I am pleased to present this report describing the work undertaken by WHO in the Eastern Mediterranean Region during 2017 and the early part of 2018.
This period pre-dates my time in office as Regional Director, which began on 1 June 2018. I would therefore like to begin by paying tribute to my predecessor as Regional Director, the late Dr Mahmoud Fikri, and to Dr Jaouad Mahjour, who took over as Acting Regional Director after Dr Fikri’s sad and untimely demise. Reviewing this report, I am struck both by the enormity of the health-related challenges facing the Eastern Mediterranean Region and by the great progress that is being achieved in spite of those challenges. That progress is testament to the contribution of Dr Fikri, Dr Mahjour and previous regional directors, and to the work of WHO’s staff and partners in the Region under their able leadership.
In part, the challenges that face WHO reflect the scale of our ambition. One of our major strategic aims is universal health coverage: we want to help our Member States ensure that everyone in the Region can access the health services they need without running the risk of financial penury in doing so. Clearly, that aim will not be achieved quickly, but efforts continued apace in 2017 and I am pleased to report some progress.
WHO undertook a range of activities with our Member States in the Region to strengthen their health systems towards achieving universal health coverage. We helped them develop and advance their distinct visions and strategies to improve health financing in each specific country context. Notable achievements included providing technical support for a landmark new social health insurance law in Egypt and for the implementation of strategic health purchasing in the Islamic Republic of Iran and Sudan.
Health workforce development received a boost in October 2017 with the endorsement by the 64th session of the Regional Committee of a framework for action. We are now working to scale up implementation of the framework, to ensure that every country has a supply of highly qualified health personnel with an appropriate skill mix to meet its current and future needs.
Another major task in ensuring access to health care for all is to define which health services and interventions should be provided and financially covered for the population. In this regard, essential health service packages were assessed and supported in six countries: Afghanistan, Egypt, Palestine, Saudi Arabia, Somalia and Yemen.
Providing those services is not just a job for the public sector. On the contrary, our Member States have recognized the crucial role of private sector health care in the Region. Responding to a mandate from the Regional Committee, WHO prepared a framework for action on effective engagement with the private health sector to expand service coverage for universal health coverage, to be presented to the Committee at its 65th session in 2018.
Universal health coverage also requires effective and comprehensive health information systems to measure health needs and outcomes. In this regard, again, there have been encouraging results despite many challenges. Intensive work with Member States to strengthen country health data and measurement systems has led to a remarkable improvement in core indicator reporting, with an average increase of 15% in indicators reported at the regional level in the period 2014–2017.
We will continue working to improve both health systems and health information systems in the year ahead.
WHO is committed to promoting health across the life course. That means identifying and seizing opportunities for health promotion at critical stages in people’s lives. Reproductive, maternal, newborn, child and adolescent health are all high priorities and received much attention during 2017 and early 2018. Progress was uneven, with clear setbacks in countries affected by humanitarian crises, but there were notable achievements too. Iraq, United Arab Emirates and Yemen launched strategic plans on maternal and child health, while Sudan became the first country in the world to apply the Accelerated Action for the Health of Adolescents (AA-HA!) implementation guidance to develop a strategic plan for adolescent health and development.
At the other end of the life course, WHO is promoting a new concept of healthy ageing that is built around the functional ability of older people, rather than the absence of disease. Several cities in the Region have embraced the Organization’s global age-friendly cities initiative, with Sharjah in the United Arab Emirates enjoying particular success.
The past year also saw significant efforts to promote health and tackle deep-seated problems such as road traffic accidents, gender-based violence and environmental risks. WHO supports the Health in All Policies (HiAP) approach to help Member States effectively address the underlying social determinants of health. These are huge challenges with no instant solution, but painstaking multisectoral efforts offer the hope of improvement over time.
For example, avoidable environmental risks cause at least 850 000 deaths each year in the Region. The Regional Committee’s endorsement of a regional framework for action on climate change and health in October 2017 has paved the way for a integrated/multisectoral, evidence-based policy response, and I look forward to reporting on the implementation of the framework next year.
Closely tied to health promotion is the fight against noncommunicable diseases (NCDs) including cardiovascular diseases, cancer, diabetes and chronic respiratory diseases. NCDs take a severe toll in the Region, and unfortunately WHO’s Noncommunicable Disease Progress Monitor 2017 indicated that countries are not on course to reach NCD target 3.4 of the Sustainable Development Goals by 2030.
However, there has been some progress in each of the four key areas of the regional framework for action on the prevention and control of NCDs. That includes governance, with WHO supporting our Member States to develop multisectoral NCD action plans: eight of the 22 countries in the Region now have an operational strategy or action plan.
It also includes a lot of work to help prevent and control risk factors. Efforts to scale up implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC) enjoyed some success in spite of the tactics of the powerful tobacco industry to undermine these efforts. Several Gulf Cooperation Council countries introduced tobacco excise tax, and WHO collaborated closely with them. Furthermore, many countries took steps to improve the nutritional content of food, including taxes on sweetened beverages, policies to reduce salt consumption, limit saturated fatty acids and virtually eliminate industrial production of trans fatty acids. Twelve countries implemented at least one national campaign to promote physical activity.
Extensive work was also undertaken to enhance surveillance, monitoring and evaluation in relation to NCDs and to reorient health services for better NCD management. Endorsement of a regional framework for action on cancer prevention and control by the 64th session of the Regional Committee was a landmark achievement, as was the deployment in the Syrian Arab Republic of a new WHO emergency kit for the management of NCDs during emergencies.
Mental health is a challenging issue in the Region. It is often stigmatized and has a low political and public health profile, with institutional care remaining the dominant model of care in most countries. The theme of World Health Day 2017 was Depression: let’s talk, and WHO helped to develop a mental health literacy package and targeted campaigns to build on that momentum. Meanwhile, efforts to integrate mental health treatment into primary care continued through the Mental Health Gap Action Programme (mhGAP) and school mental health package.
Reducing the transmission and impact of communicable diseases remains one of the core elements of WHO’s mission, and one that saw considerable progress in the Eastern Mediterranean in 2017.
We are getting ever closer to achieving our global aim of eradicating poliomyelitis. The number of wild poliovirus cases fell to the lowest level ever recorded. However, as long as wild poliovirus is circulating anywhere, there remains a risk of it spreading or of circulating vaccine-derived polioviruses (cVDPV) emerging, especially in countries affected by complex emergencies. Effective surveillance, preparedness and response are all crucial, and we will continue to work with countries to maintain and improve these areas of work.
The prevalence of HIV in the Region remains low but is rising, and too few of those infected are receiving antiretroviral therapy. Viral hepatitis is a significant cause of mortality, especially in Egypt and Pakistan, but there have been welcome improvements in testing and treatment. Meanwhile, detection of tuberculosis is improving but remains well below the global target rate of 90%.
The reported number of confirmed malaria cases was 1.36 million in 2017. Fourteen countries in the Region are free from indigenous malaria transmission, with good progress in several others, but protracted emergencies complicate efforts to control the disease in many malaria-endemic countries. WHO is developing an integrated strategy for malaria and other vector-borne disease interventions, particularly in countries experiencing complex emergencies.
The security situation can also make vaccination challenging. However, overall regional immunization coverage was maintained at 80%, with an increase in average coverage of diphtheria-tetanus-pertussis (DTP3) vaccine. Measles case-based laboratory surveillance is implemented in all countries, and seven countries are close to achieving the measles elimination target.
In response to a resolution of the Regional Committee in October 2017, countries are now developing national action plans on antimicrobial resistance; two had already been officially submitted to WHO by December, with eight others at an advanced stage. Extensive work was also undertaken to improve surveillance, raise awareness and promote behaviour change.
In one area, the Eastern Mediterranean Region is the uncontested global leader: health emergencies. More than 76 million of our people are directly or indirectly affected by conflict, environmental threats and natural disasters.
WHO responded to 10 graded emergencies in the Region during 2017, including four Grade 3 major emergencies in Iraq, Somalia, Syrian Arab Republic and Yemen. Somalia was classified as a Grade 3 emergency in May 2017, requiring a scaled-up Organization-wide response. The dengue fever outbreak in Pakistan was assigned a Grade 1 emergency from July 2017 to January 2018. Other graded emergency countries included Afghanistan, Libya, Pakistan and Palestine.
Our work in emergency settings faces severe constraints, not least insecurity: 80% of all attacks on health workers recorded globally by WHO in 2017 occurred in the Eastern Mediterranean. In addition, health systems are often limited or non-existent in affected areas; there are shortages of skilled personnel; and funding is insufficient.
Yet despite these challenges, WHO and our partners continue to provide life-saving support where it is most needed. In 2017, WHO’s logistics hub in Dubai delivered 791 tonnes of medicines and medical supplies to 20 countries in the Region and beyond, reaching more than 23.5 million beneficiaries in Iraq, Somalia, the Syrian Arab Republic and Yemen alone.
WHO led or jointly led health sector coordination in eight countries in the Region where the health cluster has been activated. In the Gaza Strip, the health cluster prevented the closure of 14 public hospitals and 18 nongovernmental organization hospitals by providing fuel for generators. In Iraq, health cluster partners immunized 99% of target children in newly accessible areas. In Yemen, health partners were able to reach 6 million people with life-saving health services. In Pakistan, health partners are underpinning the transition from emergency to development in the Federally Administered Tribal Areas (FATA). In the Syrian Arab Republic, health partners supported 14.4 million medical procedures and provided 8.6 million courses of treatment.
Outbreaks of emerging infectious disease were successfully contained in Pakistan (dengue fever), Somalia (cholera), Sudan (acute watery diarrhoea) and the United Arab Emirates (travel-associated Legionnaire’s disease), thanks to rapid field investigation and deployment of surge staff from the Regional Office, the involvement of Global Outbreak Alert and Response Network (GOARN) partners, and swift implementation of public health containment measures in the affected countries.
Meanwhile, efforts also continued to tackle longer-term capacity issues. The Emergency Medical Team (EMT) initiative was launched to establish a cadre of skilled national multidisciplinary medical teams to act as first responders when emergency strikes; the WHO Emerging and Dangerous Pathogens Laboratory Network was established to develop high-security laboratories for the timely detection, management and containment of outbreaks; and work is underway to develop new partnerships and new models of funding.
Emergency preparedness is another crucial aspect of our work. In 2017, support was provided to Egypt, Iraq, Jordan and Pakistan to conduct risk assessments and develop their all-hazards preparedness and response plans; a hospital emergency course was conducted in Bahrain, Libya and Sudan; Kuwait, Oman, Saudi Arabia and United Arab Emirates were supported to undertake additional voluntary joint external evaluations (JEEs); and Iraq, Libya, Syrian Arab Republic and Yemen were helped to prepare for JEEs.
The role of WHO’s staff and Member States in the Eastern Mediterranean is not limited to the Region; we also help to shape the Organization’s global strategy. In 2017, that included contributing very actively to WHO’s Thirteenth General Programme of Work, which was finalized and launched in May 2018, and Member State representatives also attended high-level meetings at WHO headquarters in Geneva, contributing to setting the agenda on a range of issues.
Improving WHO’s own management and performance remains a strategic priority. During 2017, the Organization continued to improve its planning, forecasting, implementation, monitoring and evaluation capacity aimed at more efficient use and distribution of limited resources. All audits of WHO in the Region resulted in satisfactory or partially satisfactory ratings, showing continued improvement in controls and a deep commitment to compliance with established standards and procedures. We will continue our efforts to optimize performance going forwards.