Regional framework for action
In September 2018, the United Nations General Assembly staged the third high-level meeting on noncommunicable diseases to review progress made in implementing the 2011 Political Declaration of the High-level Meeting of the United Nations General Assembly on the Prevention and Control of Non-communicable Diseases. According to WHO’s Noncommunicable Disease Progress Monitor 2017, despite some promising trends, national progress in implementing key strategic interventions under the four areas (governance, surveillance, prevention and health care) of the regional framework for action has been limited and remains insufficient for countries to reach noncommunicable disease target 3.4 of the SDGs by 2030. Obstacles to progress in the Region include a lack of multisectoral coordination and engagement, especially of non-health sectors, weak national public health and health system capacities for prevention and control of noncommunicable diseases, and interference by industry impeding the implementation of the “best-buys” and other recommended interventions, including raising taxation on tobacco, alcohol and sugar-sweetened beverages.
Governance
During 2017, WHO continued to support countries in developing multisectoral noncommunicable disease action plans, incorporating noncommunicable diseases into national development plans and United Nations Development Assistance Framework (UNDAF) plans, and setting up national noncommunicable disease targets. Eight out of 22 countries (36.4%) in the Region now have an operational multisectoral national policy, strategy and/or action plan that integrates noncommunicable diseases and their shared risk factors, while 16 (72.7%) have incorporated noncommunicable diseases into their national development agendas. Furthermore, building on work to mobilize and strengthen the capacity of regional civil society organizations for the prevention and control of noncommunicable diseases, WHO promoted the creation of a regional noncommunicable disease alliance.
Prevention and control of risk factors
In 2017, WHO continued to provide technical support to scale up implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC) in countries. Collaboration continued with the U.S. Centers for Disease Control and Prevention (CDC) for the implementation of the Global Tobacco Surveillance System (GTSS) in countries of the Region, and with the WHO FCTC Secretariat to strengthen tobacco control. This included a regional planning workshop on the WHO FCTC 2030 initiative to strengthen WHO FCTC implementation towards achieving the SDGs, a regional meeting to support full execution of the decisions of the seventh session of the Conference of Parties (COP7), and a multisectoral workshop to promote the entry into force in the Region of the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products. Additionally, WHO provided technical support to the League of Arab States to develop model tobacco control legislation.
Following the 2016 Gulf Cooperation Council agreement on implementing tobacco excise tax, several member countries of the Gulf Cooperation Council have started implementation, and regional training on implementing successful tobacco taxation policies was provided by WHO.
To support national tobacco control efforts, information resources were produced to highlight key findings of the WHO report on the global tobacco epidemic 2017, raise awareness of tobacco industry activities in countries and promote the SimSmoke tobacco control policy simulation. A resource on graphic health warnings was finalized in collaboration with the University of Waterloo, Canada.
Further collaboration with international organizations is needed for better tobacco control implementation, as is strengthening national capacity to counter tobacco industry tactics. Developing a regional action plan for tobacco control is a priority in order to move forward on tobacco control and fully meet WHO FCTC commitments.
The Region continues to experience an epidemiological and nutritional transition that is contributing to high rates of overweight and obesity, with half of all adult women (50.1%) and more than two in five adult men (43.8%) estimated to be overweight or obese in 2014. The evolution of overweight and obesity is closely linked to physical inactivity and unhealthy diet, with the Region having the highest prevalence of physical inactivity in adults (31%)[TB1] , and higher levels among women (37%) than men (26%).
In this context, promoting healthy diet has been identified as a key strategic and cost-effective intervention in the regional framework for action for the prevention and control of noncommunicable diseases. In 2017, the adoption of national policies to reduce population salt/sodium consumption was fully achieved in eight countries (36.4% of countries in the Region), and partially achieved in six (27.3%). Additionally, the adoption of national policies to limit saturated fatty acids and virtually eliminate industrially produced trans fatty acids in the food supply was fully achieved in 12 countries (54.5%). Furthermore, WHO’s recommendations on the marketing of foods and non-alcoholic beverages to children were adopted in seven countries (31.8%) and the countries of the Gulf Cooperation Council added “sin” taxes on sweetened beverages and soft drinks (100% and 50% on energy drinks and soft drinks, respectively).
Twelve countries (54.5%) implemented at least one national public awareness and motivational communication for physical activity, including mass-media campaigns for physical activity behavioural change. This included high-income countries such as Gulf Cooperation Council countries and the Islamic Republic of Iran.
Nutrition data collection and analysis remain a challenge in the Region. Effective policy-making and accountability require effective nutrition surveillance and monitoring and evaluation systems. Developing a roadmap for action to address obesity is another priority for the Region, and has been advanced through dissemination of the recently published WHO document Proposed policy priorities for preventing obesity and diabetes in the Eastern Mediterranean Region (2017).
Surveillance, monitoring and evaluation
In 2017, 12 Member States set time-bound national targets for surveillance, monitoring and evaluation based on WHO guidance. Countries continued to strengthen noncommunicable disease risk factor surveillance systems by implementing the WHO STEPwise approach to noncommunicable disease surveillance (STEPS) and the Global Tobacco Surveillance System with its components, the Global Youth Tobacco Survey (GYTS), the Global Adult Tobacco Survey (GATS) and Tobacco Questions for Surveys.
Morocco and Oman were able to complete data collection for national-level STEPS, with Oman integrating the GATS questionnaire into its national STEPS survey successfully, while Egypt, Lebanon and Sudan completed data analysis for their national-level STEPS surveys. Qatar and Somalia made progress in the development of a protocol for national-level STEPS implementation in early 2018, while United Arab Emirates integrated its national-level STEPS questionnaire into the World Health Survey and embarked on the data collection phase.
Pakistan, under a donor funding mechanism, was selected to implement the GATS repeat survey in 2018, while Saudi Arabia continued its work on GATS implementation, and the Islamic Republic of Iran, Kuwait, Morocco, Oman, Palestine and Tunisia completed the data analysis for their GYTS repeat surveys. In collaboration with the International Agency for Research on Cancer (IARC), Jordan, Syrian Arab Republic and United Arab Emirates received training on CanReg5 software, an open source tool to input, store, check and analyse cancer registry data following international standards (ICD-10).
All countries in the Region successfully completed the noncommunicable disease country capacity survey for 2017. The survey is a periodic assessment of national capacity for the prevention and control of noncommunicable diseases, and is designed to monitor progress towards implementation of the United Nations Political Declaration and the regional framework for action on the prevention and control of noncommunicable diseases. The survey covers: health system infrastructure; funding; policies, plans and strategies; surveillance; primary health care; and partnerships and multilateral collaboration. The information collected will be used to assess country progress at the United Nations General Assembly and the World Health Assembly in 2018. Updated regional status and country profiles based on country capacity survey results for 2017 were developed to assist countries in identifying gaps, challenges and the way forward.
Health care
In 2017, in line with the SDGs and universal health coverage agenda, WHO scaled up its support to countries in the Region in reorienting health services for better management of cardiovascular diseases, cancer, diabetes and chronic respiratory diseases and their risk factors, with a focus on primary health care, including in crises and emergencies. In particular, support was provided for the development and implementation of national cancer control programmes. A milestone was reached in October with the endorsement by the 64th session of the Regional Committee of a regional framework for action on cancer prevention and control.
Guidance and country support was also given for the management of noncommunicable disease care in crises and emergencies. A notable achievement was the deployment in the Syrian Arab Republic of a new WHO emergency kit for the management of noncommunicable diseases during emergencies. The emergency health kit includes medical equipment and 22 essential medicines for chronic diseases such as hypertension, cardiac diseases, diabetes, chronic respiratory diseases, and selected mental health and neurological conditions. The kit also includes noncommunicable disease management protocols for health care workers, based on WHO standards. The new kit will now be available in the WHO catalogue for all countries in need. Expansion of its deployment is expected soon in other countries facing emergencies, such as Iraq and Yemen.
Mental health
Following the endorsement by the Regional Committee in 2015 of the regional framework to scale up action on mental health, the area of mental health and substance abuse is beginning to gain traction. In order to monitor and report on global and regional targets, data were collected and compiled using the Mental Health Atlas questionnaire. Since 2015, a regional course in leadership in mental health has been developed and hosted annually by the American University in Cairo to strengthen institutional capacity in countries.
To bridge the treatment gap for mental health problems through integration within primary health care, the WHO Mental Health Gap Action Programme (mhGAP) was initiated or scaled up in many countries in 2017, including Afghanistan, Egypt, Iraq, Jordan, Lebanon, Libya, Pakistan, Palestine, Somalia, Syrian Arab Republic and Tunisia. WHO support was provided to the Islamic Republic of Iran to review the national programme for suicide prevention, to Afghanistan and Tunisia in developing suicide prevention programmes, to Oman, Qatar and United Arab Emirates to develop their national autism plans, to Qatar and Tunisia for the development of dementia plans, and to Afghanistan, Lebanon and Sudan to review and draft mental health legislation and regulations. To promote mental health and prevent mental disorders, a school mental health package was developed that is being piloted in Egypt, Islamic Republic of Iran, Jordan, Pakistan and United Arab Emirates, and is being used in other WHO regions.
During 2017, technical support continued to be provided to strengthen mental health and psychosocial support for populations in Iraq, Libya and Yemen, and those affected by the Syrian crisis, in coordination and collaboration with United Nations agencies, nongovernmental organizations, national stakeholders and academic institutions, with a focus on needs assessment, capacity-building and enhancing access to services. This led to the development of a regional mental health and psychosocial support capacity-building course, piloted in Saudi Arabia, the development of a curriculum for enhancing the capacity of general nurses for provision of mental health care, piloted in the Syrian Arab Republic, and the field testing of a psychosocial intervention package to be delivered through non-specialized health workers in emergencies, including the piloting of an electronic version in Egypt, Jordan, Lebanon and Syrian Arab Republic.
In collaboration with the United Nations Office on Drugs and Crime (UNODC), technical support was provided to set up opium substitution treatment services in Egypt, Kuwait and Palestine, expand services in Lebanon, Morocco and United Arab Emirates, and review national strategies in Iraq and Jordan. Furthermore, the annual regional capacity-building workshop for mid-level managers on substance use policy development and service delivery was held and WHO is continuing to contribute to the field trials of different versions of chapter 6 of the International Classification of Disease, Eleventh Revision (ICD-11) and treatment and prevention standards for substance use disorders.
Despite this progress, challenges remain, with mental health continuing to have a low political and public health profile. The stigma attached to mental health leads to discrimination in resource allocation and service development, delivery and utilization, with institutional care remaining the dominant model of care in most countries, thereby compounding under-resourcing with inefficiency. To overcome these challenges, WHO will continue to strengthen its collaboration with regional and global partners to implement the provisions of the regional framework to scale up action on mental health and enhance public mental health literacy through the development of a mental health literacy package and targeted campaigns, building on the momentum generated by the World Health Day 2017 Depression: let’s talk campaign.