Annual report of the Regional Director 2013
Universal health coverage
In 2013, WHO advocated with its Member States the move towards universal health coverage in order to expand population coverage, ensure the availability and accessibility of needed health services, and improve financial protection for those who use health care services. The move towards universal health coverage has created many opportunities for Member States to accelerate progress but has also highlighted gaps and challenges in the different health system components that will need to be addressed to accelerate the move.
In its 60th session, the WHO Regional Committee for the Eastern Mediterranean discussed the challenges and opportunities with regard to moving towards universal health coverage and endorsed a vision, strategy and roadmap (EM/RC60/R.2) for Member States. Short health system profiles were developed for each country which provide an overview of health system performance and a summary of the challenges and priorities for health system strengthening towards universal health coverage.
This was followed by an international event at which high-level representatives from 20 countries of the Region, as well as international and regional experts and development partners, such as the World Bank, endorsed a framework for action that will guide future support to countries in moving towards universal health coverage. Activities to build health system capacity to accelerate progress towards universal health coverage included workshops for the sub-regional group of Gulf Cooperation Council, G5 countries, and countries eligible for support from the GAVI Alliance.
Work in 2014 and beyond will focus on supporting Member States to implement the framework for action and assessing the progress that countries make in achieving universal health coverage.
Health financing
As noted in last year’s annual report, the Region is characterized by a high share of direct out-of-pocket expenditures for health, which is a major impediment to the move towards universal health coverage. Many countries in all three groups of countries in the Region continue to lack a clear vision as to how to improve their health financing systems. There is inadequate understanding of health financing concepts and similar lack of capacity in the conducting of health financing studies and tools, particularly national health accounts, OASIS (Organizational assessment for improving and strengthening health financing), household health expenditure and utilization surveys, and cost–effectiveness studies, and the application of these tools to inform decision-making.
Several activities were held to build national and regional capacities in promoting concepts and the use of health financing tools to engage countries in discussions around strengthening national health financing systems. Global experiences in progress towards universal health coverage were shared at the high-level event on accelerating progress towards universal health coverage. Over 100 delegates participated, including ministers of health and policy-makers, development partners, civil society organizations and global experts. A high-level seminar was held in early 2013 on options for health care financing in the Region followed by a sub-regional meeting on health financing for the member states of the Gulf Cooperation Council (GCC), which comprise the group 1 countries. Among other issues, the particular case of expatriate populations was discussed and options on how to cover them were reviewed. Two regional capacity-building activities on national health accounts and costing using the one health costing tool were conducted. In addition, country-specific health financing workshops were held in three countries and a national health system conference was supported in Morocco, aimed at developing the vision for the future of the health system. Several policy papers were developed on key topics around universal health coverage, including multi-sectorality, and the role of strategic purchasing.
Needless to say, much work is needed in this area. Our plan is to continue to reinforce WHO’s technical capacity in health financing to respond to the need to provide advice and build capacity in Member States in the development and implementation of sound health financing policies to achieve universal health coverage.
Health governance
Improving governance in health remains a major issue for all countries as they work towards increasing equity and fairness in health care delivery, updating public health laws and legislation, and improving accountability. The right to health – or health as a human right – is not yet a routine part of policy-making. As health assumes increasing importance in the global development agenda, there is an increasing realization of the need to develop capacities in health diplomacy and reinforce coordination with the foreign policy and other sectors. The second regional health diplomacy seminar was conducted for officials in foreign affairs and health to promote coordination between the two sectors in addressing health challenges that require political solutions and skills.
Support for improving governance, accountability and transparency included assessments in 12 countries to better understand the policy and planning function of the Ministry of Health. Technical support was provided to four countries to review their respective national health policies and strategies. Two assessment tools were developed to support health system development. The first was used to assess the status of the right to health in four countries, and the second to assess public health legislation in five countries. An expert meeting identified gaps in public health law in the Region and galvanized action to respond to these gaps, including the setting up of a regional network of experts on public health law. Work will continue in 2014 and beyond to develop clear guidance for countries in strengthening health legislation. Special emphasis will be given in 2014 to the prevention of noncommunicable diseases.
Of particular concern in the Region is the presence of political crisis and social unrest in several countries, a situation which has led to a domination of emergency-oriented activities in the health sector. This has contributed to further weakening of government institutions in some countries and their ability to increase and improve the predictability of external assistance, and their alignment and harmonization with government priorities.
Health workforce development
The major challenges facing countries in the area of health workforce development include shortages and maldistribution, especially of nurses, midwives and allied health professionals, training and continuing education, and retention of competent professionals. In several countries in groups 2 and 3, human resources management systems are weak and coordination in health workforce development is inadequate. An important region-wide concern is the need to ensure that the migration, movement, rights and obligations of the health workforce are consistent with the WHO global code of practice on the international recruitment of health personnel.
While the gaps in the development of the health workforce are clear, solutions to address these gaps are not always evident to Member States. To respond to this challenge, work started in 2013 to develop a comprehensive strategy to guide countries in implementing effective approaches in the production, distribution, training and retention of health professionals. The strategy, which will be based on a review of regional and international experience, will be discussed in an intercountry meeting in 2014.
It is evident from working closely with countries that most Member States do not have adequate capacity in public health. Supporting countries in this area is considered a priority by the Regional Office. Experience and skills in public health are essential for national health development. A regional consultation reviewed options for improving public health capacity, and discussed ways to develop a regional public health leadership programme and improve the quality of public health education and training, addressing the dichotomy between teaching and practice, and improve investment in public health research. We are now working with other international public health institutions in establishing a public health leadership programme which will be open to mid-level public health managers in Member States starting in 2014.
Nursing and midwifery is another area that requires greater attention. A consultation on nursing education was convened to review and update the regional standards for nursing and midwifery education, and develop a regional framework for nursing specialization. A prototype curriculum for pre-service nursing education and a post-basic specialty mental health nursing prototype curriculum were developed.
WHO support was provided to build national capacity in areas such as leadership and management for nurses and midwives and how to conduct a health workforce projection. Nursing and midwifery regulation was strengthened in three countries. In Afghanistan, a strategic national plan for human resources for health and a strategic plan for the ten institutes of health sciences to promote educational development of nursing, midwifery and allied health sciences and increase production were finalized.
The regional fellowships programme benefited 94 fellows from countries across the Region.
We believe that WHO’s work in strengthening medical education has not received adequate attention in recent years despite the important challenges that countries currently face in this area. In scaling up, we first need to conduct an accurate situation analysis, identify constraints and agree on priorities for action. For this reason, a major study on medical education in countries of the Region has been initiated in coordination with the World Federation of Medical Education. The purpose is to review the quality and appropriateness of medical education programmes across the Region, share best practices and identify areas for improvement. Our plan is to provide clear strategic directions for this area of work in 2014.
At the Third Global Forum on Human Resources for Health, 14 Member States made commitments and agreed to monitor and report progress on these. The forum is organized by the Global Health Workforce Alliance, which is hosted by WHO.
Essential medicines and technologies
Access to medical products, including essential medicines, vaccines, blood products, diagnostics and medical devices remains a challenge that is exacerbated for many countries by the failure to fully implement the use of quality-assured generic medicines, irrational use of medicines and inefficient procurement and distribution systems. In addition, countries have not fully used available tools (such as health technology assessment) to help them make informed decisions in relation to investments in health technology. Underpinning the challenges in the area of essential medicines and health technologies is the need to strengthen national regulatory authorities in most countries.
Important steps were taken in advancing the use of health technology assessment in the Region with an intercountry meeting on health technology assessment attended by 18 countries. The meeting triggered the initiation of a health technology assessment network of regional and international experts, as well as the setting up of national programmes and the mapping of existing national and region-wide health technology assessment resources.
National medicines policy documents were updated in two countries and capacity was strengthened in 18 countries to conduct surveys to assess the national pharmaceutical sector by using WHO level II methodology.
The work in strengthening access to medicines and health technology included building up regulatory capacity. Although training was conducted for some countries in 2013, this area requires intensive work in WHO to reinforce technical support to Member States in 2014 and beyond. Capacity-building continued under the WHO good governance for medicines programme.
Integrated service delivery
The three groups of countries face varying health system challenges. The predominant challenges in the area of health service delivery are expanding access, improving quality of care and strengthening referral systems In addition to the need for improved training, deployment, distribution and development of the health workforce, capacity of health care providers in managing financial and human resources will have to be reinforced. Poor management capacity is compounded by the lack of effective hospital autonomy and public–private partnerships.
The quality of care and the level of patient safety need to be improved. Studies in some countries have shown the prevalence of adverse events to be as high as 18% of hospital admissions.
Several studies were conducted to deepen understanding of health service delivery challenges in countries. For the first time a regional analysis of the private health sector was conducted and presented during the pre-session of the Regional Committee. An assessment of the main characteristics of general operations, internal control structures and service delivery aspects of public sector hospitals was completed in all countries. The findings showed that the average length of inpatient stay across the Region is almost 5 days (range 3 to 8 days) and the average bed occupancy is 85% (range 33–100%). A mapping study on accreditation of health care institutions was also carried out in the Region.
Several tools and guidelines were developed or updated. These include a conceptual and strategic approach for establishing family practice programmes, guidelines to scale up the community health workers’ programme in countries as an approach for moving towards universal health coverage, guidelines for establishing home health care programmes for the elderly, and a manual on community-based disaster risk reduction, developed in collaboration with the regional programme on emergency and humanitarian response. In addition, the patient safety assessment tool was revised and the patient safety curriculum for medical schools translated into Arabic and widely disseminated.
All countries require support in building and sustaining effective family medicine programmes. This area will be given priority in 2014 by conducting an assessment of the current status of family practice in countries of the Region together with a review of international experience and development of approaches to strengthen family medicine to achieve universal health coverage.
Health information systems
The situation with regard to health information systems in the Region is highly variable. Many countries have several areas that require strengthening, including policy and legislation, human and material resources, indicators for monitoring and evaluation, and skills to collect, analyse and disseminate accurate and timely information to inform decision-making. Following the endorsement in 2012 of resolution EM/RC59/R.3 on health system strengthening, concerted efforts to support countries to improve their health information systems were undertaken. A situation analysis of civil registration and vital statistics was undertaken in all countries using a rapid assessment approach to identify major gaps and challenges. The results were discussed in a regional meeting of stakeholders with the aim of reaching consensus on ways and means to improve the level and quality of registration of births and deaths. Further in-depth assessments were conducted in nearly half of the countries, and the results were used to develop a regional strategy to strengthen civil registration and vital statistics which was endorsed by the Regional Committee (EM/RC60/R.7).
In order to help countries to strengthen their health information systems, a core list of indicators covering three key areas – health risks and determinants, health status and health system performance – was developed. This was discussed in an intercountry meeting and the initiative of having an agreed list of indicators was subsequently endorsed by the Regional Committee. The current status in countries was reviewed in relation to each core indicator, in terms of data collection, data generation, analysis, dissemination and use for policy development and evaluation. The gaps identified in these areas will be discussed with countries in an intercountry meeting planned for 2014. A regional health observatory was launched to ensure that all health-related information are is accessible and used for better planning at both regional and country level, and this core list of indicators will be included in it. Some Member States have repeatedly reported differences between mortality estimates produced by the United Nations agencies and figures reported nationally. In order to reduce inconsistencies and to ensure timely and transparent consultation with national authorities, a meeting was held with countries on the maternal and child mortality estimates produced by the UN inter-agency groups for monitoring MDGs 4 and 5.
eHealth
There is only limited use of eHealth within health systems in the Region at present. National eHealth strategies need to be developed to meet the financial challenges to health systems, increasing demand for efficiency and higher expectations from citizens. The World Health Assembly (resolution WHA 66.24) has urged Member States to develop national policies and to plan for appropriate eHealth services and implementation of health data standards in their countries.
While several countries have embarked on initiatives of one kind or another, there is a recognized gap in national capacities to manage the development of national strategies and policies. Progress in the adoption and implementation of health data standards is slow and the lack of national networks to support flow of information within the health system is an impediment to the development of eHealth.
The key considerations in developing a national strategy were highlighted at a regional meeting which also saw the launch of the HealthNet initiative to establish dedicated, reliable, operational national health networks. The Regional Office coordinated with national focal points to complete a survey on eHealth and innovation in women and children’s health conducted by the WHO Global Observatory on eHealth. Preliminary analysis shows that two of the nine countries concerned have partially implemented national eHealth policies, which now need updating, seven have at least one electronic information system to collect and report health data at the district level, and three have major women’s and children’s health initiatives that are supported by eHealth.
