The Work of WHO in the Eastern Mediterranean Region
Annual Report of the Regional Director
1 January - 31 December 1995

Health systems and services development

3.1 Organization and management of health systems based on primary health care
3.2 Human resources for health
3.3 Essential drugs
3.4 Quality of care and health technology

3.1 Organization and management of health systems based on primary health care

Health system research 

The Regional Office provided technical support for the development of national health systems research (HSR) programmes in Cyprus and Yemen. An organizational structure for a health systems research unit adapted to local needs was suggested.

A consultation meeting on health systems research was held in Bahrain from 24 to 27 December 1995 to develop and propose a national health research policy and strategy with emphasis on HSR, decide on the most suitable structure for the promotion of health research and on the research priorities in the area of health and discuss and agree on coordination mechanisms for health research.

In the Islamic Republic of Iran, two courses on research methodology were conducted in 1995 by a national temporary adviser: one for mid-level managers and the other for senior experts.

The Director of the Office of Research Policy and Strategy Coordination at WHO headquarters visited Morocco in November 1995 to advise the government on supporting/strengthening the National Institute of Health Systems Research.

Primary health care support 

Efforts continued during the year to develop primary health care (PHC) infrastructure and to create an environment conducive to achieving the goal of health for all (HFA) through the PHC approach. In order to meet the quest of countries to ensure sustainable coverage by health interventions, innovative approaches, such as basic minimum needs (BMN) and "accelerating PHC", were introduced and used by some countries of the Region. Being based on a sound scientific foundation, PHC is promoting the quality assurance approach to ensure effectiveness and efficiency of health care systems.

The basic minimum needs approach 

Currently, about half of the countries in the Region are embarking on the basic minimum needs approach. The status of BMN programmes varies from one country to another. The overall assessment is that BMN is gaining momentum and is expanding.

An important indicator of the success of the BMN approach is its ability to replicate itself in the country. It is heartening to note that in most countries where BMN started before 1994, new areas launched BMN activities. Table 3.1 shows this replicability of BMN in many countries, including Somalia (despite the difficult situation in that country).

The BMN concept had spread to more countries (now 12 countries have BMN programmes or use BMN methodology); more districts and villages than before are adopting this approach.

The following countries are not included in the table as they have not yet embarked any BMN model areas: Bahrain, Cyprus, Kuwait, Lebanon, the Libyan Arab Jamahiriya, Oman, and the United Arab Emirates.

BMN, as an approach, had been used in an adapted form in the Syrian Arab Republic for accelerated and integrated PHC and, in Egypt and the Islamic Republic of Iran, in healthy villages. This is an indication that BMN tools and elements and methodology could be disseminated for use in similar developmental and public health initiatives.

BMN became known to other organizations and is recognized as a comprehensive approach. Several joint programmes were developed during 1995 with the following partners:

Somalia IFAD (International Fund for Agricultural Development) is supporting a project in Wenla Weyne

Yemen WHO headquarters (with funds from donors)

Morocco UNDP is interested in partnership with WHO

Egypt UNICEF is working with WHO and national authorities in BMN promotion.

At the country level, national partners also varied:

• Ministries of health were always involved in all BMN programmes.

• Other central, national and local authorities, for example governors are also becoming involved, either as the main responsible executing agency or together with MOH (examples are in Egypt, Tunisia and Yemen).

• Communities played a pivotal role in ensuring the success of BMN programmes in most countries.

• NGOs are partners in BMN projects in Egypt, Jordan and Tunisia.

In 1995, teams from Egypt, the Islamic Republic of Iran and Pakistan visited the Noor Al Hussein Foundation (NHF) in Jordan-a nongovernmental organization-which is actively involved in BMN promotion.

• The BMN project in Alexandria, Egypt, received visiting teams from Jordan and Morocco.

• Through a WHO grant, the Noor Al Hussein Foundation is providing technical support to Yemen in developing BMN tools, elements and methods.

• Following a review, a standard BMN survey methodology was widely disseminated for incorporation in urban and rural settings.

• The BMN kit (a reference operational manual introducing the various aspects of BMN and guiding those interested in knowing and applying BMN tools, elements and methodologies as well as concepts) was distributed to all Member States and interested institutions.

In order to meet the numerous requests received from countries that wished to study BMN experiences, the Regional Office supported a BMN training centre in Jordan and provided facilities. This training centre allows for a continuing relationship between regional offices, countries and other training centres. The courses offered by the Centre will be tailored to meet the needs and pace of BMN development of interested countries. The centre will also facilitate networking among Member States in BMN matters.

An intercountry meeting was held in Amman, Jordan, from 24 to 27 December 1995 to foster further exchange of experience and review possible evaluation tools.

Development of district health systems 

The "catchment area"-the area from which patients come to a health unit-concept is being implemented in various forms-in some countries as an operational planning unit to judge equity of distribution of service and accessibility to health care. The catchment areas in Bahrain, Djibouti, Jordan, Kuwait, Oman, Pakistan, Qatar and Yemen, coincide with the administrative divisions of the countries. In other countries (Cyprus, Egypt, the Islamic Republic of Iran, Saudi Arabia, Sudan and the United Arab Emirates), the "catchment population" concept is being implemented using population rather than geography to define catchment.

In some countries, private agencies and NGOs are determining the catchment areas and/or population (Afghanistan, Lebanon, Somalia); in others (Morocco and Yemen) with nomadic populations, there is a different form of service.

Health development structures 
Preparations were under way in the Syrian Arab Republic to accelerate PHC in selected districts through local organizations such as the Youth Union.

In Lebanon, local NGOs are important partners in providing health services in the country. In Saudi Arabia, "health friends" are involved in improving the performance of PHC centres.

District health infrastructure and services

The development of the PHC infrastructure at the district level was provided using different initiatives. National training activities for the development of human resources for PHC were decentralized in Afghanistan and Pakistan.

Integration of PHC elements and acceleration of HFA were implemented in the Islamic Republic of Iran and launched recently in Jordan, the Syrian Arab Republic and Yemen. Strengthening of capabilities at the district level of PHC managers continued in the Libyan Arab Jamahiriya, Oman, Tunisia and Yemen.

Integrating the training of PHC workers at the district level was planned in Afghanistan, Iraq and Somalia. In Iraq, health centre reform is taking place to introduce decentralization and self-reliance.

A handbook for PHC workers at the health centre level was prepared in Lebanon. This is a quick reference text, covering the concept of PHC, PHC programmes at the health centre level, the job descriptions of PHC directors at governorate and qada (district) levels, as well as the health centre physician, dentist, midwife, nurse health inspector and the officer in charge of the health centre. This manual, developed with assistance from WHO, is an important step towards implementing the PHC strategy.

Referral support to PHC

The district health level, in order to function effectively, must have an efficient and effective referral system. The experience of selected countries in the referral system of PHC was reviewed at an intercountry consultative meeting held in Lahore, Pakistan, from 9 to 13 April 1995.

The functional components of the referral system (community, physical infrastructure, health care providers, communication, management information system, resources and finance, and administration and organization) should be analyzed in the context of community involvement, technology, research and equity.

The experience of some countries in referral support to PHC was reviewed in relation to regulations, technical guidelines, training, and research. It was found that the referral system is not always congruent to the expanding levels of care (in, for example, Jordan, Lebanon, Pakistan and Yemen). In Lebanon, the cost of referral cases consumed a substantial amount of the health ministry's budget. In 1993, a study in Kuwait showed that the cost of a specialist visit was Kuwaiti dinars (KD) 5-8, compared to the cost of an ambulatory care visit of KD 2.62. This meant that those bypassing the PHC system represented a considerable expense to the national health care system. Some countries (for example Egypt and Saudi Arabia) promulgated policies and/or legislation regarding referral support to PHC.

With multiple providers of health care, including the private sector, regulations and guidance should be provided to ensure vertical and horizontal referral. In Saudi Arabia, a plan for organizing referral system, adopted in 1988, yielded rational and increasing utilization of PHC services.

In Oman, there is an extensive well-equipped network of subcentres, health centres, hospitals and teaching institutions coupled with the decentralized wilayat health system. Standard referral forms have been developed. However, there is excessive demand for referral to hospitals. In other words, achieving high accessibility to health care in a short period in Oman has led, at the same time, to a high demand for secondary care.

Research on referral support to PHC

Several studies on referral support to PHC were undertaken. In Jordan, a joint teaching-cum-research project in Al Sareeh Comprehensive Health Centre (ACHC) was developed by the Ministry of Health and the Department of Community Medicine at the Faculty of Medicine of the University of Science and Technology in Irbid. The ACHC was developed as a referral centre covering a catchment population of 40 000 and is supporting three PHC centres. The improved basic and specialized services in ACHC are strengthening the confidence of the community in the PHC system and a rational use of secondary care is being seen. A comprehensive document on the findings obtained and lessons learned from this experience will be prepared. The partnership of the University and Ministry of Health in this process is worth mentioning.

The hierarchy of the health care delivery system in Pakistan has six tiers, with inadequate harmony of referral between the levels. A small-scale study undertaken in two hospitals revealed that 25-28% of the patients came from outside their expected catchment areas. It was considered that the health care of 44-77% of those attending the two hospitals could have been dealt with adequately at lower levels.

In Oman, it was found that only 41% of hospital visits required referral to specialty clinics and the rest were general practice and emergency visits. It was concluded that a more efficient referral system should remedy the over-utilization of the open system of PHC and save up to 20% of health resources. The optimum target is to reduce the number of visits from 7 to 5 per capita per year.

Primary health care review and studies

A three-year research and development project to achieve health for all by the year 2000 through the district health system was launched in Brujen District in the Islamic Republic of Iran, where four cities or city zones and 44 villages were benefiting from this project. The project consisted of 14 elements pertaining to PHC and HFA covering a wide range of areas, such as training of female health volunteers in order to involve them more, improving administration and logistics, and economics of health. The project also covered activities related to the integration of some programmes, such as tuberculosis, brucellosis, mental health, oral health and occupational health. In addition to these activities, healthy cities and sanitation in the villages were also incorporated in the project, making use of the experience of the Islamic Republic of Iran in these two programmes. In order to meet other priority activities in the Brujen district, the project included elements to increase public awareness for emergency preparedness and response, improve drug supply and nutrition as well as provide education to married men (to enlist their support to family welfare programmes).

The implementation of this project was carried out jointly by medical universities and other related sectors operating at the district level.

The results of the study were being analyzed and a report will be produced.

Other promotional activities of PHC

Home health care. A meeting on home health care was held in Cairo in October 1995 to discuss the subject in the context of cultural heritage of the Region. The meeting highlighted the different issues pertaining to home health care, and also suggested some operational activities and directions for action to promote and operate home health care as one of the strategies to achieve HFA. A document was being prepared on the subject.

Study visits on PHC. Several study tours, involving 57 fellows, were arranged to the Islamic Republic of Iran to observe the PHC system in operation in that country.

PHC experience documentation. The Regional Office, in collaboration with UNICEF, supported the Ministry of Health in Oman in documenting its experiences and lessons learned from PHC. This publication will be used by the Ministry of Health officials at different levels, teaching institutions and international organizations, to research and improve health care in the country.

Support to secondary and tertiary care

Several countries focused on the strengthening of secondary health care in 1995. Orientation of hospital staff to PHC management was imparted in Bahrain, the Libyan Arab Jamahiriya, Morocco, Tunisia and Yemen. It was expected that the establishment of a new unit for Health Management Support in the Regional Office would strengthen the technical support provided by WHO to Member States in the area of secondary and tertiary care.

Appropriate technology and its maintenance 

Morocco, the Syrian Arab Republic and Yemen launched several organizational initiatives at central and governorate levels to improve logistics of health services. The three countries also embarked on decentralizing the repair and maintenance of medical equipment to the governorate level.

Central workshops, database and communications were strengthened in Morocco, Oman and the Syrian Arab Republic to improve the management of medical equipment. Technical cooperation among countries of the Region started between Bahrain, the Syrian Arab Republic and Yemen.

Standard specifications and total quality management of medical equipment were reviewed in the Syrian Arab Republic, in collaboration with the various related medical, industrial, teaching, legislative, trading and planning institutions.

Five manuals on medical equipment, such as ECG, anaesthesia, X-ray, were produced as reference guidelines for physicians and technicians of hospitals.

Preventive maintenance plans were implemented in Egypt and are planned for Iraq.

Fellowships were awarded to train technicians and managers of repair and maintenance workshops. The Regional Office promoted the use of centres of excellence in the Region (Bahrain, Cyprus and the Syrian Arab Republic) for training and provision of technical expertise.

Support was provided to Egypt, Jordan and Qatar in strengthening their medical emergency services through formulation of national plans, development of health personnel, and provision of essential supplies and equipment for medical emergency services.

3.2  Human resources for health

Human resources policy formulation, planning and management 

The year 1995 marked the intensification of activities in the area of human resources policy and management in response to changing priorities within the Region. Copies of the Manual for human resources policy analysis, developed by headquarters and tested in two countries in the Region, were distributed to all countries. Countries were urged to start activities aimed at the formulation of national plans for human resources policy and management. A number of activities including national meetings, workshops and consultation on the subject, are scheduled for the first half of 1996.

In response to country needs in the area of continuing education of health personnel, a task force met in the Regional Office from 24 to 27 July 1995, to review and follow up on the progress since the first regional meeting on continuing education held in 1992, and to develop the outline of a plan of action for strengthening continuing education activities in the Region. The task force developed an outline of a "national system of continuing education for health personnel" for use by Member States. During 1996, the Regional Office will extend support to those countries that wish to develop their national systems for continuing education.

The Regional Office continued to emphasize the need to develop postgraduate training in public health and other specialties, particularly in countries that lack the resources for such activities. By the end of 1995, the number of WHO-supported postgraduate training programmes rose to 13-three each in Sudan and the Syrian Arab Republic, two in Jordan and five in Yemen. Some of the programmes were subjected to intensive evaluation by WHO consultants for their content and impact on the health care system, and the results of the evaluation process was, on the whole, positive. During 1995, the Regional Office completed the development of a training manual for a postgraduate training programme in community medicine. The development of similar training manuals for other specialties is planned for the 1996­97 biennium.

WHO continued to support activities aimed at the development of a close relationship between medical education and the health care delivery system. It is realized that both systems are interdependent and could benefit technically and financially from a close relationship. In this area, the Regional Office supported and actively participated in the Eastern Mediterranean Regional Conference on Medical Education held in Al Ain, United Arab Emirates, from 29 January to 1 February 1995. As a sequel to this meeting and in response to its main recommendation, a high level Ministerial Consultation on Medical Education and Health Services was organized by EMRO in Cairo from 4 to 6 December 1995. The consultation made important recommendations aiming at strengthening and formalizing the relationship between the two important sectors of medical education and health services. The Regional Office is planning a follow-up meeting during 1996 to monitor developments in the implementation of the recommendations of the consultation and will provide technical support to national initiatives in this area.

General fellowships 

The number of applications for fellowships received increased to 972 in 1995, as against 729 in 1994 and 655 in 1993.

There was a sharp increase in the number of fellowships awarded in 1995 (734), compared to 1994 (421); the increase was evident in certain countries-particularly Afghanistan, Bahrain, Morocco and the Syrian Arab Republic (see Table 3.2).

The decline in the average duration of fellowships continued in 1995, when it was 2.94 months, against 3.43 in 1994 and 3.93 in 1993. In 1995, 72.5% of all fellowships awarded were of less than 2 months' duration (Figure 3.1).

Placement within the Region also continued to increase. In 1995, 60% of the fellowships were placed for training in countries within the Region (Figure 3.2). Internal (in-country) fellowships decreased slightly (from 13.3% in 1994 to 11.9% in 1995).

The distribution of fellowships in 1995, by area of study, showed little change from that in previous years (Figure 3.3).

The twelfth national fellowships officers meeting held in Amman, Jordan, from 13 to 16 November 1995, brought together 19 participants from the Region, as well as representatives from WHO headquarters, the Department of Health of the United Kingdom, and the WHO Regional Offices for Europe and, for the first time, the Americas.

A number of important issues related to the administration and evaluation of the fellowships programme were discussed. Some of the recommendations arising out of the meeting were:

• The need to link fellowships, through a careful analysis, with management and development of national human resources policies and strategies;

• To give preference to national training activities, which are cost-effective in training a large number of fellows, they build up the capabilities of national institutions, and they are in line with WHO policies and country priorities;

• To propose that four weeks should be the minimum period for a fellowship;

• To encourage development of training courses in national languages;

• To increase fellowship opportunities for nurses and midwives;

• To have English-language tests tailored to meet the needs of the WHO regional fellowships programme.

Development of medical sciences education 

Educational development activities

Efforts were directed towards promoting collaboration among educational development centres (EDCs) for improving health personnel education and health care delivery systems. The Pakistan College of Physicians and Surgeons in Karachi, and the Medical School of Gezira, Wad Medani, Sudan, submitted proposals to WHO for their educational development centres being considered for designation as WHO collaborating centres.

The following three intercountry workshops held in 1995 brought together participants from the countries of the Region during which discussions and recommendations were focused on priority areas.

• Meeting of directors and managers of the educational development centres, Tunis, 22-25 May 1995, to promote the role of the EDCs, within the country and within the EMR, and to support the role of WHO collaborating centres in areas related to educational development of human resources;

• Group meeting on the application of the manual entitled Workload indicators of staffing needs, held in Cairo, Egypt, 5-7 June 1995;

• Workshop on the application and use of a computer-based HRH supply and requirements projection models for planners of human resources for health and policy-makers, held in Amman, Jordan, 1-8 October 1995.

Consultants in areas of curriculum development, teachers training, research methodology, construction of examination tools and evaluation, community­oriented medical education and problem­based learning were assigned to the Islamic Republic of Iran, Morocco, Pakistan, Qatar, Saudi Arabia and the Syrian Arab Republic.

The Educational Development Centre of Shaheed Beheshti Medical School in Teheran, the Islamic Republic of Iran, launched an M.Sc. programme in health personnel education. Short-term consultants were provided to deliver lectures.

In the field of promoting the use of national languages in medical education:

• Arabic reference books and textbooks relevant to undergraduate medical students were procured from different publishers in Arab countries and distributed to medical faculties with a view to promoting awareness about the availability of such publications and their utilization in medical education;

• the Regional Office supported the Arab Centre for Medical Literature (ACML), Kuwait, to hold a meeting in Kuwait from 8 to 10 April 1996 on Arabicization of Medical Education. The support included travel costs for 50 participants from Arab countries and 50 packages of WHO publications to be distributed during the meeting; and

• Arabic textbooks on nutrition and on community medicine are nearing completion. It is hoped that both the publications will be ready for distribution in 1996. The Arabic translation of Guyton's Physiology will be also ready in 1996.

An English-Arabic teaching/learning material database program was completed and distributed to countries. This program enables educational institutions to develop and exchange databases of teaching/learning materials relevant to health personnel education.

Development of nursing and paramedical resources 

The response to the resolution of the Forty-first Session of the Regional Committee (EM/RC41/R.10) on the need for national planning for nursing and midwifery development in the Region was varied. A number of countries initiated action to establish and strengthen nursing units in ministries of health; some took steps to develop national plans of action and many to improve basic nursing education. Only two countries initiated action to enact legislation to control the quality of nursing and midwifery services. It should be noted that only three countries have nursing and midwifery legislation. This is an area that deserves considerable attention from Member States if the quality of nursing is to be improved.

In an effort to provide Member States with guidelines on nursing education, the third meeting of the Regional Advisory Panel of Nursing was convened in Tunis, Tunisia, during September 1995 to propose regional standards and future directions for basic and post-basic nursing education. The members of the Panel stressed the need for 12 years of education prior to entry into nursing schools. They also focused on ways and means for streamlining the number of nursing education programmes that are responsible for producing various categories of nursing personnel. The guidelines included minimum standards required in relation to the numbers and qualifications of teaching staff, educational resources, the curriculum and teaching/learning environment and evaluation. Model prototype curricula were also prepared for consideration by those responsible and involved in nursing education in Member States.

Several countries were reviewing the quality of their nursing services and were developing systems of quality improvement. During 1995, technical assistance was provided to Kuwait and the United Arab Emirates for the review and implementation of their quality assurance systems. The study on nursing, midwifery and paramedical personnel, initiated during the previous biennium in Lebanon, was completed. The data related to the practice of nursing pointed very clearly to the need to develop quality improvement programmes for nursing practice-a situation frequently encountered in many other countries.

In Bahrain, a situation analysis was undertaken to explore the possibility of starting a post-basic nursing education programme in occupational health nursing. While a large number of countries did have occupational health programmes, with the increasing interest shown by many countries in productivity, the role of occupational health nurses in workers' health promotion and prevention becomes crucial. Yet this area has not been receiving sufficient consideration, and nurses are usually sent outside the Region for training in occupational health nursing.

In Egypt, the School of Nursing of the National Institute of Cancer initiated an one-year post­basic programme in cancer nursing. The programme will provide the country (and eventually the Region) with well-qualified nurses who could contribute to cancer control programmes. The curriculum, which was developed with technical assistance from the Regional Office, focuses on prevention, treatment/management, care, pain relief and rehabilitation of cancer patients and their families.

In an initiative to develop a series of nursing textbooks in Arabic, the Regional Office set up three working groups to develop outlines for textbooks on "Introduction to Nursing", "Community Nursing" and "Psychiatric Nursing".

Paramedical personnel resource development

In response to requests from some countries, the Regional Office took the initiative to strengthen training as well as performance of various categories of health care providers. Member States were asked to nominate focal points for establishing a viable network of individuals who would participate in implementing and evaluating the various aspects of this initiative. Three targets were identified for the coming biennium-one dealing with establishing a database about paramedical personnel, the second focusing on basic education and training and the third dealing with improving the performance and management of these categories.

Activities were also being undertaken to collect relevant information about various categories in order to identify the main issues and problems that needed to be addressed in the preparation of a regional strategy and a plan of action.

3.3 Essential drugs

Ensuring availability and rational use of drugs 

During 1995, efforts continued to achieve the targets of the Eighth General Programme of Work. In this regard, the Regional Office assisted Member States in strengthening their commitment and capacities for implementing their national drug policies (NDPs) in an effort to make the available essential drugs safe, effective, of good quality and accessible at affordable cost. The overall aim is to improve the accessibility of health care services at all levels of the national health care system. The Action Programme on Essential Drugs at WHO headquarters collaborated with the Regional Office in attracting extrabudgetary support to programmes in eight countries in the Region. Similarly, the Drug Management and Policies Unit at headquarters continued its collaborative support to the Regional Office in its activities, through extrabudgetary funds, in the installation the software modules developed.

The main areas that received priority are described below.

National drug policy and master plan development. Support was provided to countries in the development of comprehensive master plans for the national pharmaceutical sectors to facilitate the implementation of NDP activities. Moreover, this plan provides a framework for policy-makers and administrators to follow up on the pharmaceutical policies within their national health policies.

Most countries developed their NDPs and several others (Djibouti, Jordan, Lebanon, Palestine) committed themselves to developing their drug policies.

A consultative meeting on operational research as a component of NDP was held in Teheran, the Islamic Republic of Iran, in November 1995.

Computerization of national pharmaceutical systems. In line with the global revised drug strategy, Cyprus, Morocco, the Syrian Arab Republic and Tunisia, in collaboration with the Division of Drug Management and Policies at headquarters, were actively involved in the development of applied software packages for drug registration, drug quality control, and drug management and inventory control.

During 1995, the WHO Model Software for Drug Registration was installed in Bahrain, Egypt, Lebanon, Morocco and Yemen. The Module for Drug Inventory Control was finalized and would be used in Lebanon, Morocco and Yemen to strengthen the administration of central medical stores. The Module for Drug Quality Control was extensively tested in collaboration with Cyprus and the Syrian Arab Republic.

National list of essential drugs. The basic component of an NDP is the national list of essential drugs, which should be reviewed at regular intervals. Most countries have developed their national lists of essential drugs, which were selected based on pharmacological, therapeutic and economic principles. During 1995, Afghanistan and Egypt developed multilevel lists, while Tunisia and Yemen updated their existing lists, and Djibouti was in the process of finalizing its list.

Drug quantification. Member States were encouraged to implement an appropriate methodology for drug supply/drug quantification for the public sector.

Sudan continued to conduct refresher courses for drug supply officers and storekeepers. WHO staff in Somalia were planning training courses in drug supply management based on their particular situation. A basic list of drug supplies was prepared to cover PHC. The distribution of donated drugs was coordinated in Somalia by WHO staff. WHO activities, especially in drug supplies and stores management, were supported by active involvement of international NGOs. Afghanistan and Lebanon received additional support to build up their national capacities in drug procurement, storage and distribution. Training in pharmaceutical management was provided in Djibouti, Pakistan and Yemen.

Promotion of the concept of rational use of drugs. The regional Essential Drugs Programme supported the inclusion of the essential drugs concept in the curricula of schools of medicine and pharmacy and in paramedical training institutions. Member States were encouraged to update their curricula of schools of medicine and pharmacy by introducing clinical pharmacology and clinical pharmacy.

Afghanistan, Egypt, Iraq, Pakistan, Saudi Arabia, Sudan and Tunisia organized in-service training courses and workshops on improving prescribing and dispensing practices for professional and mid-level medical staff. Nongovernmental organizations in Afghanistan, Pakistan, Sudan and Somalia supported essential drugs activities mainly by conducting training courses on rational use of drugs.

An intercountry university workshop on introduction of essential drugs and of rational prescribing concepts into university curricula was held in Jeddah, Saudi Arabia, in March 1995. Participants from the United Arab Emirates also attended this workshop.

Support was provided to Afghanistan, Egypt, the Islamic Republic of Iran, Lebanon, Pakistan and Sudan to enable them to participate in a training course on problem-based teaching of pharmacotherapy developed for schools of medicine, held in Groningen (The Netherlands) in August 1995.

Establishment of national drug information systems. Support was provided to countries for the establishment of national drug information centres to promote the rational use of drugs and the distribution of reliable, unbiased drug information.

WHO provided Member States with various publications on drug information, such as the Eastern Mediterranean Region Drugs Digest (published by EMRO), WHO Pharmaceutical Newsletter, WHO Drugs Information and the Essential Drugs Monitor.

Member States were encouraged to update and publish regularly their national drug formularies. Afghanistan was drafting its national formulary.

Information, education and communication. All Member States of the Region have the major problem of poor communication between health professionals and patients and irrational prescribing and dispensing at all levels of health care as well as self-medication. Sudan was actively involved in information, education and communication (IEC) activities for schoolchildren and adults to increase public awareness of drug use. Tunisia was in the process of developing IEC activities for the general public.

Promotion of regional self-sufficiency in essential drugs and vaccines 

The availability of drugs could be increased by achieving self-reliance in the manufacture of drugs. During 1995, Iraq received extensive support in rehabilitating its local drug production capability by obtaining necessary supplies and raw materials. Training was provided to Egypt in pharmaceutical production.

Efforts to strengthen production of high quality vaccines in the Region continued throughout 1995, particularly in Egypt, the Islamic Republic of Iran and Pakistan, whose national authorities are the main vaccine producers in the Region.

In Egypt, a workshop was held in March 1995 to review all the studies carried out for almost three years on various aspects of vaccine production, quality assurance and quality control. The workshop made several recommendations, and WHO, UNICEF and USAID are closely following the implementation of these recommendations with the government of Egypt.

Extensive efforts continue in Pakistan in developing quality assurance of the vaccine production. In addition, WHO has provided supplies and equipment worth nearly US$500 000 to enhance national capabilities to produce poliomyelitis vaccine. Similar support was extended to the Islamic Republic of Iran, in particular equipment to enhance DPT vaccine production.

EMRO continues to emphasize the need for independent national quality control authorities in all countries of the Region, in particular in those producing vaccines.

3.4 Quality of care and health technology

Ensuring quality, safety and efficacy of drugs and biologicals 

National quality assurance systems. Sustaining the mechanisms of quality assurance is an integral part of an NDP, and emphasis was placed on activities such as updating drug legislation and regulations, implementing good manufacturing practices (GMP), as well as good laboratory practices (GLP), good storage practices (GSP), strengthening national quality control and drug inspection systems.

Since 1994, UNDP, in collaboration with WHO, has been implementing a project on developing the national quality assurance system of the Syrian Arab Republic.

Establishment of a legal framework for GMP. Lebanon, Sudan and Yemen updated their drug legislation and regulations, as well as good manufacturing practices rules.

In line with the global initiative to combat the import, export and smuggling of spurious, counterfeited or substandard pharmaceutical preparations, many countries in the Region were in the process of implementing guidelines related to the WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce.

Ensuring drug quality. Regulatory enforcement is dependent on the existence of an effective pharmaceutical inspectorate system and an adequate quality control laboratory. During 1995, Jordan, Pakistan and Sudan conducted national seminars for drug inspectors on drug quality assurance issues in the field of drug manufacturing. Fellowships were provided to strengthen drug inspection to Egypt, Jordan, the Libyan Arab Jamahiriya and Palestine.

Quality control of drugs. A number of countries received technical assistance, material support or training in various aspects of drug quality control. Lebanon was assisted in the preparation of a comprehensive plan for establishing a national drug quality control laboratory. Tunisia improved its drug control capacity by moving to a newly constructed building. A review was made about the quality assurance system in the Libyan Arab Jamahiriya. Sudan was rebuilding its capacity in drug quality control. Yemen received additional support to complete the establishment of various sections of the national drug quality control laboratory. Egypt, the Islamic Republic of Iran, Kuwait, Saudi Arabia, Sudan and Tunisia received training or technical assistance in conducting bioavailability/bioequivalence or stability studies.

Quality control of biologicals. Egypt, the Islamic Republic of Iran, Jordan, Pakistan and Tunisia were in the process of improving and maintaining adequate facilities for vaccine production and quality control. Technical assistance, training or material support was provided.

A consultative meeting on quality assurance of vaccines involving vaccine production countries was held in Pakistan in July 1995.

Promotion of appropriate traditional medicine 

Traditional medicine

During 1995, the regional Traditional Medicine Programme developed guidelines for the formulation of national policies for traditional herbal medicines. A format was developed for drafting monographs on traditional herbal medicines included in the regional core list of medicinal plants.

Member States were encouraged to develop their national quality assurance systems for the medicinal plants industries in their countries.

Egypt and Pakistan were provided support in their operational research studies on the use of herbal remedies.

A consultative meeting on the rational use of traditional medicines was held in Cairo, Egypt, in April 1995.

Development of health care quality assurance system 

Quality assurance of PHC received special attention during 1995. A working paper was presented to the nineteenth meeting of the Regional Consultative Committee held in the Regional Office on 25-26 May 1995, and the subject of quality assurance of health care was also on the agenda of the Forty-second Session of the Regional Committee held in Cairo in October 1995. It is gratifying to note that quality assurance was included in the proposed programmes of collaboration for 1996-97 biennium by many countries.

Table 3.3 summarizes the situation of various activities in relation to quality promotion, monitoring and improvement in the Region.

In Saudi Arabia, the programme was implemented in all PHC centres with the PHC Department in charge of all promotive activities in the Kingdom. In addition to this, several hospitals were involved in promoting their quality services through an accreditation system.

In Cyprus, PHC quality has a cost-effective rationale through a proposed national health insurance scheme yet to be developed.

In Lebanon, a few private hospitals were using quality assurance and, through it, mediating with the Ministry of Health for a catchment area capitation scheme. In such a scheme, each resident of a catchment area pays a mandatory flat fee and receives a full range of health care in return. This scheme has some similarity to "health management organization" experience.

Health laboratory technology support 

WHO continued to support countries of the Region in establishing and upgrading their national networks of health laboratory services in a harmonious and integrated manner, with a proper referral system and with emphasis on the peripheral level in support of primary health care. Continuous improvement of health laboratory services is one of the Regional Office's top priorities, as it is a way of meeting the requirements of providing support to medical care, epidemiological surveillance and environmental monitoring.

A regional plan of action was formulated by the directors of health laboratory services in the Region at a meeting in Rabat, Morocco, in November 1988, and amendments were made to the plan at a further meeting in Nicosia, Cyprus, in June 1994. Following these meetings, countries in the Region continued to improve their microbiological facilities in health laboratory networks and to establish basic virology units within their laboratory departments. The aim is to strengthen the role of health laboratories in disease prevention and control by ensuring disease detection and early identification of epidemics. Health laboratory facilities need to be improved in order to offer services to the Vaccine Preventable Diseases Control and Immunization Programme (VPI). In order to help improve the microbiological services and enhance the establishment of an appropriate referral system, the Regional Office prepared technical guidelines on the collection and transportation of microbiological specimens.

Difficulties were encountered in some countries that were either affected by prolonged United Nations sanctions or civil war.

The upgrading of health laboratory services continued to be based on the regional plan of action for health laboratory improvement and establishment of quality assurance programmes. Emphasis was laid on continuing education programmes and supervision, which are essential to maintain competency and acquire new skills as technology develops. The Regional Office awarded fellowships covering different disciplines of health laboratory sciences and supported national and intercountry training courses and workshops. Attention was also paid to the importance of interaction between "performers" of laboratory testing and "users" of laboratory results, as well as proper utilization and cost-consciousness, with improved test-requisitioning behaviour. The role of medical schools was considered and emphasized during the visits of WHO staff to countries and at intercountry workshops.

In order to enhance the developmental process, methods were standardized and catalogues of test availability compiled, or were being compiled in many countries, during 1995. Diagnostic manuals in national languages, especially for peripheral and intermediate levels, were prepared in a few countries. Interruption of services due to lack of reagents is a problem for many countries, and to overcome the problem, the Regional Office continued to promote and support the attempts by nine countries in the Region to produce reagents locally, especially simple reagents. Assistance was provided to a few others to procure reagents.

Quality assurance continued to be a top priority. Remarkable national efforts were and are being made to establish and upgrade quality assurance programmes in 16 countries in the Region. Ten countries were participating in the International External Quality Assessment Scheme of different disciplines of laboratory medicine. The Regional Office continued to support these national efforts by all means, including the involvement of international scientific organizations, local and overseas training and assignment of WHO consultants. The Regional Office recognizes that health laboratory management is an essential element of quality assurance and, therefore, supports the upgrading of managerial skills of health laboratory staff.

The reference laboratory in Teheran, the Islamic Republic of Iran, was nominated as a regional training centre for quality assurance in health laboratories. This centre is twinned to one of the international institutions, namely the Institute for Standardization and Documentation in Medical Laboratories (INSTAND) in Germany. The Regional Office assisted in setting up a workshop in the reference laboratory in Teheran to train trainers in quality assurance in health laboratories on clinical chemistry, microbiology, immunology and haematology.

EMRO and INSTAND agreed to establish a three-week training course on quality management and quality assurance in Germany in order to contribute to the development of quality assurance programmes in developing countries.

A number of health laboratories in the Region were twinned with well-known laboratories in Europe: the Poisons Control Centre, Tunis, Tunisia, with the Poisons Control Centre, Brussels, Belgium; the Reference Health Laboratory, Teheran, the Islamic Republic of Iran, with INSTAND; and the Salmaniya Medical Centre Laboratory, in Manama, Bahrain, with the Medical Laboratories, Karolinska Hospital, Stockholm, Sweden. Other similar arrangements are under way.

One of the activities that received special attention during the year was the strengthening of poison control centres. An intercountry seminar on setting up of poisons control centres and the use of the INTOX package (developed by the International Programme on Chemical Safety, IPCS), was conducted in Hammamet, Tunisia, from 6 to 9 June 1995. The seminar was attended by representatives from 15 countries, at which the present situation was reviewed. Different aspects of establishing and strengthening of poisons control centres were presented and discussed. Recommendations and a plan of action for developing national poisons control centres were formulated.

Surveillance of antimicrobial resistance is one of the important elements of the regional plan to address emerging diseases. A consultation on establishing a regional network on resistance to antimicrobial agents was held in the Regional Office, Alexandria, from 19 to 23 November 1995 at which guidelines on antimicrobial resistance surveillance were prepared. This consultation was held after a situation analysis followed by designation of national focal laboratories in 18 countries to be part of the regional network. (The establishment of such a network is included in the regional plan formulated by the directors of health laboratory services at their meeting in Nicosia, Cyprus, in 1994.)

Another consultation on drug interferences in medical laboratory testing was held at the Regional Office from 17 to 21 December 1995. One result of this consultation, will be a manual entitled, Unexpected results in laboratory medicine: Analytical interference.

In order to support the developmental process in laboratory services, the Regional Office continued its efforts to prepare manuals and guidelines on various priority areas. The following manuals were under preparation: Selection of basic equipment for laboratories with limited resources; Unexpected results in laboratory medicine: Analytical interference; and Guidelines on antimicrobial resistance surveillance.

Health imaging technology support 

Provision of film-badge services and thermoluminescent dosimetry to countries of the Region, in collaboration with the International Atomic Energy Agency and WHO headquarters, continued during the year. The Regional Office continued to emphasize the needs for countries to develop their capabilities in radiation protection and its support in this direction.

Ensuring safe blood and blood products 

The development of blood transfusion services in the countries of the Region was continuing according to regional and country-specific plans of action. The activities that were being strengthened through a WHO/AGFUND collaborative project aim at the provision of safe blood, blood components and blood products, based on voluntary, regular, non-remunerated blood donations, without undue pressure or inducement. An evaluation carried out showed that most countries continued to make significant progress towards achieving targets established in the regional plan formulated by the directors of blood transfusion services at their meeting in Nicosia, in 1991, and amended in Amman in 1993 and Tunis in 1995. This development took into account the training of personnel, donor recruitment and donor motivation, ensuring appropriate collection and screening, as well as appropriate use of blood products, quality assurance, technology of separation of components and local production of reagents. The two regional training centres in Amman and Tunis continued to play an important role in this field.

An intercountry workshop on transfusion medicine (appropriate use of blood, blood components and blood derivatives) took place in Amman, Jordan, from 12 to 16 March 1995. The general objective of the meeting was to develop criteria for the best practice in the utilization of basic blood components that are feasible and adapted to the local needs on capabilities of countries in the Region to improve the quality and safety of transfusion practice. Trends in transfusion medicine were reviewed. The workshop was attended by participants, mainly users of blood and blood derivatives, from 12 countries.

Another workshop on distance learning materials for safe blood and blood products was held in Amman from 20 to 24 March 1995. The workshop was attended by 21 participants from 13 countries. The overall objective of the workshop was to assist national blood programmes to establish distance learning programmes in blood safety in order to strengthen and expand the training for the staff working in blood transfusion services and hospital blood banks. The participants developed a broad plan of action and scheduled the establishment of national distance learning programmes in blood safety.

In order to support the developmental process in blood transfusion services, the Regional Office continued its efforts to publish manuals and guidelines. In addition to those brought out previously, the following were under preparation: Microbiological aspects of blood transfusion; and (in collaboration with WHO headquarters) Establishing distance learning on blood safety.

The following blood transfusion centres were twinned: the Blood Transfusion Centre, Tunis, Tunisia, with the Red Cross Laboratory, Berne, Switzerland; and the Blood Transfusion Centre, Amman, Jordan, with the Blood Transfusion Centre, Groningen, The Netherlands. The two centres in Jordan and Tunisia were designated as WHO collaborating centres for transfusion medicine.