Health systems strengthening

Situation in 2012

The need for strengthening of health systems in the Region was abundantly clear in 2012, and remains so today. Inequities in health are widespread, not just among group 2 and 3 countries but also in group 1 countries . Exposure to health risks is rising, particularly to the key causes of noncommunicable diseases – the Region’s leading killers. Health care costs are increasing and health insurance coverage is low, leading to high out-of-pocket health expenditure which drives many families into poverty. Access to quality health care – and sometimes any health care at all – is beyond the reach of a significant portion of the Region’s population. While modern networks of health infrastructure, skilled health care professionals and advanced medical technologies and pharmaceuticals are fully available to citizens in some countries, this is certainly not the case in all countries. Such differences in the strength of health systems contribute to divergent health outcomes, such as in life expectancy, maternal mortality and infant and child mortality.

Health information systems, including civil registration and vital statistics systems, are failing to capture vital information necessary for health system planning, development and monitoring. This includes reliable data on births, deaths and of causes of death, and key health indicators. While there are variations between countries in the quality of the health information system, all countries lack a comprehensive and fully functioning system that can provide the required information in a timely and reliable manner for planning and policy-making.

Capacity and resources for emergency preparedness and response are inadequate and fragmented. The violence, destruction of infrastructure, including health care infrastructure, and displacement of tens of millions of people, has become a severe crisis for health systems that were inadequately prepared. In direct response to these and other severe health challenges, the Regional Office, working with country offices, ministries of health, WHO headquarters and other partners, began the process of strengthening the health systems of Member States.

In October 2012, the Regional Committee endorsed a resolution (EM/RC59/R.3) on health systems strengthening in countries of the Eastern Mediterranean Region. The resolution, which concluded that improving population health of the Region “can only be realized through well performing national health systems which assure universal access to effective and good quality health care”, urged Member States to focus on seven strategic priorities (Box 1). These became the objectives for strengthening health systems.

Progress 2012-2016

Leadership and governance: The multi-faceted area of health system strengthening began with an in-depth review of the health systems in the Region and the subsequent development of a brief health system profile for each country. The two-page profiles, which are produced annually, in consultation with Member States, provide critical information on each country and a brief assessment of strengths, weaknesses, opportunities, challenges and priorities. They are aimed at helping policy-makers to focus on the assets and challenges within their countries and provide a useful opportunity and entry point for dialogue, especially during missions to countries. A range of capacity development courses to strengthen government policy-making and decision-making, on health legislation and regulation, health and human rights, and health policy and planning, have been offered in parallel.

A major impediment to progress in public health in many countries has been a lack of capacity to develop and implement evidence-based health policies and programmes. As part of the efforts to strengthen leadership, a leadership for health programme was launched to promote skills among mid-level and senior level public health officials in countries. So far, more than 50 future leaders in public health have graduated. The programme, offered in collaboration with the Harvard School of Public Health, aims to develop future leaders who can address, proactively, local and national health problems that have direct impact on population health. Another leading initiative was the assessment of essential public health functions in the Region. Led by the Regional Director and advised by a global committee of renowned experts, this work established for Member States the specific functions of public health that are essential for the health and wellness of their populations. This was followed by the development of tools and self-assessment guides for countries to identify gaps in their public health capacity. The assessment was implemented in two countries as a pilot experience and will be rolled out to other countries of the Region.

In the area of health governance, an initiative was launched to build capacity in health diplomacy. This concerns the negotiations that Member States engage in at global level, in particular, around health issues that affect all countries and that shape the global policy environment surrounding health. Annual seminars have brought together key players from ministries of health and foreign affairs, diplomats, parliamentarians and experts to discuss the key global health issues of the moment and to learn from each other. Year on year this has proved to be a most useful dialogue from which all participants learn and which is contributing to strengthening the relationship between health and foreign policy in the Region. Several countries are implementing national seminars and workshops.

Universal health coverage: The most important goal for strengthening health systems in countries is the achievement of universal health coverage – and that means for everyone, all countries and both citizens and noncitizens. Universal health coverage must include interventions to tackle the most important causes of morbidity and mortality for the whole population, including the marginalized and vulnerable, as well as protection against catastrophic health costs that can cause financial ruin for families. It is an important target of the health goal of the Sustainable Development Goals and vital for ensuring effective response to the growing impact of noncommunicable diseases. The endorsement, in 2012, by the Regional Committee of universal health coverage as the overarching priority led to the development and subsequent endorsement, in 2014, of the Framework for action on advancing universal health coverage (UHC) in the Eastern Mediterranean Region. This is a strategic policy document that will help to achieve this vitally important initiative for every individual and family in the 22 countries of the Region.

The framework includes a set of strategic actions to achieve universal health coverage that are evidence-based, cost-effective and feasible, and all of which would be supported by corresponding actions by WHO. They include, for example, establishing a multisectoral steering mechanism under the stewardship of each Ministry of Health. They also include actions to enhance financial risk protection, which would ultimately help reduce the share of out-of-pocket spending, and thus of catastrophic health expenditure, and impoverishment. The framework also aims to ensure that each country’s social health insurance coverage scheme contains a package of essential services, including preventive and curative services. Finally, it guides countries to expand coverage to vulnerable groups, particularly the poor and those in the informal sector, and to collect data to allow monitoring of progress toward population coverage.

Following the endorsement of the regional framework for universal health coverage, it is now necessary for each country to implement the recommended actions (Box 2.). To that end, WHO has extended support through health system review missions aimed at identifying challenges and opportunities to create national universal health coverage strategies. By mid-2016 in-depth health system reviews had been conducted and national strategies and plans developed in 10 countries. Almost all countries, including group 3 countries, are actively exploring options for universal health coverage, including the important topic of expanding population coverage through social health insurance, and covering the informal and vulnerable groups.

Health information systems: Two interconnected initiatives are being spearheaded by WHO in the Region to address the gaps in, and fragmentation of, health information systems in countries. These initiatives, started in 2012, are vitally important for the future development of evidence-based health policy-making, planning and monitoring.

In the first of these initiatives, WHO has been working intensively with Member States to review and strengthen their health information systems through expert consultations, intercountry meetings and widespread consultation with countries. In 2014, a framework for health information systems was endorsed by the Regional Committee. It provides 68 core indicators to monitor health in three areas: health risks and determinants, health status, including morbidity and mortality, and health system response. For each indicator WHO has provided a detailed analysis of the attributes (meta registry) which covers the source of data, the tool used to generate them and requirements for analysis, use for policy development and dissemination. In the past two years, Member States have started to adopt and report on the core indicators. However, to date, no country is able to report on all of them. Addressing this challenge is essential for all countries. A comprehensive report of the gaps in each country’s data has been shared with ministers of health and a comprehensive assessment is followed to identify the priorities for addressing them. The next step for WHO is to provide technical support to countries, as required, to strengthen their health information systems.

The second initiative, endorsed by the Regional Committee in 2013, focuses on improving civil registration and vital statistics, with specific emphasis on strengthening cause-specific mortality statistics. As a result of the rapid and comprehensive assessments that were conducted in collaboration with the ministries of health and other national stakeholders, there is now a comprehensive picture of the strengths and weaknesses of the civil registration and vital statistics systems in all countries. The gaps are considerable: more than 30% of all births were not registered in this region and just below 20% of deaths were reported with causes specified. The gaps that exist in each country were shared with Member States and technical support has been offered based on the regional strategy endorsed by the Regional Committee. Since the assessments were conducted, the number of countries reporting cause of death statistics from the Region has increased, from 7 in 2012 to 13 in 2016. Still, all countries, irrespective of their current achievement, need to do more to improve the accuracy of cause-specific mortality data, which is essential for monitoring health and also the Sustainable Development Goals.

Health workforce: This initiative involves not only developing the number of health care professionals and other health workers needed in countries but also the quality of the workforce. This is a critical area for health in the Region. Attracting quality health care workers is now very difficult in some countries where there is ongoing instability and conflict and from which many health professionals have been forced to flee with their families. In other countries, pay and working conditions are inadequate to sustain the workforce required. Working in collaboration with ministries of health, several strategies have been pursued to strengthen the health workforce.

A regional framework for health workforce development has been developed in consultation with Member States. The evidence-based framework, which is fully aligned with the global health workforce strategy, provides options for tackling some of the most difficult problems facing countries.

Strengthening medical education is key to health development in the Region. This area of work has been stalled in WHO over the past decade. Intensive work with countries and the International Federation of Medical Education was put into conducting a clear assessment of the situation of medical education in different countries and a regional framework was developed to address existing challenges, based on international experience. The framework is an approach to scaling up the development of quality physicians, beginning with establishing and strengthening the regulatory capacities, providing standards and guidelines for new medical schools, encouraging/strengthening education development centres, building capacity of educational leaders and establishing national independent accreditation programmes. Attracting and retaining competent faculty and developing adequate resources for training are also included. For each priority, short-term and long-term actions by Member States are outlined, matched by specific technical support from WHO.

The development of a regional strategy aimed at strengthening nursing and midwifery has been equally important, since nurses and midwives provide a major proportion of health care services worldwide and in the Region. A significant shortage of nurses and midwives exists in this region, and the strategy recommends strategic actions in five key areas: governance and regulation; workforce management systems; practice and services; access to quality education; and research.

Access to quality health care: Delivery of quality health care services for populations is based on the values and principles of primary health care. Family practice has been promoted as the principal approach for delivering integrated, person-centered primary care in the Region. However, countries have many gaps and challenges in offering full-fledged family practice programmes that are responsive to the changing demographics and disease burden. The major efforts undertaken to strengthen primary health care have included a situation review, strategic guidance to countries, building country capacity and advising on scaling up the production of family physicians. Programmes and tools to improve the quality of care and patient safety have been developed for all levels of patient care. The patient safety assessment manual was updated and a toolkit was developed to support patient safety programmes.

Two new areas of work have been instituted into the strategic priorities of health system strengthening: hospital management and the role of the private health sector.

A situation analysis of public sector hospitals in the Region was conducted and a capacity-building workshop was developed in which senior hospital managers from inside and outside the Region shared best practices on hospital care and management. Subsequently, a network of hospital managers and policy-makers was established to promote collaboration in these areas.

The private health sector is one of the major health providers in most countries. It has expanded rapidly and is often under-regulated. Partnerships with the private sector to deliver publicly financed essential health services can be an important means of population health improvement. For this opportunity to be realized, however, the private health sector needs to be well regulated, based on defined standards and enforcement. Government oversight and stewardship is essential, and a laissez faire approach is not acceptable. The work on the private health sector began with an analysis of the private health sector and was followed by a series of capacity-building workshops and consultations aimed at engaging and regulating private sector health care for universal health coverage.

Essential technologies, including medicines: Access to health technologies, including medicines, vaccines, biologicals and medical devices, can mean the difference between wellness and widespread disease for populations and life and death for individuals. Yet, in many countries, a high percentage of the population lacks regular access to essential technologies, including medicines, while quality assurance is problematic and irrational use is widespread. Government capacity to regulate may be supply-driven, which can result in wasted expenditure and purchase of inappropriate products. There is growing recognition that the weak performance of national health systems in this area is a major constraint to health development.

In response, a robust health technology assessment tool was launched. This assessment is a multidisciplinary decision-making process that uses information about the medical, social, economic, organizational and ethical issues related to use of a health technology. It supports the formulation of safe and effective health policies that are patient-focused and seek to achieve both the best value and best patient outcomes. The tool can provide cost–benefit evaluations to make purchase decisions within a given budget, and can help reduce waste and inefficiencies resulting from inappropriate investments. It also can be valuable to countries working towards universal health coverage.

Pharmaceutical sector profiles were also developed for all countries. The profiles provide a detailed description of the components of the national drug policy, with an indicator score card, as well as the challenges and priorities for action.

Way forward

The framework for universal health coverage and the work with health ministries in collaboration with country offices is very promising and will lead to real progress, if the commitment to this process is maintained and expanded. Special attention will be given to finalizing country-specific roadmaps for universal health coverage, including health financing and service delivery strategies. Experiences and lessons learnt from initiatives both inside and outside the Region will be shared.

Future work in leadership and governance will focus on strengthening of ministries of health, building their capacities for better regulation of the health sector, greater multisectoral involvement, effective decentralization and increased accountability and transparency. Strengthening the capacity of public health in ministries of health is key. The leadership for health programme, which has been successful for two consecutive years, will pay greater dividends as time goes on and as graduates progress in their careers. The programme aims to graduate up to 30 public health leaders from the Region every year. The plan is for the leadership programme to be eventually outsourced to an academic institution in the Region to ensure sustainability.

Accurate data from health information systems is absolutely vital to improve the health of populations. Every country of the Region needs to mobilize high-level political commitment and support from relevant sectors to fulfil the promise of health information system initiatives, especially collection of comprehensive cause-of-death data. Member States have repeatedly expressed concern about the validity of estimates that are used to report on health status in countries. While the methods to generate estimates are improving at the global level, there is no alternative to such estimates unless countries develop reliable data collection and reporting systems. WHO is developing methodologies to assess the validity of the reported indicators so that the results of the assessments will help the countries improve their information systems at a national level. Every country will need to consider the gaps in reporting on the 68 core indicators of the regional health information framework recently provided by WHO and develop a plan. Countries should also consider the areas in their civil registration and vital statistics systems that were identified by the comprehensive assessment and subsequent WHO reports as requiring strengthening.

Health workforce development is critical to every other health initiative. Clear strategies to build the workforce of the future have been developed and will be discussed with Member States at the 63rd session of the Regional Committee. Political and educational leadership at the country level is now necessary to move forward.

The support to medical schools will continue through the implementation of the regional framework for medical education. The framework will be discussed in a ministerial-level meeting for the health and higher education sectors which is planned to take place in the fourth quarter of 2016. Every country is expected to review the nursing and midwifery workforce situation based on the regional framework for action. WHO will provide technical guidance and support through a network of international and regional experts.

Regional programmes for capacity-building and technical support aimed at expanding access to quality health care, including enhancing primary care through expansion of family practice, should be expanded to accelerate progress towards universal health coverage and improve patient safety. Engaging the private health sector is an essential component of the journey to universal health coverage. WHO’s work in 20162017 will continue to provide guidance on strengthening the role of private sector in moving towards universal health coverage and regulating it.

Intercountry meetings on the assessment and regulation of essential technologies have begun with the purpose of establishing guidelines to support Member States. Countries need to finalize, and then implement, action plans to institute health technology assessment and regulation. WHO will continue to provide capacity-building and technical support for every step towards full implementation of the assessment for countries. In addition, international donors are potentially interested in supporting health technology assessment and regulation.