Annual report of the Regional Director 2018

Introduction Strengthening health systems for universal health coverage Promoting health across the life course

Noncommunicable diseases Communicable diseases WHO Health Emergency Programme

Implementing WHO management reforms Annexes Previous reports

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Promoting health across the life course

Key areas of focus included the health of women before, during and after pregnancy and the health of the newborn, children, adolescents and older people. By identifying critical stages in the life-course that influence health, opportunities for health promotion can be recognized and addressed along the continuum of care. As well as promoting healthier populations, the approach involves addressing the social and environmental determinants of health through multisectoral action and advocating for Health in All Policies.

While reproductive and maternal health is critical for achievement of the WHO triple billion goals and Vision 2023, the Eastern Mediterranean Region ranks fifth among the six WHO regions in terms of reproductive and maternal health indicators. During 2018, technical support was provided for strategic planning in many countries. Afghanistan, Egypt, Iraq, Libya, Morocco, Oman, Pakistan, Qatar, Sudan, Tunisia, United Arab Emirates and Yemen all finalized reproductive and maternal health strategic plans. A regional framework for action on preconception care 2019–2023 was endorsed by the 65th session of the Regional Committee for the Eastern Mediterranean in October 2018. The following month, a regional meeting on engaging countries and strengthening partnerships towards better maternal and child health was held in Amman, Jordan. It provided an opportunity to introduce national programme managers to updated WHO guidelines and recommendations on family planning and preconception, antenatal and intrapartum care, and to develop country plans of action. In order to respond to reproductive and maternal health needs in crisis situations, a special edition of the medical eligibility criteria wheel for contraceptive use was developed, suitable for service delivery in humanitarian settings.

The average rate of caesarean section in the Region is 21%, with country rates ranging from one of the world’s highest (52% in Egypt) to the lowest (2% in Somalia). To assess caesarean section practices in the Region, research activities were supported during 2018 in Egypt, the Islamic Republic of Iran, Lebanon, Morocco and Syrian Arab Republic, and an informal consultative meeting was held on WHO recommendations on nonclinical interventions to reduce unnecessary caesarean sections. In October, following the 65th session of the Regional Committee, a technical meeting took place in Khartoum, Sudan, on the surge in caesarean sections in some countries of the Region. Work is underway to build on that meeting and optimize the use of caesarean sections in the Region.

Between 1990 and 2017, the under-five mortality rate decreased by 51% in the Region, from 102 deaths per 1000 live births to 50. However, the neonatal mortality rate has declined more slowly, by 35% since 1990. Around 458 000 newborns died in 2017, accounting for more than 54% of all under-five deaths. In terms of Sustainable Development Goal (SDG) targets, by the end of 2017, seven out of 22 countries in the Region had an under-five mortality rate higher than the global target for 2030 (25/1000 live births), while eight had a neonatal mortality rate higher than the global target for 2030 (12/1000 live births). The main causes of mortality in the neonatal period are prematurity (21%), pneumonia (15%), intrapartum-related complications (13%) and neonatal sepsis (9%). Pneumonia, diarrhoea and injuries remain the main causes of death among children under the age of five. There are many underlying causes of the continued high neonatal and child mortality in the Region, including humanitarian crises, making it the region with the highest neonatal mortality.

Adolescents make up around a fifth of the population of the Region (129 million). The adolescent mortality rate in the Region in low- and middle-income countries is 115 deaths per 100 000, which is the second highest in the world. The top five causes of mortality among adolescents are collective violence and legal intervention, road injury, drowning, lower respiratory infections and interpersonal violence. The top five causes of loss of disability-adjusted life years (DALYs) among adolescents are collective violence and legal intervention, iron-deficiency anaemia, road injury, depressive disorders and childhood behavioural disorder.

In 2018, a draft regional neonatal, child and adolescent health implementation framework 2018–2023 was developed to support countries in implementing GPW 13 and regional priorities, and a workshop was held to build the capacity of WHO country office focal points to manage and coordinate reproductive, maternal, neonatal, child and adolescent health plans and activities. Furthermore, country capacity was built in the areas of essential newborn care, Integrated Management of Childhood Illness, care for child development and adolescent health strategic planning. To strengthen and integrate child and adolescent health services within national preparedness and humanitarian response plans, implementation of the regional operational guide on child and adolescent health in humanitarian settings was initiated in Sudan; implementation in Libya and the Syrian Arab Republic will follow.

The Eastern Mediterranean has the highest neonatal mortality rate of any WHO region

The Regional Office is collaborating with WHO headquarters to develop a platform for innovation and change in responding to the health and social needs of older populations. This will enable WHO to collaborate with partners and draw on the best expertise available to identify innovative solutions to improve the health of older people. The draft platform will be made available in mid-2019 for consultation with Member States and is scheduled to be on the agenda of the Seventy-third World Health Assembly in 2020.

The Integrated Care for Older People (ICOPE) guidelines outline evidence-based interventions to manage declines in the intrinsic capacities of older people within the community. In June 2018, a consultative meeting was held in Beirut, Lebanon, on promoting the integrated care approach for older people and strengthening implementation of the Global action plan on the public health response to dementia 2017–2025 in the Region. The meeting introduced the concepts, approaches and parameters of ICOPE and outlined the steps required to support its implementation in the Region.

In May 2018, the results of a WHO global survey on progress in implementing the Global strategy and action plan on ageing and health were reported to the Seventy-first World Health Assembly. To assess progress, WHO collected data on 10 indicators from countries and regions. Responses from countries in the Eastern Mediterranean Region were complemented by information collected for a regional survey on ageing completed in late 2017. The information will be used to strengthen country programmes. Close collaboration with key stakeholders to foster national efforts to address the health needs of older people in the Region is a prerequisite for achieving Health for All by All and ensuring that no one is left behind.

The Eastern Mediterranean Region has the third highest road traffic fatality rate (18 per 100 000 population) worldwide. Most deaths occur in middle-income countries, while high-income countries have an overall fatality rate three times the global average rate of similar countries. Males and younger people are hardest hit. In September 2018, the Eastern Mediterranean Regional Forum for Road Safety Legislators was established as a regional chapter of the Global Network for Road Safety Legislators. A draft road safety strategic framework on accelerating action on global road safety targets in the Eastern Mediterranean Region has been developed, in consultation with Member States, to guide countries in designing and implementing context-specific and comprehensive road safety policies and action plans based on the Safe System approach. WHO also supported countries to strengthen their emergency care systems, with Jordan and Sudan completing their assessments to identify priority actions.

The Region has the second highest prevalence of violence against women (37%), which is further exacerbated in emergency situations. During 2018, countries were supported to strengthen their health system response to gender-based violence in both development and emergency contexts. The development of action plans was supported in Egypt, Jordan, Morocco, Pakistan, Sudan, Tunisia and United Arab Emirates, while Afghanistan, Iraq and Syrian Arab Republic received support under WHO’s global initiative to integrate gender-based violence into the health response in emergencies. Furthermore, 19 countries are implementing the Global status report on preventing violence against children survey. A side-event on gender-based violence in emergencies was organized during the 62nd session of the Commission on the Status of Women at United Nations Headquarters in New York in March 2018.

Based on WHO estimates that 15% of the population lives with some form of disability, the Region is home to almost 100 million people with disabilities. Reported disability prevalence in countries ranges between 0.4% and 4.9%. About 4.9 million people in the Region are blind, 18.6 million have low vision and 23.5 million are visually impaired, while 10.7 million people aged 15 years and older have disabling hearing loss. The Middle East and North Africa region accounts for about 3% of all people aged over 65 globally with disabling hearing loss.

In accordance with Regional Committee resolution EM/RC63/R.3 on improving access to assistive technology, a draft strategic action framework on improving access to assistive technology in the Region has been developed and was reviewed at a consultative meeting held in Pakistan in May 2018. At the global level, with leadership efforts by the Government of Pakistan, the Seventy-first World Health Assembly endorsed resolution WHA71.8 on improving access to assistive technology. The resolution reinforces the commitment of Member States, WHO and partners to work together to improve access to assistive technology for everyone, everywhere.

During 2018, a regional consultation on the draft World report on vision was organized, and Iraq, Libya, Morocco and Saudi Arabia finalized their eye care assessment reports. In July, the Region participated in the third stakeholders’ meeting for the WHO programme on preventing deafness and hearing loss and in the consultation to develop the World report on hearing. The Islamic Republic of Iran was supported to finalize its ear care assessment report.

The Region faces many challenges in addressing violence, injuries and disabilities, including insufficient financial and human resources at country and regional levels, weak implementation and evaluation of policy and legislative frameworks, the absence of a Safe System road safety approach combined with insufficient multisectoral coordination, weak and fragmented data systems with widespread underreporting, and significant gaps in emergency and trauma care and rehabilitation services.

In 2019, the regional violence, injuries and disabilities programme is being reviewed in response to GPW 13 and Vision 2023. In addition, road safety and assistive technology regional frameworks will be piloted in countries, efforts to strengthen the role of the health system in addressing gender-based violence and violence against children will be scaled up, and road maps for strengthening emergency care systems will be developed based on country assessments.

GPW 13, with its mission to promote health, keep the world safe and serve the vulnerable, positions health promotion as an essential strategy to meet the needs of Member States. However, the Region lacks a strategic approach to health promotion within national health policies and interventions, and there is limited national capacity to plan, implement and evaluate health promotion interventions.

To address this, a detailed review was commissioned to systematically assess the available literature and analyse the type and effectiveness of health promotion and education interventions in the Region. It found that most are formative research interventions to build the evidence base.

During 2018, a leadership course was initiated in partnership with the United Nations System Staff College for ministries of health and WHO country offices to enhance policy-level understanding of health promotion, particularly in the context of the health and well-being approaches called for by GPW 13 and Vision 2023. Another course has been initiated in partnership with the WHO Collaborating Centre for Public Health Education and Training at Imperial College, London, to build the capacity of health workers and managers in health promotion, and tools on leaving no one behind have been adapted to the regional context. To broaden partnerships for health promotion capacity-building at country level, several academic and nongovernmental institutions have been identified for collaboration with WHO. The selected institutions are being assisted to build their capacity for eventual recognition as WHO collaborating centres on health promotion. Recognizing the role of youth as change agents, a process has been initiated to develop a strategic approach to youth engagement in health. A regional town hall on youth was held in December 2018, with participation from large numbers of young people, youth organizations and WHO staff.

Physical activity is being promoted in the Region to reduce health risks and enhance the quality of life and wellbeing. Two key actions in 2018 were the development of a regional plan of action on physical activity promotion and a social media campaign in Arabic, English and French. Several countries of the Region were provided with financial and technical support to promote physical activity, including Egypt, the Islamic Republic of Iran, Iraq, Jordan, Lebanon, Morocco, Pakistan and Tunisia. In 2019, a regional social media campaign on physical activity will be implemented and the regional plan of action on promotion of physical activity will be finalized.

Dental and oral health are essential components of overall health and well-being. However, this area is often ignored among health priorities at country level. WHO initiated a regional survey on oral health policies, systems and practices in 2018. To effectively engage community health workers in oral health promotion, the development of capacity-building tools was initiated, as was a package of oral health interventions to address the needs of displaced populations in the Region.

The social determinants of health are the conditions in which people are born, live, grow and age, and the wider set of forces and systems shaping the conditions of daily life. With the adoption of the SDGs, they are receiving renewed attention. However, in the Eastern Mediterranean Region, progress in addressing the social determinants of health has remained limited. Vision 2023 advocates action in non-health sectors and addressing the social determinants of health as a priority.

In 2018, several steps were taken to promote policies and action on the social determinants of health. A review was commissioned to map research and interventions on the social determinants of health and provide recommendations for action. The review acknowledged the limited availability of published literature on the social determinants of health in the Region, but identified education, income, employment, food availability, conflict and the status of women as some key priority areas for the attention of policy-makers.

The 2017 Global gender gap report revealed significant gaps in women’s economic participation, education, health and socio-political empowerment in the Region. Recognition of the public health value of gender mainstreaming remains inadequate, and there is a corresponding lack of national capacity, dedicated human resources and funding in this area. This is further compounded by the security situation and instability in many countries. Despite this, efforts are continuing to strengthen health system response to gender-based violence in both development and emergency contexts. WHO is actively participating in related United Nations inter-agency initiatives, including the Gender Thematic Group, to promote joint initiatives and gender mainstreaming at the regional level. In 2018, technical support was provided on gender equality and safeguarding to Lebanon and the emergency whole-of-Syria response.

In view of the complex political and security situation in the Region, and the central role of peace as a determinant of health and development, work has been initiated to identify opportunities for health as a promoter of peace in the Region. Work to develop a regional framework on community engagement in health has also been initiated.

Environmental risk factors such as air, water and soil pollution, chemical exposures, climate change and radiation contribute to more than 100 diseases and injuries. Recent WHO estimates for food safety, chemical exposure, air pollution and occupational risks show that avoidable environmental deterioration has escalated, causing the death toll to exceed the 850 000 premature annual deaths estimated in 2016 (1 in 5 of all deaths in the Region). Environmental risk factors contribute to more than 23% of the total burden of disease, constituting a triple environmental health burden through the impact of noncommunicable diseases, communicable diseases and emergencies. The burden is even higher among children: it is estimated that 26% of childhood deaths and 25% of the total disease burden in children under five could be prevented through the reduction of environmental risk factors such as air pollution, unsafe water, chemicals, lack of sanitation and inadequate hygiene. Air pollution alone is responsible for about 100 premature deaths in children per 100 000 population. Against this background, WHO’s Regional Centre for Environmental Health Action (CEHA) was reviewed during 2018 to strengthen the Organization’s ability to address environmental risk factors in the Region.

In resolution EM/RC65/R.2, the 65th session of the Regional Committee endorsed the regional framework for action on health and the environment (2019–2023), promoting health and wellbeing by addressing the determinants of health and reducing environmental risk factors through multisectoral approaches and Health in All Policies. In line with the regional framework for action on climate change and health 2017–2021, 11 countries are updating their national health and climate profiles. Implementation of the regional plan of action to implement the roadmap for an enhanced global response to the adverse health effects of air pollution (2017– 2022) has started improving air quality monitoring and reporting; the number of regional cities reporting their ambient air quality monitoring data through the WHO Global Urban Ambient Air Pollution Database has increased by 25%. As a result, estimates of the burden of disease due to air pollution were refined in 2018 in all countries of the Region.

During 2018, regional training was conducted on monitoring SDG 6 (ensure availability and sustainable management of water and sanitation for all) targets 6.1, 6.2, and 6.3 on water, sanitation and hygiene. Furthermore, support was given to the Arab Forum on Sustainable Development 2018 to produce a regional report, and status reports were completed on water and sanitation, including in-depth monitoring of SDG 6 targets on safely managed drinking water and sanitation services in two countries and global analysis and assessment of sanitation and water in 11 countries. Environmental health and food safety assessment and technical support missions were conducted to Bahrain, Egypt, Iraq, Lebanon, Libya, Oman, Pakistan and Saudi Arabia, and implementation of 16 national workplans on food safety was followed up.

Avoidable environmental risks now cause more than 850 000 deaths per year in the Region

On chemical safety, support was provided to the chemicals and health network to address the health aspects of the Strategic Approach to International Chemicals Management (SAICM) framework, and to the regional campaign to phase out lead in paints. Within the framework of the cross-programme initiative on antimicrobial resistance, five countries were enrolled in the Tricycle Project (Egypt, the Islamic Republic of Iran, Jordan, Morocco and Pakistan) to implement an integrated trans-sectoral surveillance system for bacterial resistance to antibiotics in humans, the environment and the food chain. Ad hoc support was provided to countries during event alerts through the International Food Safety Authorities Network (INFOSAN) system, and WHO led the investigation and analysis during the fish kill episode in Iraq, providing timely findings and conclusions on the root cause.