Noncommunicable diseases
At the third High-level Meeting of the United Nations General Assembly Special Session on Noncommunicable Diseases in September, countries renewed their commitment to reduce premature deaths from noncommunicable diseases by one third through prevention and treatment, and to promote mental health and well-being. Gaining political support is a huge step in this fight, but efforts need to be stepped up to meet SDG target 3.4, which is unlikely to be met at the current rate of progress and with a business-as-usual approach. Countries need to take responsibility for delivering agreed strategic interventions under the four areas (governance, surveillance, prevention and health care) of the regional framework for action for the prevention and control of noncommunicable diseases which they have endorsed.
Although many policies are in place in the Region, bold and innovative action is required to accelerate progress towards achieving SDG target 3.4 between now and 2030, in line with the recommendations of the WHO Independent High-level Commission on Noncommunicable Diseases. Countries must increase national investments and capacity, mobilize funds, foster collaboration and engagement with key stakeholders, set specific priorities, and reorient health systems according to national contexts and needs.
Governance
During 2018, WHO continued to support countries in developing multisectoral noncommunicable disease action plans, incorporating noncommunicable diseases into national development plans, and setting up national noncommunicable disease targets, stressing the importance of a whole-of-government, whole-of-society approach. Egypt and Oman launched national multisectoral noncommunicable disease action plans, while missions were conducted in Jordan, Qatar and Tunisia to support the development and implementation of their action plans. Overall, 10 of the 22 countries in the Region now have plans.
In July, economic tools to support national noncommunicable disease responses were recommended to countries, based on global evidence. They include using fiscal measures to help reduce noncommunicable disease risk factors while generating government funds for health care, and developing national noncommunicable disease investment cases to promote a comprehensive national response. A costing exercise was conducted in Oman, and development of a noncommunicable disease investment case initiated in the Islamic Republic of Iran.
Prevention and reduction of risk factors
WHO continued to provide technical support to countries during 2018 to scale up implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC), noncommunicable disease “best buys” and the MPOWER measures. In October, the 65th session of the Regional Committee for the Eastern Mediterranean endorsed a regional strategy and action plan for tobacco control and a regional framework for action on tobacco control.
Collaboration continued with the WHO FCTC Secretariat to strengthen tobacco control. Egypt and Jordan were selected to join the WHO FCTC 2030 initiative, and workplans for the initiative were finalized and adopted. A joint regional meeting was held with the FCTC Secretariat to prepare countries for the eighth session of the Conference of the Parties in October 2018, and regional training was jointly conducted on implementing Article 5.3 of the WHO FCTC on ending tobacco industry interference in tobacco control policies. The training concluded with a call for funding proposals from nongovernmental organizations and government to support implementation of the Article, leading to five projects being selected for funding. Similar national-level training was conducted specifically for Pakistan, given the strong tobacco industry presence there. Collaboration continued with the United States Centers for Disease Control and Prevention on implementing the Global Tobacco Surveillance System in countries of the Region, with the Bloomberg Initiative to Reduce Tobacco on implementing tax increases in Pakistan and healthy cities in Jordan and Morocco, with the Gulf Cooperation Council on strengthening taxation systems and evaluating the health impact of tobacco use in member countries, and with the League of Arab States to support the regional adoption of model tobacco control legislation based on the WHO FCTC. Funds from the Government of Italy supported new initiatives in Egypt to implement tax increases and Sudan to implement graphic health warnings.
Several achievements were noted in 2018. The Islamic Republic of Iran, Pakistan and Qatar became Parties to the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products, meaning five countries in the Region are now Parties to the Protocol. Sudan and Tunisia began drafting new tobacco control laws, and Qatar a new bylaw, while Saudi Arabia issued a new tobacco control by-law. Saudi Arabia also adopted plain packaging (to take effect in 2019), making it the first country in the Region to do so, while Pakistan increased the size of its graphic health warnings from 40% to 50%. Bahrain, Saudi Arabia and United Arab Emirates started implementing tobacco excise taxes, with other member countries of the Gulf Cooperation Council moving forward on this as well, and tobacco control needs assessments were conducted in Qatar, Sudan and United Arab Emirates. To support national tobacco control efforts, information resources were produced for World No Tobacco Day (on tobacco and cardiovascular diseases) and on the impact of tobacco control policies. A focus is now required on implementing tobacco control measures, together with policy development, in order to bridge the gap between policy and enforcement.
Malnutrition takes a heavy toll on the health, well-being and sustainable development of populations in the Region. Some countries, especially those affected by conflict, continue to experience high levels of food insecurity, undernutrition and micronutrient deficiencies. Half the Region’s adult women, more than two in five men and 15% of children are overweight or obese; unhealthy diet and physical inactivity are key contributors to this burden. There have also been marked changes in the Region’s dietary patterns, shifting towards higher-energy diets dominated by increased intake of fats and sugars. However, in SDG 2 countries expressed the ambition to end all forms of malnutrition by 2030, including achieving internationally agreed targets on overweight and obesity.
To help realize this goal, the 65th session of the Regional Committee endorsed a regional framework for action on obesity prevention. In addition, a comprehensive regional strategy for improving nutrition and tackling unhealthy diets was finalized through consultation, and will be presented for endorsement by the Regional Committee in 2019. Eighteen countries of the Region have developed national nutrition strategies and/or action plans, and Afghanistan, Pakistan, Somalia, Sudan and Yemen have joined the Scaling Up Nutrition Movement, comprising governments, civil society, the United Nations, donors, businesses and researchers in a collective effort to improve nutrition and stimulate progress towards the SDGs.
To support national efforts, a nutrition profiling model was developed to help countries regulate the marketing of unhealthy foods and beverages in schools. Sin taxes have now been introduced on sugar in Bahrain, the Islamic Republic of Iran, Morocco, Oman, Saudi Arabia and United Arab Emirates, and more than 17 countries in the Region have developed full or partial legal documents on the Code of Marketing of Breastmilk Substitutes. However, implementation remains a big challenge.
Supplementation and food fortification with essential micronutrients (iron and folic acid) has been addressed in almost all countries of the Region through voluntary and mandatory regulations. Countries are scaling up programmes, including growth monitoring, food-based dietary guidelines, obesity control and prevention, and promoting healthy diet. Skills and knowledge have been developed in the management and treatment of severe cases of acute malnutrition, which has triggered countries in emergency situations to expand nutrition stabilization centres for the treatment of severe and complex cases of malnutrition, particularly in Afghanistan, Djibouti, Iraq, Pakistan, Sudan, the Syrian Arab Republic and Yemen. Support is still needed from WHO, UNICEF and other specialized UN agencies and nongovernmental organizations.
Surveillance, monitoring and evaluation
In 2018, 13 Member States set timebound national targets for surveillance, monitoring and evaluation based on WHO guidance. Countries continued to strengthen noncommunicable disease risk factor surveillance systems by implementing the WHO STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) and the Global Tobacco Surveillance System, including its components the Global Youth Tobacco Survey (GYTS), Global Adult Tobacco Survey (GATS) and Tobacco Questions for Surveys (TQS).
Egypt, Oman and Sudan successfully completed national-level STEPS and released fact sheets presenting the results, while Afghanistan completed STEPS data collection, and Somalia is in the process of survey completion. Jordan, Kuwait and Qatar made progress in developing a protocol for national-level STEPS implementation in 2019. All countries integrated TQS. United Arab Emirates integrated its national-level STEPS questionnaire into the World Health Survey for 2018 and completed data collection and analysis.
Pakistan is planning GATS repeat implementation under a donor funding mechanism, while Saudi Arabia progressed its work on GATS implementation through self-funding. Bahrain, Kuwait, Oman, Qatar and Tunisia successfully completed GYTS repeat data analysis and released results fact sheets. Egypt, Iraq and Palestine are preparing GYTS repeat surveys.
Following Regional Committee resolution EM/RC/65/R.1, endorsed in October 2018, steps have been taken to finalize the draft NCD surveillance system training package and make it available to Member States in 2019 to support them in implementing the WHO global monitoring framework. During 2018, in collaboration with the International Agency for Research on Cancer (IARC), Oman and United Arab Emirates received training on their cancer registries, while Egypt, the Islamic Republic of Iran, Iraq, Jordan, Morocco and Tunisia received training on strengthening their noncommunicable disease surveillance systems and implementing the WHO global monitoring framework on noncommunicable diseases. Moreover, the report on the 2017 noncommunicable diseases country capacity survey is being prepared for publication.
Health care
In line with the SDGs and the universal health coverage agenda, in 2018 WHO scaled up its support to countries in the Region for reorienting health services to better manage cardiovascular diseases, cancer, diabetes and chronic respiratory diseases, and their risk factors, with a focus on primary health care, including in crises and emergencies. Support was provided to develop and implement national cancer control programmes based on the regional framework for action on cancer prevention and control, endorsed in 2017.
Djibouti, the Islamic Republic of Iran, Pakistan and Sudan received support to integrate noncommunicable diseases into primary health care, and Afghanistan and Sudan were supported to develop and/or implement national cancer control programmes. Guidance and country support was also given for the management of noncommunicable disease care in crises and emergencies. The noncommunicable disease emergency health kit was procured by Afghanistan, Libya and Yemen. In collaboration with Primary Care International, training for health care providers in using the kit was conducted in Afghanistan.
In December 2018, a mission was conducted to Morocco on the Global HEARTS Initiative (to prevent premature deaths from cardiovascular diseases) and the Initiative to Eliminate Cervical Cancer. Morocco was selected as one of the fast-track countries globally for the elimination of cervical cancer. In September 2018, WHO announced the Global Initiative for Childhood Cancer, which aims to reach a survival rate of at least 60% for children with cancer by 2030. Work on this in the Region is planned for 2019.
Following World Health Assembly resolution WHA71.14 on rheumatic fever and rheumatic heart disease, endorsed in May 2018, a regional consultation was held to review and finalize a regional framework, to be presented for endorsement by the Regional Committee in 2019, and steps were taken to establish a regional expert network to carry forward action on rheumatic heart disease in the Region. The framework is a roadmap for implementing the global resolution at regional level and serves to guide Member States on developing or adapting comprehensive and effective national rheumatic heart disease programmes. The regional consultation was organized in partnership with Reach and the World Heart Federation, global leaders in rheumatic heart disease prevention and control.
Mental health and substance use
Mental health and well-being cuts across all three strategic “one billion” priorities. The WHO mental health action plan 2013–2020 and the regional framework to scale up action on mental health provide countries with operational guidance and help to monitor progress on GPW 13 and the health-related SDGs. The number of countries experiencing complex emergencies and the epidemiological transition in the Region poses a challenge, but also an opportunity, for scaling up mental health and psychosocial support services. During 2018, mental health strategies
and legislation were reviewed, developed or updated in Afghanistan, Egypt, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Somalia, Sudan and United Arab Emirates, in accordance with the indicators and targets in the WHO mental health action plan 2013– 2020 and the provisions of the UN Convention on the Rights of Persons with Disabilities. National autism plans were developed for Oman, Qatar and United Arab Emirates, and a dementia plan for Qatar. Support was provided to Afghanistan, the Islamic Republic of Iran and Tunisia to develop and strengthen national suicide prevention plans. Furthermore, a regional mental health atlas was finalized, mapping the resources and capacities available for mental health in the Region.
The annual regional course on leadership in mental health was hosted by the American University in Cairo to strengthen institutional capacity in countries, and participants from several countries of the Region participated in the international diploma on mental health, law and human rights at the International Islamic University in Islamabad, Pakistan. To integrate mental health within primary health care, the WHO Mental Health Gap Action Programme (mhGAP) continued in Afghanistan, Egypt, Iraq, Jordan, Lebanon, Palestine, Pakistan, Somalia, Syrian Arab Republic and United Arab Emirates. Draft guidance on integrating mental health into primary health care was finalized in collaboration with WHO headquarters. Piloting of a curriculum to enhance the capacity of general nurses in providing mental health care was initiated in Iraq and continued in the Syrian Arab Republic.
Action to tackle substance use
Substance use is a serious threat to public health globally, linked to crime, sexual abuse and interpersonal violence as well as a broad range of substance ‐ induced disorders.
The public health response in the Eastern Mediterranean Region to date has been inadequate, with only one in 13 people in the Region receiving treatment. However, WHO is working with Member States to step up action. A regional framework for strengthening public health action on substance use has recently been developed, and will be presented for endorsement by the Regional Committee in 2019.
Work in 2018 also included the annual regional capacity-building workshop for mid-level managers on substance use policy development and service delivery, developed and conducted in collaboration with the National Rehabilitation Centre in Abu Dhabi. Furthermore, the Regional Office continues to contribute to field testing of treatment standards for substance use disorders, and to the joint development of prevention standards by WHO and the United Nations Office on Drugs and Crime (UNODC).
The school mental health package has been piloted and is now being used in Egypt, Islamic Republic of Iran, Jordan, Oman, Pakistan, Qatar and United Arab Emirates, and in other WHO regions. Moreover, in collaboration with WHO headquarters, the Regional Office is contributing to randomized controlled trials on psychosocial interventions, including for children and adolescents. During 2018, technical support continued to strengthen mental health and psychosocial support for populations in Iraq, Libya and Yemen, and for those affected by the Syrian crisis, in coordination and collaboration with UN agencies, nongovernmental organizations, national stakeholders and academic institutions.
