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Strengthening health systems for universal health coverage

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Universal health coverage

In 2016, the framework for action on advancing universal health coverage in the Eastern Mediterranean Region was updated. The framework provides a clear roadmap for Member States to transform their health systems to progress on the three dimensions of universal health coverage, and specifies the type of support that WHO and other development partners can provide.

In 2016, guided by the framework, five countries (Islamic Republic of Iran, Iraq, Pakistan, Palestine and Saudi Arabia) took concrete steps to review and reform their health systems in line with the goals of universal health coverage. In addition, Sudan finalized several specific health strategies to reform the health system and endorsed the Khartoum Declaration on universal health coverage in January 2017. The framework also influenced the development of a framework for action for universal health coverage in Africa, developed jointly with the World Bank, Japan International Cooperation Agency, the African Development Bank and others.

In 2016, the second round of the leadership for health programme took place, with 30 policy-makers and mid- and high-level managers from the Region taking part. The programme, developed in collaboration with the Harvard School of Public Health and the Graduate Institute of International and Development Studies in Geneva, aims to strengthen the leadership function of the ministries of health in the Region to pursue the health agenda, including universal health coverage.

Health financing

Functioning health financing systems are critical to achieve the goals of universal health coverage. Such systems are often compromised by insufficient public funding, lack of equitable financial protection and inefficient use of resources in the Region.

In 2016, WHO supported countries to identify ways to reform revenue raising, and pooling and purchasing arrangements. Attention focused on developing health financing strategies for universal health coverage. Nine countries were guided to develop their health financing strategies through capacity-building, in-depth analysis, experience-sharing and policy dialogue. Attention was also given to institutionalizing health accounting, with a focus on disease distribution. Training was provided to 16 countries on the system of health accounts 2011, including on estimating expenditure by disease groups. A new area of work was started to enhance alignment between public financial management and health financing, with a first assessment conducted in Sudan. Efforts were intensified to develop benefit packages for universal health coverage, as part of an ongoing collaboration with the Disease Control Priorities Network. A high-level policy forum was held to establish a region-specific list of highest priority interventions for countries to consider when developing their own essential health services packages.

In 2017, assessment of the health financing systems in the Region will continue in order to identify challenges and ways to tackle them. Development of universal health coverage packages and public financial management will also continue, with a focus on capacity-building and institutional development. Particular attention will be given to the health financing requirements of specific health programmes, including noncommunicable diseases, essential public health functions and emergencies.

Health governance and human rights

National health policies, strategies and plans guide a country to define its priorities for improving the health and well-being of its people and achieving universal health coverage. Ongoing efforts to evaluate the status of national health planning included an assessment of health policy and planning functions in the ministries of health in preparation for a workshop on health sector strategic planning. As part of the regional effort to encourage countries to adopt the Health-in-All-Policies approach to achieve the health-related Sustainable Development Goals (SDGs), a related workshop is being planned in collaboration with the Social Research Center of the American University in Cairo. A main focus of the 2030 Agenda is leaving no one behind. Efforts are therefore being made to reinforce health equity and human rights in WHO work as part of the actions to achieve the Sustainable Development Goals.

Weak health governance, accountability and transparency remain obstacles to strengthening health systems performance in the Region. In collaboration with the UNDP Regional Bureau for Arab States, the Regional Office is working to strengthen health system accountability and reduce the risk of corruption in the health sector. Additionally, a regional accountability assessment framework and capacity-building tool for enhancing accountability and governance functions of health systems has been developed. 

To strengthen national capacities to support health legislation and regulation, an introductory course on the role of law in health system strengthening in the Region was developed and delivered to experts from five countries. In addition, in collaboration with the O’Neill Institute, Georgetown University, 10 priority legal interventions for noncommunicable diseases were identified and policy briefs were developed to be shared with the countries. 

During 2017, focus will continue to be placed on adapting and applying the established know-how to the regional setting. Particular attention will be given to policy development and health legislation, capacity-building, and the integration of health equity and human rights in all policies and health programmes.  

Global health initiatives 

The global health initiatives collaborative work in the Region covers several areas: AIDS, tuberculosis and malaria, immunization programmes, maternal and child health, tobacco use, human resources, emerging diseases, nutrition, health promotion and health system strengthening. The Global Fund and Gavi, the Vaccine Alliance are the main institutions that provide substantial funding to eligible countries in the Region. Seven countries – Afghanistan, Djibouti, Pakistan, Somalia, Sudan, Syrian Arab Republic and Yemen – are eligible for Gavi support on immunization and health system strengthening, and 12 are eligible for Global Fund grants, including the seven supported by Gavi.

Protracted social and political unrest in most grant-recipient countries continues to be a major challenge. Insecurity in many places hampers access to social services with the health sector being the worst affected, and the loss of human capital has severely weakened health services and systems in affected countries. Furthermore, global health initiatives have created parallel systems that undermine the holistic approach for health system development, and the principles of external aid, such as ownership and harmonization, are not adequately applied.

In 2016, in collaboration with the Global Fund, regional training was conducted to strengthen the role of country staff in securing partnership with the Global Fund. In addition, joint appraisal missions to Gavi-supported countries were carried out to review grant implementation, identify challenges, assess grant management and propose priorities for 2017. 

In 2017, capacity development on an integrated approach for health system strengthening will be organized for relevant country focal points. The regional vision and strategy for strengthening partnerships for universal health coverage will be finalized. Support will be given to improving reports and records with a focus on country experiences with global health initiatives.

Health workforce development 

Tackling health workforce challenges remains a pressing priority in the Region. Overall health workforce shortages continue in addition to concerns about the quality, relevance and performance of health workers. The need for an adequate and competent health workforce is acknowledged as a critical element in moving towards universal health coverage and achieving the SDGs. 

To respond to the health workforce challenges in the Region, an action framework for health workforce development 2017–2030 has been developed and is being finalized to guide countries to enhance their health workforce. Capacity-building for health workforce governance was undertaken through a regional workshop organized in collaboration with the World Bank, and a health workforce planning and management workshop for Jordanian officials in Amman. 

In 2016, further efforts were made to strengthen medical education through implementation of the framework for action on reforming medical education. An expert consultation on health profession education allowed further dissemination of the framework, highlighted the priorities and outlined the way forward. A regional guide for the development of nursing specialist practice in the Region was prepared which explains a nurse specialist, the educational requirements for designating a nursing specialty and the necessary regulatory mechanisms. At the country level, the Council of Accreditation for Medical Colleges in Iraq launched its national standards for accreditation of medical education in August 2016.

The regional framework for strengthening nursing and midwifery in the Region 2016–2025 was finalized in 2016 and shared with ministers of health. The framework guided the development of the Iraq and Pakistan nursing and midwifery strategies, and the Somali midwifery strategy. 

A number of countries face protracted crises, which have led to shortages of health workers and jeopardized their safety and security. The remaining health workers have had to deal with the existing and emerging conditions, including mental health problems. A short course on mental health nursing in emergencies was developed with the first training provided in the Syrian Arab Republic in August 2016. The fellowship programme has continued to support countries to build national capacities in the five regional priority areas and 50 fellowships were awarded in 2016 in the Region. 

In 2017, WHO will continue to provide technical assistance to countries to develop strategies and plans to tackle health workforce challenges. These will take account of population needs and the dynamics of the labour market. Assistance will also be given to build governance capacity for implementation of health workforce strategies. Emphasis will be placed on strengthening the primary care workforce, especially a team approach in family practice. With the increasing involvement of the private sector in education and employment of the health workforce, health workforce regulation requires greater attention. Efforts will continue to tackle the health workforce challenges in countries with protracted crises so as to ensure access to care.

Essential medicines and technologies 

Within the context of health system development and universal health coverage, sustainable access to medical products (medicines, vaccines and medical devices) and health technologies is essential. To achieve this, countries should be supported to improve policies on health technology research, regulation, assessment and management. 

Member States are showing more commitment to increasing transparency and accountability in the pharmaceutical sector through the good governance for medicines programme. A subregional meeting was held in 2016 for countries who are currently developing policies and action plans to improve governance of medicines, Afghanistan, Egypt, Islamic Republic of Iran, Oman, Pakistan, Palestine, Sudan and Tunisia. The transparency evaluation reports for three of these countries have already been reviewed and published.

A survey on availability of essential medicines in the Region showed that shortages were increasingly frequent in most countries. Medicines in short supply are mostly products that are old, off-patent or difficult to formulate, or produced by a few or a sole manufacturer. Some of the reasons for shortages relate to production and marketing (e.g. lack of raw materials or fragmented markets), and others to characteristics of the supply chain system.

Countries were supported in the implementation of WHO’s global action plan on antimicrobial resistance. Planned training courses in 2017 will support the provision of reliable data on national consumption of antimicrobials, which is a prerequisite for understanding the epidemiology of antibiotic resistance.

Regional challenges in accessing controlled medicines for therapeutic use are wide-ranging and include regulatory, legal, policy, awareness and economic factors. The Regional Office is planning to develop a regional strategy to achieve balance in access to and regulation of controlled medicines in 2017.

Pakistan was supported to determine the scope of traditional/alternative treatment and to review the education system for traditional medicine. Technical guidance on intellectual property rights and their implications for research and development of medical products continued in 2016. A national workshop was organized in Egypt to discuss intellectual property rights and patency in Egypt, as well as legislation and law enforcement for counterfeit medicines.

Regulation of medical products, in particular medicines and medical devices, is a priority in countries of the Region. Through the WHO national regulatory authorities benchmarking tool, assessments of the regulatory capacity of Egypt, Iraq, Lebanon, Saudi Arabia and Syrian Arab Republic were conducted and performance gaps were identified. Accordingly, detailed institutional development plans for their regulatory authorities were developed. The Eastern Mediterranean Drug Regulatory Authority Conference was held in Tunisia in 2016 to enhance cooperation between regulatory authorities in the Region. 

A regional publication on developing regulation on medical devices and integrating it into the existing functions of regulatory authorities was prepared and shared with countries during the intercountry meeting on strengthening medical devices regulation in the Region, held in Saudi Arabia in 2016. The meeting resulted in the development of roadmaps for designing and implementing a regulatory programme for medical devices in 15 countries. Currently, Bahrain, Sudan and Egypt are being assisted in the development/enhancement of their regulatory functions for medical devices. It is expected that more countries will be supported in 2017. 

Technical support was provided in 2016 to: the development of a global model on medical devices regulation; the regulatory harmonization efforts in countries in the Intergovernmental Authority on Development which include Djibouti, Somalia and Sudan from the Eastern Mediterranean Region; and the Jordan Food and Drug Administration in its first international congress for drug regulators.

The regional health technology assessment network continues as an active platform for information exchange and knowledge sharing. Technical support was provided to the Islamic Republic of Iran, Oman and Tunisia to enhance or establish national health technology assessment programmes in their national health systems. Contribution was made to the development of a list of noncommunicable disease medicines and medical supplies for inclusion in a new emergency health kit for the management of noncommunicable diseases in humanitarian disasters and emergencies in the Region. In addition, a list of supplies for family planning/reproductive health/maternal health was also developed for inclusion in the interagency emergency health kit.

In the area of health technology management, a tool was developed that can be used by countries to prioritize medical devices based on their public health needs. The next step is to share findings with manufacturers and donors to explore the possibility of reducing manufacturing costs for priority medical devices to make them available to the regional population. The tool is expected to be finalized and shared with countries in 2017.

To increase access to and better management of assistive technologies, an assessment tool was developed which collects baseline information on national systems used for the provision and management of products for mobility, vision, hearing, personal care, communication and cognition assistance. The results of the assessment, which will be shared in 2017, will help improve coverage, policies and finances, increase availability and affordability, and enhance staff capacity and service provision.

Integrated service delivery

During 2016, support to countries in health service delivery was based on the WHO Framework for integrated people-centred health services, which was adopted by the World Health Assembly in May 2016. Within this context, WHO carried out a situation analysis out on service provision focusing on the family practice approach, assisted countries to build capacities in hospital care management and to increase access to comprehensive and quality health care services, provided evidence-based policy options, and monitored service provision in moving towards universal health coverage. 

Experiences from other regions and good practices related to integrated people-centred health services were shared with the countries in several regional meetings. Guidance on strengthening emergency health care services was developed based on a situation analysis that was conducted in 12 countries of the Region. 

In view of the importance of service delivery to universal health coverage, the 63rd session of the Regional Committee for the Eastern Mediterranean in 2016 adopted a resolution for scaling up family practice. In response to this, the Regional Office in collaboration with American University of Beirut developed a six-month online course on improving knowledge of the general physicians. An advocacy video on family practice was made and shared with countries on different occasions including during the world and regional conferences for family doctors in Brazil and United Arab Emirates. Several activities aimed at embedding quality of care within health care delivery in countries of the Region were carried out in 2016. These include: the development of a quality framework for primary care with 34 indicators, which has been piloted in four countries of the Region; technical support on patient and community engagement for quality as part of the people-centred integrated service delivery; the establishment of a patient safety system at the health care facility level based on the WHO improvement tool kit. In addition, technical assistance was provided to countries on the development of national policies and a strategy for quality as well as the mapping and review of health care accreditation programmes. 

An assessment tool was developed on engagement of the private health sector in service delivery which will be tested in three countries of the Region: Jordan, Oman and Pakistan. Family practice profiles were developed for countries and distributed at the 63rd Regional Committee to inform country strategies to expand family practice. Pakistan initiated a hospital reform process in Punjab province with WHO technical support, and two model districts were selected for implementation of the family practice approach. Patient safety and quality of care remain a challenge in many countries, particularly those facing emergencies because of fragmentation of the health system.

During 2017, WHO will continue to provide technical support to Member States on scaling up service provision based on the family practice approach. This includes organizing short training courses to strengthen the capacities of general physicians in four countries, establishing family practice training centres in three countries, developing a model of primary health care service for countries in emergencies, establishing a family practice advisory group, and implementing tools and guides on assessment of private sector performance and private sector regulation, contracting and partnership. Countries will be assisted to establish their national quality policy and strategy and ensure better institutionalization of effective quality and safety programmes, particularly at the primary health care level, and to expand the WHO patient safety friendly hospital initiative. A consultation will be organized to develop a guide for accreditation of health care facilities. A hospital management training course is being planned. In addition, WHO will support countries in crisis to enhance health system resilience and strengthen service delivery through community health workers and outreach teams.

Health information systems

As part of efforts to strengthen country health data and measurement systems and in line with the political momentum around data as part of the 2030 agenda for sustainable development, a technical package, with interventions proven to be highly effective in strengthening country health data systems, was developed in collaboration with WHO headquarters, international nongovernmental organizations, and country and regional experts.

In addition, to support routine health information systems and enable countries to report on the 68 regional core indicators (endorsed by the Regional Committee in 2014) and the SDGs, and following the intercountry workshop conducted in 2016 and technical discussions prior to 63rd session of the Regional Committee, key SDG indicators are incorporated in the regional core indicators list. Comprehensive reviews of the health information system were conducted in Jordan, Libya and Pakistan to support the ministries of health in strengthening the current systems that provide health-related information. Comprehensive health profiles of the current situation, challenges, gaps, opportunities and way forward for each country and health programme were published. 

The implementation of the regional strategy for the improvement of civil registration and vital statistics (CRVS) remains one of the key priorities of technical support to strengthen the collection and quality of vital statistics and causes of deaths in the Region. Two more countries, Bahrain and Saudi Arabia, conducted comprehensive assessments of their CRVS systems. Twenty-one countries now have complete assessments, CRVS road maps and national plans of action for CRVS system improvement. Moreover, Syrian Arab Republic also evaluated progress in the implementation of its CRVS improvement plan. During 2016, WHO headquarters launched an ICD-10 startup mortality list (SMoL) in conjunction with a DHIS2 platform. DHIS2-SMoL is an electronic application to facilitate cause of death collection and coding. It was introduced to countries during national CRVS implementation workshops and training was conducted in Libya. In the same context of improving the quality of ICD-10 coding of deaths, the Regional Office introduced Iris automated coding of deaths for the very first time ever in the Region. Sixteen countries which produce annual mortality statistics were invited to the Iris workshop. Towards more partner coordination and harmonization, the Regional Office collaborated with the United Nations Economic and Social Commission for Asia and the Pacific and for West Asia, United Nations Economic Commission for Africa and the League of Arab States in support of CRVS strengthening. 

To address the major gaps in reporting indicators that are mainly generated from population-based surveys, a new type of health examination survey was developed by WHO that focuses on behavioural and biological risk factors, health care utilization, health status and household expenditure. The first of these was conducted in Tunisia with government support.

Several challenges remain within health information systems. Population-based surveys and health information systems assessments need to be conducted on a regular basis in many countries. The ongoing conflicts in the Region and lack of resources continue to be among the main challenges to the improvement of CRVS systems. Intensive efforts are required for capacity building among physicians in high quality certification of deaths. Several capacity-building workshops on the DHIS2-SMoL are planned for 2017 and countries will be encouraged to introduce ICD-10 compliant certification of deaths in their undergraduate medical education.

Research development and innovation

WHO continued to support capacity building for research through workshops on: data management, interpretation and implementation strategy; good health research practices; and developing policy briefs. A research priority-setting exercise was conducted and the results used in a call for proposals for the tropical disease research small grants scheme. In 2016, calls for proposals for the scheme resulted in support for 8 priority research projects from six countries, and grants for research priorities in public health resulted in support for 10 research projects in eight countries. The Eastern Mediterranean Research Ethics Review Committee met to discuss ethical review of research funded by WHO and involving human subjects. In 2016, 47 WHO collaborating centres were supporting WHO activities in the Region. 

The Eastern Mediterranean Health Journal continued its regular monthly publication, including a special issue on influenza and emerging respiratory infections in the Eastern Mediterranean Region. The Journal received its first impact factor in 2016, a measure of the yearly number of citations to recent articles in that journal. 

In the area of eHealth, profiles were developed for each Member State based on results of an eHealth survey conducted in 2015–2016. Evidence-based mobile eHealth (mHealth) applications were initiated and implemented in Tunisia (smoking cessation, diabetes control) and Egypt (diabetes control, smoking cessation, eLearning and telemedicine). 

The way forward will focus on supporting Member States to improve their institutional capacity for the conduct, governance and oversight of research, and for the use of research evidence in decision-making.