This report focuses on the major work that has been undertaken in the past year in regard to the strategic priorities in the WHO Eastern Mediterranean Region that were endorsed by the WHO Regional Committee for the Eastern Mediterranean in 2012. These are: health systems strengthening towards universal health coverage; maternal and child health; noncommunicable diseases; communicable diseases, particularly health security; and emergency preparedness and response; as well as WHO management and reform. The report also reflects some of the very great challenges facing the Region at this time, challenges which have, in some areas, created new demands to maintain the pace of progress and imposed competing priorities. I am pleased, nevertheless, to highlight the important milestones that have been achieved in the core areas.

A major priority, early in 2013, was an initiative, in collaboration with United Nations partners, UNICEF and UNFPA, to accelerate progress towards achieving Millennium Development Goals (MDGs) 4 and 5, which concern reducing child mortality and improving maternal health, respectively. We called the initiative “Saving the lives of mothers and children” because this was exactly what we wanted to achieve. A high-level meeting in Dubai, attended by ministers of health, higher education and planning, among other stakeholders, resulted in the Dubai Declaration, which was subsequently endorsed by the Regional Committee and which provided a guide to the way forward for all countries. WHO then worked with nine countries where action was considered a priority to develop comprehensive acceleration plans and work was started to fund and implement these.

The acceleration plans are inevitably ambitious and some of the nine countries may not be able to achieve full implementation and meet the MDG targets. Nevertheless, they give those countries a better chance of ending 2015 with positive progress to show, and of entering the post-2015 agenda with renewed confidence and commitment. In order to initiate immediate action and to kick start implementation of the country road maps, seed funding was provided to the nine countries from WHO resources during the second half of 2013.

With this initiative, the lives of many more mothers and children will have been saved. However, the level of achievements made will undoubtedly depend to a great extent on the political commitment of governments and their ability to translate this commitment into concrete action. Solidarity and support from other countries and partners in the Region will remain crucial.

The Regional Committee, having identified universal health coverage as the overarching priority for health systems strengthening in 2012, endorsed a regional strategy and road map in 2013. Universal health coverage, with its emphasis on equity and quality, is now the umbrella for all our work in health systems. The current situation in the Region with regard to equitable access to health care of acceptable quality varies widely among countries. Gaps exist in every country and so every country has important work to do to improve such access and promote health. Our aim is demonstrable improvement in the three key dimensions required for universal health coverage – financial risk protection, service coverage and population coverage – as well as in prevention and health promotion services. The road map outlines, among other things, what countries can do to reduce direct out-of-pocket spending on health care by citizens, and to adopt a multisectoral approach by engaging relevant stakeholders. By the end of 2013, a regional framework for action was also in place to guide countries on the steps needed at country level, and several countries have now embarked on a path forward. This is solid progress and I look forward to seeing further development in the coming year.

Two other significant milestones were achieved in health systems strengthening, in the area of health information. Health information systems are weak and fragmented in many countries and there are major gaps in all countries. We have adopted a practical approach to strengthen health information systems in the Region by focusing on three key components: monitoring of health risks and determinants, monitoring of health status including morbidity and mortality, and assessing health systems performance. A core list of indicators covering these three key components has been developed through intensive discussions with representatives from relevant sectors of Member States and will be presented in final form to the Sixty-first Session of the Regional Committee. Based on in-depth analysis of the current status in reporting for each of the core indicators, a regional strategy to address gaps and build national capacity will also be presented for review and approval during the Regional Committee.

Rapid and comprehensive assessments of civil registration and vital statistics, conducted in all Member States in 2013 showed major gaps and weaknesses. Most countries are not reporting accurate and complete cause-specific mortality statistics which are key for assessing health status and monitoring international commitments. Working closely with countries and regional partners, a regional strategy to strengthen civil registration and vital statistics was developed jointly with countries and other stakeholders and was endorsed by the Regional Committee.

Together, these two initiatives not only lay the foundation for stronger national health information systems but, if pursued and made full use of in countries, will enable better decision-making and strengthen national planning and monitoring of health development.

Progress in other areas was slower but important groundwork was laid for developing comprehensive guidance for countries in public health law, such laws being outdated in most countries, as well as in health workforce development, a strategic approach to family practice, better access to essential medicines and technologies, and engagement with the private sector. Considering the major role the private sector plays in providing health care in the Region, it is becoming crucial not only to ensure that appropriate governance and oversight of the private sector are in place, but also to involve it in supporting and implementing public health policy and achieving universal health coverage. At the same time, preparatory work has been done to review regional and international experiences and develop guidance for countries in strengthening the integration of prevention and management of noncommunicable diseases and mental health disorders into primary health care. Two major intercountry meetings will be organized for this purpose in 2014.

Prevention and control of noncommunicable diseases is absolutely crucial in our region, where the epidemic of cardiovascular disease, cancer, diabetes and chronic respiratory disease is rapidly increasing the toll of early death and has already overwhelmed many health systems. Having established a regional framework for action on noncommunicable diseases in 2012, with very clear and targeted outcomes based on the United Nations Political Declaration of 2011, the focus switched to putting this into action.

Not enough is being done by countries in reducing risk factors like tobacco use, unhealthy diet and physical inactivity. In order to help Member States in scaling up, much of the work done in 2013 was to provide concrete guidance to policy-makers in implementing the proven measures , especially the ‘best buys’ interventions. Technical guidance on salt and fat intake reduction was developed, and several countries have already started implementing the guidance. This can be expected to have a marked impact on population health.

I am hopeful that a similar consensus can be achieved on a comprehensive multisectoral approach to improving the diets of children. The Region needs to step up action on physical inactivity, for all age groups; 2013 witnessed extensive preparation for a comprehensive multisectoral forum on physical activity, held in February 2014. Attention was also focused on advocacy and providing technical support to countries in implementing the proven tobacco control measures including tobacco taxation but, again, progress has been slow. Two countries, Morocco and Somalia, have still not ratified the WHO Framework Convention on Tobacco Control.

Communicable diseases dominated the public health headlines in 2013. Polio outbreaks in Somalia and the Syrian Arab Republic, and continuing circulation of poliovirus in Afghanistan and particularly Pakistan, were serious setbacks to the eradication programme. However, in a welcome show of unity and solidarity, Member States pulled together and agreed on action. The Regional Committee’s declaration of the spread of wild poliovirus an emergency for the Region and the development of the regional action plan facilitated positive commitment and effective action in the short-term to successfully contain the outbreaks. At the same time, the work on the establishment of the Islamic Advisory Group has resulted in strong support from the Islamic community to improve advocacy to reach children in security-compromised districts where militants have banned immunization and have intimidated and attacked health workers. The regional polio eradication programme witnessed considerable strengthening in terms of expertise and capacity to respond, with a technical surge unit established in Jordan. Nevertheless, while we continue to work intensively with Afghanistan and Pakistan in reaching children in security compromised areas, polio eradication will be difficult to achieve without political solutions to a situation which has, in 2014, led to polio being declared a public health emergency of international concern.

The emergence of the new Middle East respiratory syndrome coronavirus (MERS-CoV), which gathered momentum throughout 2013 and into 2014, vividly highlighted the value of the International Health Regulations (2005). The priority given, and actions taken, by countries hit by MERS-CoV in investigating cases and in acting to address the issues involved are to be commended. This, together with the intensive and highly coordinated technical support provided by the three levels of WHO, has set an example that bodes well for the future of health security in the Region. Now, all Member States must focus on fulfilling the core capacity requirements for implementation of the Regulations by June 2016.

Also dominating the headlines in 2013 was the humanitarian situation, with unprecedented numbers of people needing humanitarian assistance across the Region. By the end of the year an estimated 42 million people in over half the countries were affected by natural hazards and political conflict. WHO established an emergency support team in Jordan to provide a single consolidated response to the crisis in Syrian Arab Republic and this has since been reviewed and expanded to provide a more effective response. The humanitarian situation in the Region is a huge challenge for public health, for ensuring basic health services and for long-term rehabilitation of health systems. Not only are local communities and the displaced at risk, but health and humanitarian aid workers and health facilities are increasingly targeted also. Lack of funding remains a key challenge in ensuring an effective health response in emergencies but there are positive actions that can be taken to strengthen national preparedness and response. These include the adoption of a national disaster risk management strategy that addresses all hazards and covers all sectors. This has been a successful approach for many countries in the world but few countries in the Region have such a strategy in place and I very much hope we can move towards achieving this.

Within the context of WHO reform, we made concerted efforts to address organizational impediments to WHO performance. Structural review and reorganization continued, at both regional and country level, in order to strengthen our technical work, and administrative measures were put in place to strengthen managerial performance and compliance with rules and regulations. Ensuring the right staff are in the right place at the right time is a particular challenge. The ability to attract and retain the qualities and competencies the Organization needs in the current demanding environment has been compromised by the security situation in the Region. This is an issue that we are addressing but that needs more considered solutions than are currently on the table.

Reinforcing technical cooperation with countries is a key component of the WHO reform endorsed by the World Health Assembly in 2013. One major achievement in this regard was the shift from conventional planning to a bottom-up planning approach for the biennium 2014–2015. The Region pioneered this approach during the second half of 2013 in close and intensive consultation with Member States at the highest policy-making level. We focused on the key priorities of the 12th General Programme of Work in budgetary planning. An average of ten priority programmes was targeted for the biennium which resulted in more resources for each of them and, hopefully, real impact for the selected activities. The number of work plans resulting from this exercise was nearly half that of the 2012–2013 biennium for the whole region, including country programmes. The intensive collaborative work conducted with Member States for the biennial Joint Programme Review and Planning Missions, previously conducted over a few days, was spread over several months, culminating in two-day high-level visits to countries for strategic discussion. I myself personally conducted five of these visits, and the rest were conducted at a minimum of Director level.

Overall, I am able to report good progress in specific areas of WHO’s work with Member States in 2013 through innovative approaches and scaling up action, particularly in areas of strategy development, technical guidance in translating plans into specific interventions, as well as laying the groundwork for moving forward. At the same time, we and Member States together were often constrained by unprecedented crises and events on the ground, which not only led to slowing down of progress in some cases but inevitably, also, to diversion of attention and resources to other priorities. Throughout all our work, it is clear that positive public health outcomes are rooted in the wider context of social and political development. In every one of the strategic priority areas that I have touched on, the health sector is just one player. Universal health coverage, successful primary health care, prevention of risk factors and noncommunicable diseases, health promotion, health security and emergency preparedness and response all require partnership across government, and beyond government.

Special attention was given to this wider context in 2013 in many programmes. We sought to reach out to other sectors in government, for example in relation to moving forward on prevention of noncommunicable diseases where we have involved ministries of  planning, transport, education, foreign affairs, sport, interior and finance. A similar approach was followed in WHO’s work on strengthening health systems and health information. We sought to involve non-government players, from civil society, United Nations agencies and others. The regional strategy for the coming five years on health and the environment, endorsed by the Regional Committee, is a prime example of the multisectoral nature of public health. There is no substitute for clear long-term health goals articulated as part of long-term national development plans and addressed in coordination with all sectors and stakeholders, including civil society.

Finally, it is clear that many of the Region’s health challenges would be well served by stronger health advocacy, health diplomacy and constructive social and political debate. An increasing number of the health challenges we are seeing can no longer be resolved at the technical level only – they require political negotiations and solutions, at global, bilateral and national level. Health diplomacy is particularly important for our region because many of the development issues it faces relate directly to health, and because it is disproportionately affected by humanitarian crises. It is essential that, together, we continue to build awareness and capacity in health diplomacy in Member States.

Ala Alwan
WHO Regional Director for the Eastern Mediterranean