Strengthening health systems for universal health coverage
Advancing UHC was identified as a strategic priority both in WHO’s new global strategy, GPW 13, and in our new vision for the Eastern Mediterranean Region.
Meanwhile a meeting in Salalah, Oman, in September saw health ministers sign the UHC2030 International Health Partnership’s Global Compact, confirming their commitment to achieve UHC through a whole-of-government and whole-of-society approach. The ministers also endorsed the Salalah Declaration on UHC, providing a roadmap for Member States in the Region to strengthen their health systems to progress towards UHC.
The year witnessed the establishment of several partnerships – notably with the European Union, Japan and the United Kingdom – ensuring integrated and coherent technical support to Member States in developing their national UHC roadmaps, and securing catalytic funding to help countries implement them.
Within WHO’s Regional Office, a new initiative was established – see box: The Health Systems in Emergencies Lab. A regional parliamentary forum for UHC was initiated to promote the leadership role of parliamentarians in realizing the ultimate goal of Vision 2023: Health for All by All, and material was developed to integrate UHC into the undergraduate education of future health-care professionals.
Integrated service delivery
During 2018, WHO continued to support countries to adopt an integrated people-centred health services approach. The 65th session of the Regional Committee for the Eastern Mediterranean adopted a framework for action on effective engagement with the private health sector to expand service coverage for universal health coverage. Resolution EM/RC65/R.3 called on Members States to “encourage contracting private health sector providers, including through strategic purchasing options and different financial protection arrangements, to deliver a universal health coverage priority benefits package”.
The 2018 Global Conference on Primary Health Care in Astana, Kazakhstan, reemphasized the critical role of primary health care in progress towards UHC and the achievement of health for all. As a contribution to the Astana Conference, the Regional Office co-published a new book: Family practice in the Eastern Mediterranean Region: universal health coverage and quality primary care. Produced in collaboration with the World Organization of Family Doctors (WONCA), it provides in-depth analysis of how family practice and primary health care are being developed and improved in high-, middle-, and low-income countries, and in countries experiencing emergencies.
Many hospitals in the Region, especially in the public sector, have failed to evolve in terms of operational processes and infrastructure, with standards of care and efficiency declining in many cases. The hospital sector needs to be transformed to work efficiently and effectively to help achieve UHC. In 2018, more countries from the Region were supported to institutionalize the Patient Safety Friendly Hospital Initiative, increasing regional expertise in the use of patient safety tools. Furthermore, more countries were supported to develop national quality policies and strategies, and to implement the regional quality framework for primary care. WHO also continues to strengthen guidance and support on quality and safety of medical services for countries in situations of extreme adversity. In 2018, a cross-departmental collaboration in the Regional Office involving four departments assisted eight countries in planning for the improvement of their national emergency care system, including prehospital and hospital services.
The Health Systems in Emergency Lab – new thinking on health system resilience
The humanitarian emergencies in the Eastern Mediterranean Region make work to advance UHC particularly challenging.
To address these challenges, WHO is innovating. In July 2018, the Health Systems in Emergencies Lab (HSEL) was established as a new initiative within the Regional Office. Its aim is to explore new ways to improve health system resilience by integrating health system strengthening with emergency preparedness, response and recovery. The HSEL is not a laboratory in the technical sense of the term, but rather a shared institutional space dedicated to experimenting with new ideas. It is the first of its kind, and other regions are studying it as a possible model to follow.
The HSEL is not a laboratory in the technical sense of the term, but rather a shared institutional space dedicated to experimenting with new ideas. It is the first of its kind, and other regions are studying it as a possible model to follow.
As part of its initial work with funding from the Government of Japan, the HSEL is supporting Afghanistan, Somalia and Sudan to align health system strengthening interventions with joint external evaluation (JEE) and national action plan for health security (NAPHS) initiatives. A regional framework for post-emergency health system recovery is being developed and a policy dialogue meeting on the recovery of the health system of the Syrian Arab Republic is being planned. In addition, a guiding document on implementation of the humanitarian– development–peace nexus for health is in development.
Health governance and financing
Functioning health system governance and financing arrangements are a prerequisite for ensuring effective and sustainable progress towards UHC. However, countries of the Region continue to suffer from weak governance arrangements and limited accountability and transparency, hampering health system performance. Several countries continue to lack a clear vision and comprehensive roadmap to strengthen their health systems towards UHC. Fragile states, in particular, suffer from weak institutions and limited capacity, which curtails partnership benefits and often results in vertical approaches and parallel systems. In addition, insufficient public funding for health, non-existent or dysfunctional prepayment arrangements, and inefficient use of scarce financial resources all compromise the performance of health financing systems.
In 2018, efforts were made to improve information about governance functions and actions. The establishment of a regional chapter of the global Health Systems Governance Collaborative will serve as a platform to generate knowledge and translate it into action to help countries identify progressive, fit-for-purpose approaches to enhancing their health system governance. In addition, the Region’s first atlas of health financing was launched at the 65th session of the Regional Committee, offering a coherent analysis of health financing in all 22 countries of the Region.
Special attention was given to supporting the development of national health policies, strategies and plans by undertaking governance assessments and engaging in technical cooperation for institution-building. Technical support in this area was provided to Egypt, Iraq, Jordan, Pakistan, Morocco, Somalia, Sudan and Tunisia. Support to review or develop health financing strategies was provided to Iraq, Morocco, Oman, Palestine and Sudan, while strategic purchasing was established in Egypt and Sudan to enhance equity and efficiency in the health financing system and ensure sustainability. Technical support was also provided to five countries to strengthen their systems of health accounts using System of Health Accounts 2011 methodology to monitor expenditures in their health systems for better planning, and an expert consultation was held on health financing in emergencies, with the lessons learned to be shared at the global level. Finally, collaboration took place with the WHO Regional Office for Africa to hold a meeting of ministers of health and finance to discuss public financial management and its relevance to the health sector in the African continent.
Health workforce development
An adequate and competent health workforce is critical for UHC. The Region continues to suffer from shortages of health workers and skills imbalances. In addition, protracted crises have prompted the migration of health workers and interrupted the education of health professionals, exacerbating these gaps.
Progressive implementation of the framework for action for health workforce development has increased commitment in Member States. A number of countries have developed or are developing health workforce strategic plans. In 2018, Pakistan, Jordan and Sudan developed national health workforce visions, strategies and/or policies, while Afghanistan, Bahrain, Morocco and provinces of Pakistan were developing health workforce strategic plans. Efforts have been made to enhance analysis of the health labour market and health workforce information. Health workforce data is being improved and validated through the National Health Workforce Accounts platform; health workforce observatories in Jordan and Sudan are being strengthened; and the establishment of health workforce observatories in Morocco and Punjab province in Pakistan is being supported. A special issue of the Eastern Mediterranean Health Journal (Volume 24, issue 9) focusing on scaling up the health workforce in the Region was also published.
With the increasing involvement of the private sector in the education and employment of the health workforce, regulation requires greater attention. Technical cooperation was provided to review health workforce regulation in Pakistan, which emerged as one of the priorities in the National Human Resources for Health Vision; and the Afghanistan Medical Council is being established with a strategic plan for the next five years in close cooperation with WHO.
Globally, the Nursing Now campaign was launched in 2018 to raise the profile of nursing, followed by national launches in seven countries of the Region. Efforts have been made to improve the quality of nursing and midwifery services in the Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Pakistan, Palestine, Somalia, Sudan and United Arab Emirates.
The fellowship programme continues to support building national capacities, with 16 fellowships awarded in 2018.
Essential medicines and technologies
WHO undertakes a wide range of activities to help ensure that people have access to essential, high-quality, safe, effective and affordable medical products. In 2018, this included, among other things, important work in the areas of regulation and manufacturing.
Seventeen countries attended the 2018 Eastern Mediterranean Drug Regulatory Authorities Conference meeting, which focused on regulation of similar biotherapeutic products, the threat of substandard products, the need to improve local production of essential medicines, the regulator’s role in addressing antimicrobial resistance and in emergency settings, pharmacovigilance, and the collaboration and networking of standards and practices between national regulatory authorities. A survey on regulation of biotherapeutics and similar biotherapeutics was undertaken which revealed that 60% of countries have established specific guidelines to regulate these products.
In the area of good governance for medicines (GGM), technical support was provided to Libya and Palestine. A survey of local medicine and vaccine manufacturers in the Region was conducted to collect data to help shape appropriate support for and strengthening of local production capacity.
In addition, assessment was done of the good manufacturing practice (GMP) of selected pharmaceutical manufacturers in Lebanon and of the capacity of the national regulatory authority for GMP compliance oversight. The assessment will help to develop a national strategy and plan of action for pharmaceutical manufacturing development. The Regional Office is also actively involved in the African Medicines Regulatory Harmonization Initiative to promote the domestication of the African Union Model Law on Medicines Regulation in African countries.
A policy brief on health technology assessment was developed in collaboration with the Middle East and North Africa Health Policy Forum and Tunisian health technology assessment agency to guide countries on the steps and resources needed to initiate the development of health technology assessment units. A rapid survey on the regional status of assistive technology revealed inadequate policies, systems and service delivery in several countries. This fed into a regional framework on advancing access to assistive technology which was drafted during a meeting in Islamabad, Pakistan, and will be piloted in Bahrain, Iraq and Pakistan.
Health data and health information systems
Implementing the regional framework for health information systems and core indicators for monitoring the health situation and health system performance remains a priority for technical support in the Region. Key SDG indicators are incorporated in the regional core indicators list to provide countries with a unified approach for reporting health-related indicators. Intensive work with Member States to strengthen country health data and measurement systems has led to a remarkable improvement in core indicator reporting, with an average increase of 15% in indicators reported at the regional level in the period 2014– 2018. In 17 out of 22 countries reporting of core indicators ranges from 76% to 95%; whereas in the remaining countries it ranges from 62% to 75%.
In 2018, several initiatives were taken to help countries improve data sources for the development of national indicators. Mindful that surveys are major data sources for reporting on 60% of key health indicators, WHO facilitated multisectoral, multidisciplinary national workshops to develop national strategic plans for survey implementation, and technical support continued on adapting global standardized survey tools and conducting national surveys in the Region.
A training workshop on the District Health Information System, version 2 (DHIS2) in December 2018 aimed to equip health managers and health information system focal points with the skills needed to use data generated from routine health information systems for decision-making through clear and concise dashboards. Participants from Iraq, Lebanon, Palestine, Somalia, Sudan, Syrian Arab Republic and Yemen attended.
A comprehensive assessment of the national health information system was conducted in Afghanistan, while in Libya DHIS2 was piloted to enhance the collection, processing, analysis and reporting of health data, as recommended by a comprehensive health information system assessment conducted in 2017. A regional consultation was held on SCORE, a new health data technical package developed by WHO and partners.
Enhancing WHO collaborating centres in the Eastern Mediterranean Region
WHO collaborating centres are leading research institutions designated by the WHO Director-General to support the Organization’s programme of work in specific areas of expertise.
The centres form a global network and collaborate with WHO at all three levels of the Organization.
Vision 2023 has identified scope to make more use of collaborating centres in the Eastern Mediterranean Region, including both expanding the number of institutions in the Region and deepening collaborations with centres where appropriate.
In 2018, there were 45 WHO collaborating centres in the Region, and WHO supported the establishment of a new WHO collaborating centre on ethics in Karachi, Pakistan.
Progress was also made in strengthening country capacity in the production of high quality cause-ofdeath statistics. Accurate compilation of cause-of-death data is a key step in ensuring that accurate health indicators are reported for countries, and a priority for the Region and WHO. National death certification workshops in Iraq, Lebanon, Qatar, Tunisia and United Arab Emirates trained 600 physicians and statisticians in ICD-10 compliant certification of deaths, while other activities reached participants from Djibouti, Iraq, Morocco, Saudi Arabia and Tunisia. WHO and the United Nations Economic Commission for Africa co-organized a capacity-building workshop on death certification and an open verbal autopsy tool in November 2018. During the 65th session of the Regional Committee in Sudan, ministers of health were introduced to the new form of certification of death and the verbal autopsy form. While these forms were issued in 2016, they are not still fully implemented in several countries of the Region.
During 2018, 14 countries reported mortality data using ICD-10, with data completeness above 60% for 10 countries. WHO plans to build national capacity in certification and data management tools to improve the quality of cause-of-death data for use in public health planning and evidence-based decision-making. Countries showing commitment to reporting high quality data are being supported to scale up the adaptation of automatic coding tools at the level of data collection and registration; documentation of their experience will help guide other countries in the Region.
Under GPW 13, there is greater attention to forecasting progress in health outcomes using health data and appropriate methods. Future work will focus on supporting Member States to address the remaining challenges for health information systems. In 2018, WHO worked with academic partners to develop new approaches for measuring equity in health data, and conducted a workshop for participants from Egypt, Somalia and Sudan.
Research development, knowledge management, use of evidence and innovation
In 2018, WHO support on providing access to knowledge focused on building the capacity of health care and academic institutions for better utilization of Research4Life programmes, particularly the Hinari Access to Research for Health programme. Subregional training of trainers workshops reached over 100 participants from Djibouti, Egypt, Libya and Tunisia.
The flagship monthly Eastern Mediterranean Health Journal (EMHJ) included special issues on the health workforce in the Region and scaling up prevention and control of noncommunicable diseases, and the EMHJ website was enhanced to make it more accessible and user-friendly. The EMHJ is one of few public health-oriented academic journals that remains free of charge to authors as well as users of its published content.
Analysis of national health priorities, potential opportunities for and barriers to eHealth applications was updated, while capacity-building work continued. Cumulatively, eHealth focal points from 21 countries in the Region participated in at least one of the two national eHealth strategy workshops held in 2017 and 2018. Following progress in mHealth projects in Egypt and Tunisia, WHO is now supporting mHealth projects in Sudan, with a focus on the control of diabetes, cervical cancer and breast cancer.
Unified Medical Dictionary
A new edition of the Unified Medical Dictionary (UMD) was launched at the 65th session of the Regional Committee in October 2018.
The UMD is multilingual resource, containing more than 200 000 terms in Arabic and English, with many also available in French, German and Spanish. The new edition is the fifth since work on the UMD began in the 1960s, and is available through a user-friendly online platform – see: http://umd.emro. who.int/whodictionary
Sixteen public health research projects from nine countries were recommended for funding under the Research in Priority Areas of Public Health grants scheme, including for the first time research in the areas of environmental health and health information systems. In addition, another 16 tropical disease research projects from eight countries were recommended for funding under the WHO Regional Office for the Eastern Mediterranean and UNICEF/UNDP/ World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). Capacity-building for health research continued through regional workshops on implementation research and good health research practices, in coordination with the TDR-supported regional training centre in Tunisia. National health research plans and systems in Palestine, Qatar, Saudi Arabia and Sudan were supported through joint activities and country missions.
As requested by the WHO Regional Committee for the Eastern Mediterranean at its 64th session in 2017, WHO undertook extensive analysis and consultation on ways to enhance the use of research evidence in health policy-making. This important ongoing work fed into the development of a new regional framework which will be presented to the Regional Committee in 2019.
