The life course approach
Promoting health across the life course addresses key influences on health such as family, social networks, social support, relationships, employment, income, health beliefs, and access to health care and health information. It cuts across all areas of WHO’s work including the health of women before, during and after pregnancy, and of newborns, children, adolescents, and older people, taking into account environmental risks, social determinants of health, gender, equity, and human rights. By identifying critical stages in the life course that influence health, opportunities for health promotion can be recognized and addressed along the continuum of care.
Maternal, reproductive and child health
In 2016, building on the achievements made through the implementation of maternal and child health acceleration plans in countries with a high burden of maternal and child deaths, WHO in collaboration with UNICEF and UNFPA focused on supporting Member States to address the main causes of maternal, neonatal and child deaths by adopting cost-effective, high impact interventions, prioritizing maternal and neonatal health quality of care, and strengthening the promotion of preconception care.
Technical support was provided to national efforts to develop or strengthen strategic plans for reproductive, maternal, neonatal, child and adolescent health. Strategic directions were determined and plans of action developed by all Member States who attended the intercountry meeting on the Every Newborn Action Plan (ENAP) in Amman, Jordan in April 2016. A regional workshop on promoting maternal and neonatal quality of health care was held in Morocco and attended by eight countries with a high burden of maternal and neonatal mortality. The participants were trained on using WHO tools to get a rapid overview of the situation at national and district levels, including a landscaping checklist and analysis framework. Plans of action for promoting the quality of maternal and neonatal health care were developed for implementation to begin in 2017.
Member States were supported to establish preconception care to improve the health outcomes of childbirth. WHO has identified evidence-based core and additional interventions and programmatic steps to facilitate efforts to develop preconception care in countries. In addition, country profiles were developed to foster national efforts in the prevention and management of congenital and genetic disorders.
To improve midwifery competencies in line with WHO norms, standards and guidelines, a national workshop on strengthening the Somali midwifery strategy was conducted with UNFPA in October 2016. The workshop helped in prioritizing the main gaps that need to be addressed to strengthen the Somali midwifery programme and integrate evidence-based interventions in the national midwifery care strategy. Similar activities are planned in Libya, Morocco and Tunisia to strengthen their national strategic frameworks for midwifery care.
A consultative meeting, conducted in collaboration with the Islamic Advisory Group, emphasized the role of religious leaders in raising awareness on issues related to reproductive, maternal and child health and immunization. A plan of action was developed focusing on breastfeeding, immunization, birth spacing, hygiene and sanitation, and care-seeking behaviour (especially for pregnant mothers).
A training workshop on strengthening family planning services through evidence-based guidelines and best practices, held in Tunisia, was attended by 18 Member States who developed national plans of action to ensure the provision of quality family planning services. Building national capacity in family planning is expected to contribute greatly to maternal and neonatal health protection and promotion. An expert consultation to identify core mental health interventions for integration in maternal, child and adolescent health service delivery platforms was held in December 2016.
In terms of child health, in-depth reviews of the integrated management of childhood illness (IMCI) were carried out in the Islamic Republic of Iran and Yemen and four success stories in implementation of IMCI in the Region were documented as part of a global strategic review. Innovative options for IMCI training were introduced to the Region through building the capacities of Member States in the computerized adaptation and training tool and distance learning. Core facilitators from seven targeted Member States were trained in newborn care at home. Member States were supported in the development of the newborn, child and adolescent health component of national reproductive, maternal, neonatal, child and adolescent health strategic plans. The managerial capacity of child health managers at national and subnational levels in Afghanistan was strengthened
WHO is providing technical support to Member States to maintain their commitment to reproductive, maternal, neonatal, child and adolescent health, building close partnerships with concerned United Nations agencies and key stakeholders, and mobilizing the resources required for universal health coverage of women and children.
Nutrition
Deficiencies of essential micronutrients such as vitamin A, iron, folate, zinc and iodine, continue to be widespread and have significant adverse effects on child survival, growth and development, as well as on women’s health and well-being. The regional prevalence of stunting, wasting and underweight is 28%, 9% and 18%, respectively. The countries with the highest burden of stunting are Afghanistan, Djibouti, Pakistan, Sudan and Yemen. However, many countries are on track to meet the 2025 target for stunting set by the World Health Assembly. The prevalence of overweight and obesity in adults in the Region is 27% and 24.4%, respectively, and 16.5% and 4.8%, respectively, in school age children, with the highest levels of obesity in Bahrain, Kuwait, Qatar and United Arab Emirates.
There remains a need in the Region for effective nutrition surveillance and monitoring and evaluation systems, essential for policy-making, accountability and effective programme implementation. Integrating nutrition within health systems is a challenge in many countries, particularly those where the population has limited access to health services including disease prevention, treatment and rehabilitation. Moreover, available financial resources are very limited. These issues are compounded in countries experiencing conflict and humanitarian crises.
Most Member States of the Region have now developed or reviewed national action plans in line with global WHO nutrition policies and strategies. More than 17 countries have also developed full or partial legal documents relating to the Code of Marketing for Breast Milk Substitutes, but implementation remains a challenge. In 2016, development of food-based dietary guidelines was expanded in the Region to include Afghanistan, Egypt, Islamic Republic of Iran, Lebanon, Oman, Qatar and Saudi Arabia. Egypt was the first country in the Region to conduct a landscape analysis on its readiness to accelerate action in nutrition as part of a global project supported by WHO and UNICEF.
Bahrain, Egypt, Jordan, Kuwait, Oman, Qatar and Saudi Arabia have made tremendous progress and are on track for the sustainable elimination of iodine deficiency disorders. In Afghanistan, Syrian Arab Republic and Yemen, WHO supported the establishment of health facility nutrition surveillance and the management of acute malnutrition in therapeutic feeding centres and through mobile nutrition teams. Pakistan, Somalia, Sudan and Yemen became members of the Scaling Up Nutrition (SUN) Movement, providing a great opportunity to galvanize action to ensure country progress in their efforts to reach the targets of the SDGs, particularly SDGs 1, 2 and 3. There is now supplementation and food fortification with essential micronutrients in nearly all countries of the Region.
The development of a roadmap for action to address nutrition-related noncommunicable disease risk factors such as through salt and fat intake reduction is a priority for the Region. WHO will continue to support the adoption and implementation of the United Nations Decade of Action on Nutrition (2016–2030) and encourage coordinated and comprehensive implementation of strategies by Member States to address the double burden of malnutrition. WHO is working with Member States to develop a framework of action for scaling up work on nutrition with more focus on cost-effective interventions and to support the establishment of national targets and monitoring national action plans.
WHO will continue to provide expertise at country level in specialized areas such as the adoption of legal instruments that ensure national application of international norms and standards and evidence-based interventions, engage in capacity-building for high-burden countries on prevention, management and treatment of malnutrition and support national training on healthy growth monitoring and the prevention, management and treatment of malnutrition for children under five years of age.
Health of special groups
In 2016, WHO continued to provide support to countries on ageing and health, focusing on developing policies and strategies that foster healthy and active ageing, delivering integrated person-centred services that respond to the needs of older people, and strengthening the evidence-base and monitoring and evaluation mechanisms to address key issues relevant to the health of older people. However, the prevailing humanitarian crises and limited financial resources in many countries has meant that only seven Member States have allocated funds this biennium to support the implementation of relevant activities.
WHO worked closely with local authorities in United Arab Emirates in the area of age-friendly cities and supported the organization of the Fifth Forum for Elderly Services held in Sharjah in September. Sharjah has since been declared an age-friendly city, part of the global network of age-friendly cities.
WHO will continue to support implementation of the Global strategy and action plan on ageing and health 2016–2020 in countries. Effective partnership and coordination among concerned stakeholders will be needed to overcome the limited resources in this area. The unmet needs of older persons need to be at the centre of relief efforts and programmes in countries in emergency situations.
Violence, injuries and disabilities
The Eastern Mediterranean Region has the second highest road traffic fatality rate (19.9 per 100 000 population) among WHO regions. Middle-income countries account for the vast majority of deaths, while the Region’s high-income countries have an overall fatality rate that is more than double the average rate of high-income countries globally. Efforts have been undertaken in countries to implement proven cost-effective interventions, but these are not pursued within a whole safe system approach, limiting their effectiveness. The global road traffic injury-related targets of the Decade of Action on Road Safety 2011–2020 and the SDGs (targets 3.6 and 11.2) provide important opportunities to build on existing country efforts to strengthen collective action for road safety in the Region.
In 2016, WHO continued to play its normative technical role through its work on different aspects of road traffic injury prevention and control from data to care. Expert consultations were organized to seek the input of key regional and global experts on strengthening action for road traffic injury prevention and emergency care in the Region. Together with Johns Hopkins Bloomberg School of Public Health, a regional road safety report was developed comprising an in-depth analysis of the burden of road traffic injuries in the Region and related risk factors, with proposed recommendations for countries. Implementation of a standard methodology for estimation of the cost of road traffic injuries in the Region was initiated in two countries (Egypt and Tunisia) and assessments of existing emergency care systems were completed in the Islamic Republic of Iran, Libya and Tunisia. The participation of countries of the Region in global road safety events was supported and a regional meeting held on essential services for emergency care at the primary and first level referral hospital levels. Work continues to integrate injury prevention and control in ongoing initiatives. The WHO child injury prevention policy assessment tool was piloted in the Islamic Republic of Iran as part of a global exercise in different WHO regions.
In the area of violence prevention, coordination continued with concerned United Nations agencies and the Arab League to ensure consistent messaging and sustainable interagency coordination of technical support. Mapping of health sector protocols and guidelines to address violence against women in countries was completed and focused support was maintained to strengthen the health sector response to gender-based violence in Afghanistan and Pakistan. In collaboration with the national family safety programme, Saudi Arabia, the WHO child maltreatment prevention readiness assessment tool was implemented in GCC countries.
The WHO Regional Committee for the Eastern Mediterranean issued resolution EM/RC63/R.3 on improving access to assistive technology, a landmark in the area of disability and rehabilitation. As a result, a rapid situation assessment of assistive technology provision at a system level in countries of the Region was initiated. The WHO/World Bank model disability survey was started in Pakistan and Qatar and support was provided to Oman and Sudan to develop and implement disability action plans, and to the Syrian Arab Republic to strengthen the delivery of rehabilitation services.
The average prevalence of blindness in countries ranges from 0.5% to 1.5%, with Afghanistan, Egypt, Djibouti, Somalia and Yemen having the highest prevalence. The WHO global action plan on universal eye health 2014–2019 aims to support efforts by Member States to achieve a measurable reduction of 25% (compared to 2010) of avoidable visual impairment by 2019, with special focus on developing national action plans in line with the WHO framework for action for strengthening health systems. During 2016, Afghanistan, Lebanon and Yemen developed and revised their five-year national action plans on eye health in line with the global action plan, making a total of 16 countries who have so far developed national action plans in the Region. A database was developed based on global action plan indicators to monitor the implementation of eye health national action plans in the countries of the Region, while country profiles were updated on eye and ear health, and trachoma mapped in endemic countries (Afghanistan, Egypt, Pakistan, Somalia, Sudan and Yemen).
Assessments were undertaken on the status of eye care services in seven countries and diabetic retinopathy and diabetes management systems in eight. WHO continued to build the capacity of countries to integrate eye and ear health into primary health care and national health information systems, and to promote evidence-based advocacy and planning for eye and ear health as part of the overall health system. This approach is now being adopted in most countries in the Region.
The prevalence of disabling hearing loss in the Region is estimated at between 2.7% and 4.4%, with adults accounting for 91% and children 9%. In approximately 50% of adults and 60% of children, hearing loss is avoidable through prevention and early detection. In 2016, support was provided to eight countries (Bahrain, Djibouti, Jordan, Kuwait, Morocco, Oman, Qatar, Saudi Arabia) that have undertaken surveys to estimate the prevalence of hearing loss, have national plans for ear and hearing care in varying stages of development and implementation, and have screening programmes to detect hearing loss for newborns and school children.
Major challenges that continue to impede effective action to address violence, injuries and disabilities include insufficient financial and human resources at regional and country levels. In terms of road safety and injury prevention, efforts are fragmented in the absence of a whole safe system approach, while coordination and multisectoral action are not based on sustainable mechanisms. Enforcement, implementation and evaluation of policy and legislative frameworks are insufficient, while data systems are weak and fragmented with widespread under-reporting. Significant gaps continue to exist in post-injury emergency and trauma care and rehabilitation services. In terms of disability, challenges include finding space for eye and ear health indicators in national health information systems, and integrating and delivering primary eye and ear care in primary health care. Contextual challenges also persist, including crisis and post-crisis situations in many countries.
Health education and promotion
Insufficient physical activity is one of the 10 leading risk factors for global mortality, causing some 3.2 million deaths each year. Globally, the Region has the second highest prevalence of physical inactivity (31%), although with wide variation across the Region. In 2016, there was a focus on building national capacities in the development of national multisectoral plans of action on physical activity and plans for social marketing and mass media campaigns. A survey assessing national capacity to develop and implement physical activity policies and programmes was expanded from 12 to 16 countries. In an effort to curb the rising levels of physical inactivity, 48% of countries in the Region implemented at least one national public awareness programme on physical activity in 2016. The biggest challenges facing countries are their limited capacity to mobilize non-health sectors to implement World Health Assembly recommendations on physical activity and the lack of coordination between different sectors.
Regionally, progress in implementing the recommendations on controlling unhealthy food in children has been slow, despite clear commitment by countries, while expenditure on promoting energy-dense diets has grown considerably in recent years. Only 19% of countries in the Region have implemented WHO recommendations on the marketing of foods and non-alcoholic beverages to children.
Following on from the concerns expressed by the ministerial panel discussion on the prevention of noncommunicable diseases held during the Sixty-first session of the WHO Regional Committee for the Eastern Mediterranean in 2014 and the forum on addressing unopposed marketing of unhealthy foods and beverages to children held in Jordan in 2015, an expert meeting was held to finalize a regional roadmap to address unopposed marketing of unhealthy foods and beverages to children and a survey on food marketing was initiated.
Social determinants of health and gender
In 2016, there was regional participation in the global technical meeting on measuring and monitoring action on the social determinants of health in response to the Rio Political Declaration on Social Determinants of Health. The meeting, held in June in Ottawa, Canada, focused on harmonization of monitoring systems and review of the core indicators proposed by WHO. Also in 2016, the Health-in-All-Policies (HiAP) training manual was translated into Arabic to maximize its use in the Region, and preparations were begun for a regional multisectoral consultation on HiAP. An in-depth assessment of the social determinants of health was initiated in Oman as a first step in developing national and subnational action plans.
Regional adaptation, piloting and implementation of WHO tools to support the integration of gender, equity and human rights in national policies and planning was carried out in 2016. Close cooperation continued with concerned United Nations agencies and the Arab League to promote health and human rights and gender in the Arab world, while health protocols and guidelines on gender-based violence were piloted in Afghanistan and Pakistan, involving the adaptation of WHO instruments, capacity-building and health care facility assessment.
Ongoing challenges include insufficient dedicated human resources and funding at regional and country levels, inadequate national capacity, and the security situation and ongoing conflicts in many countries of the Region.
Health and the environment
Environmental health is an area of growing importance for the Region, with environmental risk factors, such as air, water and soil pollution, chemical exposures, climate change and radiation, contributing to more than 100 diseases and injuries. The health impact of environmental risks is reflected in both communicable and noncommunicable diseases in all countries in the Region, with environmental hazards responsible for about 22% of the total burden of disease. The top environmental health-related causes of death in the Region are heart disease, stroke, respiratory infections and diarrhoeal diseases, targeting the most vulnerable, including children and the elderly. It is estimated that more than 850 000 people die prematurely every year as a result of living or working in unhealthy environments – nearly 1 in 5 of total regional deaths, with 72% of these the result of noncommunicable diseases and injuries.
About one half of environmentally-caused premature deaths are attributable to air pollution, with the rest due to chemical exposures, lack of access to water and sanitation, and other environmental hazards. Air pollution with particulate matter reaches alarming levels in many cities of the Region, with about 98% of the urban population breathing air exceeding WHO safe levels by up to 12-fold, causing about 400 000 annual deaths.
In 2016, national plans of action to implement the regional strategy on health and the environment and its related framework for action (2014–2019) were developed and adopted by many countries, and WHO was instrumental in the finalization of the strategy on health and the environment in the Arab Region (2017–2030). All countries of the Region endorsed the global roadmap on the health impacts of air pollution on health, while 82 cities in 16 countries report their air quality data to a WHO database, improving burden of disease estimates and highlighting regional specificities, such as natural dust pollution. Status reports on water and sanitation were generated for all countries and country profiles on water, sanitation and health enablers issued for 11 countries.
The needs of the Region were reflected in several global and regional processes, including WHO drinking-water quality guidelines, guidance on managing radioactivity, and the global water, sanitation and health strategy. Development of a compendium of national standards on drinking-water quality is under way. Normative and technical support was provided to countries on drinking-water quality management and sanitation/wastewater use, and training provided on water and sanitation safety management and addressing chemical and liquid waste in health care facilities.
A draft regional plan of action for food safety was developed to enable countries to fulfil the recommendations of their national food safety assessments and national profiling in order to control risk and reduce the burden of foodborne diseases, including zoonotic diseases linked to food safety. A training workshop for improving food safety laboratory was conducted, and a regional guidance document on food safety laws and regulations completed. Technical support was also provided on chemical safety in the Region. To address the heath aspects of the Minamata Convention on Mercury, participants from 12 countries of the Region were trained on phasing out mercury in the health sector.
The impact of environmental risks and the lack of environmental health services on morbidity and mortality rates is exacerbated during emergencies. Addressing the environmental health aspects of emergencies requires WHO to work with all countries to invest in vulnerability and risk assessment, preparedness, response and recovery planning.
In 2016, capacity-building in the areas of water, sanitation and health, chemical safety, food safety and waste management was undertaken for emergency-struck and neighbouring countries. A technical training workshop on environmental health services in conflicts was conducted for Syrian health personnel and United Nations staff and a field assessment of the environmental health impact of the crises in the Syrian Arab Republic was carried out, resulting in a comprehensive report with practical recommendations. Technical support and emergency supplies were provided to countries to respond to cholera outbreaks, and to the Syrian Arab Republic for securing drinking-water sources and groundwater wells near health care facilities.
Health personnel and first responders were trained on chemical exposure and trauma care, and factsheets on chemical exposure made available in local languages for the countries in conflict. Technical support was also provided to help several countries in responding to air pollution emergencies, including (with the United Nations Environment Programme) an assessment of the health impact of an Israeli industrial zone on the Palestinian population.
Climate change poses serious, but preventable, risks to public health. In the Region, it is producing more frequent and more intense heat waves, floods, droughts and dust storms. Its effects are being seen in increasing mortality and morbidity rates, including airborne respiratory diseases, water and foodborne diseases, vector-borne diseases, malnutrition, heat stress and occupational injuries. The Regional Office was instrumentally involved in the preparation for 22nd session of the Conference of the Parties to the United Nations Framework Convention on Climate Change in Marrakesh, Morocco and the WHO Second Global Conference on Climate and Health in Paris, France. With the support of WHO, eight countries developed national profiles on climate and health, tackling vulnerability, adaptation and mitigation.