This report provides an update of the situation in the Region and progress made since I assumed the post of Regional Director in February 2012 in five strategic areas: health systems strengthening towards universal coverage, maternal and child health; health security and communicable diseases; noncommunicable diseases; and emergency preparedness and response. These were endorsed as priorities by the WHO Regional Committee for the Eastern Mediterranean at its 59th session in October 2012.
At that time, the situation in various countries of the Region was already impacting population health but we could not imagine the magnitude of human crisis that would soon engulf the lives of millions of people. Today, more than half of the world’s refugees come from three countries of our region (Afghanistan, Somalia and Syrian Arabic Republic) and are hosted in just four countries (Islamic Republic of Iran, Jordan, Lebanon and Pakistan). The Region hosts the largest number of internally displaced persons as a result of conflict. The harm caused to human health is catastrophic. At this moment, there seems to be no end in sight and the crises will continue and their enormously negative impact on health in affected and neighbouring countries may even worsen.
Nevertheless, WHO and Member States, working collaboratively with each other and with partners, have made major gains in the Region by focusing efforts on the five key areas where we are making a positive contribution towards change and laying the foundation for continued development in health.
In health systems strengthening, we conducted an extensive review of the health system building blocks in countries of the Region and agreed on seven key priorities that we should collectively address during the five year period. Based on this review and in close consultation with Member States, a country profile was developed for each Member State covering the key health system indicators, achievements, strengths, weaknesses and priorities for action. An important achievement was made in moving towards universal health coverage with the development of a framework for action on advancing universal health coverage which many countries are now using as a guide to accelerate progress. This is a roadmap for achieving access to health care for the whole population, including the vulnerable and marginalized, in every country. WHO is now supporting countries in achieving this objective.
Leadership and governance for public health has also been advanced through a range of programmes. Responding to the gaps in public health capacity in many countries and working with leading international and regional experts, tools for assessing public health functions in ministries of health have been developed and successfully piloted in two countries. The assessment report for each identifies areas for strengthening and provides recommended actions. More countries will be assessed in 2016. In collaboration with the Harvard School of Public Health, a leadership for health programme has been offered which has graduated more than 50 future health leaders in the past two years.
Another major achievement is the development of the framework for health information systems, following intensive consultation with the different sectors in Member States and international experts. The framework has three key components: monitoring of key risks and determinants, assessing health status including cause-specific mortality and measuring health system response. For each component, a set of core indicators has been agreed. We are currently assessing the capacity of each country in generating reliable data for the 68 core indicators of the framework. We have also conducted an in-depth assessment of the civil registration and vital statistics system in all countries. The information generated through this programme is the most extensive and comprehensive across all WHO regions. Based on this assessment a regional strategy was developed. All countries now have a clear identification of gaps and areas that require strengthening and they have been offered technical support as they move forward in addressing the gaps.
To support development of the health workforce in the Region, a framework for action on medical education was developed, based on extensive situation analysis and a regional survey of medical schools. A similar framework provides strategic directions to strengthen education and practice in nursing and midwifery. WHO has also been building country capacity to engage with and regulate the private health sector, in order to support moving towards universal health coverage. A robust assessment of health technologies, including medicines, has been launched, including a pharmaceutical profile for each country, which can support cost-effective purchase decisions.
Among the main concerns in the Region in 2012 was maternal and child health, in particular the persistent high levels of maternal and child mortality in some countries. Most of the causes were identified as health systems issues and so a major initiative was launched on “Saving the lives of mothers and children”. Support was provided to the nine countries with a high burden of maternal and child mortality to develop strategies to improve survival and health. A situation analysis was conducted in each country to identify gaps and a country profile was developed highlighting the situation, challenges and actions needed, together with a cost analysis. This was followed by the development of multisectoral acceleration plans with detailed cost-effective interventions for each country. Most of the countries with a high burden of maternal and child mortality and morbidity have launched their plans and are currently implementing them.
For noncommunicable diseases, the Region developed a framework for action to implement the United Nations Political Declaration on Prevention and Control of Noncommunicable Diseases, which includes 17 strategic interventions in the four components of the framework (governance, prevention, health care and surveillance), and 10 indicators against which countries can measure their progress. Extensive work was done, based on review of evidence and international experience, to develop practical technical guidance on how to implement the interventions, such as tobacco control measures, salt, sugar and saturated fat reduction and elimination of industrially produced transfat, and on legislation to reduce risk factors. These guidelines are now available and are being used by many Member States. Two other major areas of focus are considered vitally important – guidance on integration of health care into primary care and continuity of treatment during emergencies and the surveillance framework that should be used by countries to monitor progress.
Brief profiles are being produced annually on each country’s response based on the progress indicators in the framework. A recent review of progress shows that a lot of work still needs to be done to meet the time-bound actions required by the political declaration and WHO will continue to support countries in their efforts to meet these targets.
Health security has been a major focus of our work in communicable diseases. Preventing and responding to outbreaks of emerging and re-emerging diseases has been a priority in the past four years with the deterioration in the public health situation in a number of countries. Massive campaigns were conducted to control significant outbreaks of polio and measles, as a result of which these were successfully prevented from further spread within and beyond the Region. Considerable work was done also to ensure Member States have the core capacities required to implement the International Health Regulations (IHR 2005). At the end of 2014, at the request of Member States, WHO carried out rapid assessments of countries’ capacity to detect and respond rapidly to a case of Ebola. The findings highlighted gaps in the outbreak prevention and control capacities of all countries, and also the limitations of the IHR self-assessment tool. The Regional Committee subsequently called for the adoption of independent assessment and the establishment of a regional assessment commission to provide technical guidance to countries and to oversee the process of independent joint external evaluation. Our region has played a leading role in harmonizing the IHR assessment tool with the Global Health Security Agenda (GHSA) tool and the development of the Joint External Evaluation (JEE) tool which is now adopted by all WHO regions and the GHSA.
Emergency preparedness and response is our fifth priority. In addition to the enormity of the challenge, health workers have fled the violence, while health care facilities and infrastructure are damaged or destroyed. Medicine and medical supplies have become scarce. Even when available, medical teams have not been able to enter many conflict zones. Health care for refugees and internally displaced persons is extremely fragmented or nonexistent. Finding health care professionals willing to serve in these areas is becoming ever more difficult.
All countries in the Region are at risk. As I have already noted, we have experienced serious threats to public health, such as the resurgence of polio and other outbreaks. Necessary chronic and preventive care needed for major noncommunicable diseases, mostly heart disease, lung disease, diabetes and cancer, has been interrupted for large numbers of people suffering from these diseases in the conflict zones.
Our work in emergency preparedness and response has focused on both strengthening our capacity to respond effectively and efficiently on the ground as situations develop, and on strengthening regional and country preparedness for disasters and emergencies. This has resulted in the establishment of new internal structures and hubs to target various critical factors of the emergency situation. Stronger partnerships with health authorities, nongovernmental organizations, community leaders, academic institutions, donors, the private sector and others are being forged, to support countries. A regional solidarity fund was established to provide immediate funding in the short-term to support acute emergencies, and efforts are being made to highlight the funding gap for countries with protracted crises as they seek to rebuild infrastructure and provide health care for their populations.
While this introduction highlights some of our biggest challenges and the main actions we have taken, the report that follows examines in more detail the work accomplished in each of the five key regional priorities, from their adoption in May 2012 to today, May 2016. The report also highlights the way forward in tackling some of the continuing challenges.
Over this period, we have focused our efforts on maximizing the results. We have also managed to strengthen the technical capacity of WHO in this region and to reinforce the quality of services provided to Member States. We continue to build capacity in WHO staff and in using an expanding network of top international experts in the five priority areas. Working jointly with partners and other stakeholders has been an important strategic direction that has characterized our work in many programme areas and should continue to expand. Only collaboratively can we address the considerable health challenges faced by our countries. We are committed to supporting them as they embark on the ambitious health targets of the Sustainable Development Goals and as they build, as well as rebuild, effective and efficient health systems for all the people in the WHO Eastern Mediterranean Region.
