Cox A.M.
        • McKevitt C.
        • Rudd A.G.
        • Wolfe C.D.
        Socioeconomic status and stroke.
        Lancet Neurol. 2006; 5: 181-188
        • Hemingway H.
        • Shipley M.
        • Mullen M.J.
        • et al.
        Social and psychosocial influences on inflammatory markers and vascular function in civil servants (the Whitehall II study).
        Am J Cardiol. 2003; 92: 984-987
        • Pollitt R.A.
        • Rose K.M.
        • Kaufman J.S.
        Evaluating the evidence for models of life course socioeconomic factors and cardiovascular outcomes: a systematic review.
        BMC Publ Health. 2005; 20: 5-7
        • Weintraub W.S.
        • Daniels S.R.
        • Burke L.E.
        • et al.
        Value of primordial and primary prevention for cardiovascular disease: a policy statement from the American Heart Association.
        Circulation. 2011; 124: 967-990
        • McLaren L.
        • McIntyre L.
        • Kirkpatrick S.
        Rose's population strategy of prevention need not increase social inequalities in health.
        Int J Epidemiol. 2010; 39: 372-377
        • Law M.
        Lipids and cardiovascular disease.
        in: Yusuf S. Cairns J.A. Camm J.A. Evidence Based Cardiology. BMJ Books, London, UK1998: 191-205
        • Ebrahim S.
        What is the best strategy for reducing deaths from heart disease?.
        PLoS Med. 2005; 2: e98
        • Capewell S.
        • Jackson R.
        Will screening individuals at high risk of cardiovascular events deliver large benefits? No.
        BMJ. 2008; 337: a1395
        • Unal B.
        • Critchley J.
        • Capewell S.
        Modelling the decline in CHD deaths in England and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention.
        BMJ. 2005; 331: 614-615
        • Kivimäki M.
        • Shipley M.J.
        • Ferrie J.E.
        • et al.
        Estimating the impact of ‘best-practice’ interventions on reducing socioeconomic inequalities in coronary heart disease mortality in a working population: the Whitehall study.
        Lancet. 2008; 372: 1648-1654
        • Townsend J.
        • Roderick P.
        • Cooper J.
        Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicity.
        BMJ. 1994; 309: 923-927
        • Main C.
        • Thomas S.
        • Ogilvie D.
        • et al.
        Population tobacco control interventions and their effects on social inequalities in smoking: placing an equity lens on existing systematic reviews.
        BMC Public Health. 2008; 8: 178
        • Frohlich K.L.
        • Potvin L.
        The inequality paradox: the population approach and vulnerable populations.
        Am J Public Health. 2008; 98: 216-221
        • Tugwell P.
        • de Savigny D.
        • Hawker G.
        • Robinson V.
        Applying clinical epidemiological methods to health equity: the equity effectiveness loop.
        BMJ. 2006; 332: 358-361
        • Institute of Medicine
        Committee on Preventing the Global Health Epidemic of Cardiovascular Disease: meeting challenges in developing countries.
        in: Fuster V. Kelly B.B. Promoting cardiovascular health in the developing world: a critical challenge to achieve global health. National Academies Press, Washington DC2010
        • Bovet P.
        • Gervasoni J.P.
        • Mkamba M.
        • et al.
        Low utilization of health care services following screening for hypertension in Dar es Salaam (Tanzania): a prospective population-based study.
        BMC Public Health. 2008; 8: 407
        • Lonn E.
        • Bosch J.
        • Teo K.K.
        • et al.
        The polypill in the prevention of cardiovascular diseases: key concepts, current status, challenges, and future directions.
        Circulation. 2010; 122: 2078-2088
      8. Pan American Health Organization / World Health Organization. 28th Pan American Sanitary Conference, 64th Session of the Regional Committee. Strategy for the Prevention and Control of Noncommunicable Diseases. Available at: Accessed July 30, 2015.

        • Morgan S.
        • Law M.
        • Daw J.
        • Abraham L.
        • Martin D.
        Estimated cost of universal public coverage of prescription drugs in Canada.
        CMAJ. 2015; 187: 491-497
        • Anyangwe S.C.
        • Mtonga C.
        Inequities in the global health workforce: the greatest impediment to health in sub-Saharan Africa.
        Int J Environ Res Public Health. 2007; 4: 93-100
      9. Mayosi B. The 10 ‘Best Buys’ to Combat Heart Disease, Diabetes and Stroke in Africa. Available at: Accessed February 27, 2015.

        • Joshi R.
        • Alim M.
        • Kengne A.
        • et al.
        Task shifting for non-communicable disease management in low and middle income countries - a systematic review.
        Plos One. 2014; 9: e103754
        • Ogedegbe G.
        • Gyamfi J.
        • Plange-Rhule J.
        • et al.
        Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials.
        BMJ Open. 2014; 4: e005983
      10. Gorter AC, Meessen B. Evidence Review, Results-Based Financing of Maternal and Newborn Health Care in Low-and Lower-Middle-Income Countries. February 2013, study commissioned and funded by the German Federal Ministry for Economic Cooperation and Development (BMZ) through the sector project PROFILE at GIZ–Deutsche Gesellschaft für Internationale Zusammenarbeit. Available at: Accessed July 30, 2015.

        • Witter S.
        • Fretheim A.
        • Kessy F.L.
        • Lindahl A.K.
        Paying for performance to improve the delivery of health interventions in low-and middle-income countries.
        Cochrane Database Syst Rev. 2012; 2: CD007899
        • Musgrove P.
        Financial and Other Rewards for Good Governance or Results: A Guided Tour of Concepts and Terms and a Short Glossary.
        World Bank, Washington2011
        • Toonen J.
        • Canavan A.
        • Vergeer P.
        • Elovainio R.
        Learning lessons on implementing performance-based financing: from a multi-country evaluation.
        KIT Development Policy & Practice, Amsterdam2009
        • Basinga P.
        • Gertler P.J.
        • Binagwaho A.
        • et al.
        Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation.
        Lancet. 2011; 377: 1421-1428
        • Fernald L.C.
        • Gertler P.J.
        • Neufeld L.M.
        Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico's Oportunidades.
        Lancet. 2008; 371: 828-837
        • Beane C.R.
        • Hobbs S.H.
        • Thirumurthy H.
        Exploring the potential for using results-based financing to address non-communicable diseases in low-and middle-income countries.
        BMC Public Health. 2013; 13: 92
        • Vanzie M.
        • Hsi N.
        • Beith A.
        • Eichler R.
        Using Supply-Side Pay for Performance to Strengthen Health Prevention Activities and Improve Efficiency: The Case of Belize.
        Health Systems 20/20, Bethesda, MD2010
        • Benderly B.
        Belize Fights NCDs with P4P, RBF Blog. The World Bank: Results-Based Financing for Health.
      11. Garside J. More mobile devices than people ‘within five years.’ Available at: Accessed April 15, 2015.

      12. WHO Global Observatory for eHealth. New horizons for health through mobile technologies. World Health Organization, Geneva2011
        • Pop-Eleches C.
        • Thirumurthy H.
        • Habyarimana J.P.
        • et al.
        Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.
        AIDS. 2011; 25: 825-834
        • Cole-Lewis H.
        • Kershaw T.
        Text messaging as a tool for behavior change in disease prevention and management.
        Epidemiol Rev. 2010; 32: 56-69
        • Lester R.T.
        • Ritvo P.
        • Mills E.J.
        • et al.
        Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial.
        Lancet. 2010; 376: 1838-1841
        • Beratarrechea A.
        • Lee A.G.
        • Willner J.M.
        • et al.
        The impact of mobile health interventions on chronic disease outcomes in developing countries: a systematic review.
        Telemed J E Health. 2014; 20: 75-82
        • Ogedegbe G.
        • Plange-Rhule J.
        • Gyamfi J.
        • et al.
        A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol.
        Implement Sci. 2014; 9: 73
        • Praveen D.
        • Patel A.
        • McMahon S.
        • et al.
        A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial.
        Implement Sci. 2013; 8: 137
        • Marr M.
        • et al.
        I-RREACH: an engagement and assessment tool for improving implementation readiness of researchers, organizations and communities in complex interventions.
        Implement Sci. 2015; 10: 64