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Strengthening health systems for universal health coverage

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Universal health coverage

In 2017, WHO intensified its efforts to support countries of the Region in developing their visions, strategies and roadmaps towards universal health coverage. Key strategic cross-cutting activities included the development of a priority benefit package for universal health coverage, enhancing engagement with the private sector and focusing on synergizing efforts through the so-called humanitarian–development–peace nexus approach, to enhance health system resilience in emergency contexts.

Health governance and financing

Clear vision, strong governance structures, functioning regulatory and financing institutions and effective partnerships are all critical to enhance health system performance towards universal health coverage.

Many countries of the Region have weak governance arrangements and limited accountability and transparency, hampering health system performance. Several countries continue to lack a clear vision and comprehensive roadmap to strengthen their health systems towards universal health coverage. In addition, insufficient public funding for health, non-existent or weak prepayment arrangements and inefficient use of scarce financial resources compromise the performance of health financing systems.

To address these challenges, special attention was given to supporting the development of national health policies, strategies and plans by undertaking governance and financing assessments and focusing efforts on building institutional capacity. Technical support was also provided to several countries to review their new national health strategies. In addition, several diagnostic tools were developed or adapted to inform health system reform and transformation. Specifically, tools for assessing accountability and public health were developed. Support was provided to countries to conduct health system governance and legal reviews, and to apply the joint framework to mitigate the risk of corruption in the health sector. In addition, work was initiated in the areas of decentralization, resilience and engagement with non-state actors. Regional training on the rule of law and HiAP was organized in collaboration with the Social Research Centre at the American University in Cairo and the League of Arab States.

Work on health financing continued to be guided by the regional framework for action for advancing universal health coverage to strengthen the performance of health financing systems and enhance the goal of financial protection. Specifically, support was provided to countries to develop their own health financing visions and strategies according to the country context, while also supporting the generation of necessary evidence. Technical cooperation with Egypt contributed to the enactment of a historic comprehensive social health insurance law, ensuring more public money for health. Support was also provided to Kuwait to review its health financing system and integrate a health financing strategy into the country’s national strategic health plan. Special support was provided to the Islamic Republic of Iran and Sudan to strengthen the strategic purchasing function of their health insurance organizations. Particular attention was given to the development of benefit packages for universal health coverage.

In the area of health partnerships, joint missions and coordinated support with GAVI, the Vaccine Alliance, and the Global Fund resulted in increased funding for health system strengthening in the form of increased immunization coverage and better control of HIV/AIDs, tuberculosis and malaria. Joint efforts with the Federal Ministry of Health of Sudan and other development partners culminated in the endorsement of a funding proposal to support governance reforms in the National Health Insurance Fund. Collaboration continued with the United Nations Development Programme (UNDP) to combat corruption in the health system.

Health workforce development

A well-qualified and well-performing health workforce will be crucial for achieving universal health coverage. Countries continue to face an overall shortage of health workers in addition to imbalances in geographic distribution and skills mix. In particular, Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen have a critical shortage of health workers. Furthermore, protracted crises have led to a loss of health workers and interruptions in health professionals’ education, exacerbating the gaps. The safety and security of the remaining health workforce continue to be a major concern. A rapid influx of refugees in some countries has led to increased workload and a decline in health workforce densities.

A framework for action for health workforce development was finalized in 2017 and endorsed by the 64th session of the Regional Committee in October. The framework provides strategic guidance for countries to address health workforce challenges. A number of countries embarked on strategic planning, and analysis of the health workforce and labour market was undertaken to guide the development of the strategic plans. The Islamic Republic of Iran, Iraq, Pakistan, Somalia and the United Arab Emirates developed nursing or midwifery strategies.

In addition, case studies were conducted in the Islamic Republic of Iran, Jordan and Lebanon to understand the challenges and gaps in the primary care workforce and how to strengthen multidisciplinary teams in family practice-based primary care. A regional prototype nursing curriculum was developed to guide the process of developing nursing curricula; and curriculum review was undertaken in several countries. Finally, support was provided to Yemen to establish a B.Sc. nursing programme at the University of Aden.

With the increasing involvement of the private sector in the education and work of the health workforce, health workforce regulation is more important than ever. Strengthening governance capacities is critical; a workshop on strengthening the health workforce was held in collaboration with the World Bank and the International Monetary Fund, and support was provided for the establishment of national medical and midwifery councils in several countries.

Health workforce observatories provide mechanisms to strengthen health workforce information and evidence. In 2017, a regional meeting on health workforce observatories was held to discuss how health workforce observatories can be scaled up, introduce national health workforce accounts and agree on a set of indicators to monitor the framework for action.

In 2018, efforts will continue to scale up implementation of the framework for action with a focus on the priorities of strategic planning to ensure availability, accessibility, quality and performance of the health workforce, strengthening health workforce governance and regulatory capacities, increasing investment in the health workforce and improving related information and evidence. Efforts will continue to tackle health workforce challenges in countries with protracted crises in order to ensure access to health care.

Essential medicines and technologies

Achieving universal health coverage will require countries to improve access to health technologies, including medicines, vaccines and medical devices. Aided by the technical support of WHO, Member States can improve access by developing national policies that promote the development of effective innovation, regulation, assessment and management programmes for health technologies within existing national health systems.

Through the programme on good governance for medicines, Member States were supported in establishing policies for implementing codes of conduct and managing conflicts of interest, increasing the public availability of information, developing membership guidelines for national committees, developing standard operating procedures for decision-making processes, establishing independent complaint mechanisms to improve protection for whistleblowers, and increasing societal engagement. An assessment report of transparency in the pharmaceutical sector in Pakistan was published in 2017. In collaboration with UNDP and the Arab Anti-Corruption and Integrity Network, specialized training on preventing corruption in the pharmaceutical sector was conducted for officials in Egypt.

Collaboration with countries continued in the implementation of WHO’s global action plan on antimicrobial resistance. Reliable national antibiotic consumption data for 2014–2016 from several countries of the Region will be published in the 2018 WHO global report on antibiotic consumption.

Surveys on national policy and regulation for traditional and complementary medicine were conducted in eight countries (Afghanistan, Jordan, Lebanon, Morocco, Oman, Somalia, Syrian Arab Republic and Tunisia). These surveys managed to identify gaps in policies, regulations and practices to be addressed by Member States. Technical support was also provided to set up policies on herbal medicine, market surveillance and vigilance systems.

Technical support was provided to the Healthcare Technology Management and Advancement centre in Lebanon to become a regional hub for innovation in health care technology. Collaboration with the centre focused on developing strategies to enhance the spirit of innovation in health technologies, investigating existing resources to promote innovation, identifying clinical gaps that need to be filled, and strengthening interdisciplinary collaboration.

Regulation of medical products – medicines, vaccines and medical devices – is a priority in the Region. Through WHO’s global benchmarking tool for national regulatory authorities, assessments of national regulatory capacity were carried out in eight countries (Afghanistan, Egypt, Islamic Republic of Iran, Jordan, Lebanon, Pakistan, Somalia and Sudan) and resulted in the development of institutional development plans for their national regulatory authorities. Follow-up on the implementation of the plans will be conducted in the next two years. An informal assessment of the national regulatory authority was conducted in Saudi Arabia. The national regulatory authority in Saudi Arabia is now enhancing its capacity to appropriately regulate locally manufactured vaccines.

In 2017, a regional publication on the regulation of medical devices was translated into French. Several countries are being assisted in the enhancement of their medical device regulatory functions. WHO supported the establishment of expert committees of the Intergovernmental Authority on Development to promote the harmonization of medicine regulation involving Djibouti, Somalia and Sudan and Member States from the African Region.

Technical support was provided to INASante in Tunisia and the National Institute of Health Research in the Islamic Republic of Iran to enhance their capacities to conduct health technology assessment studies. Regional experiences in promoting and facilitating the establishment of national health technology assessment units or agencies were shared as a model for African countries to follow during the proceedings of the 2017 annual meeting of health technology assessment agencies and international networks in Rome. Regional experience was also highlighted in a special issue of the International Journal of Technology Assessment in Health Care.

A new pharmaceutical sector country profile was piloted in Libya and Sudan. The profile provides quality information on structures, processes and outcomes of the health and pharmaceutical sectors in countries of the Region. Training was organized to enhance the management of the supply chain for medicines and medical devices in Libya.

In support of efforts to improve access to and management of assistive technologies, a rapid assessment tool was developed to collect and analyse baseline country information. Results of the regional assessment were presented at the Global Research, Innovation, and Education in Assistive Technology (GREAT) Summit in 2017. Based on findings, a regional report is being prepared to guide the development of a regional action framework to improve access to assistive technology as an essential component of universal health coverage.

Integrated service delivery

During 2017, support provided to countries in the area of 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.

An online course developed in 2016 to build the capacities of general practitioners in family medicine was conducted in Egypt, Iraq, Kuwait, Saudi Arabia, United Arab Emirates and at the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). An advisory group of family practice experts was also established to provide strategic guidance on scaling up family practice in the Region.

An important stage towards ensuring access to health care for all is to define which programmes, services and interventions should be provided and financially covered for the population. As an initial step in the development of a generic universal health coverage priority benefit package for the Region, essential health service packages were assessed in six countries (Afghanistan, Egypt, Palestine, Saudi Arabia, Somalia and Yemen).

The critical role of the private health sector in advancing universal health coverage was highlighted by countries at the 64th session of the Regional Committee in October 2017. In response, work was initiated to develop a regional framework for action on advancing the role of the private health sector in the move towards universal health coverage. Analyses of the private health sector in countries of the Region were updated in 2017 and private health sector factsheets were prepared for 18 different countries.

Technical support in the area of hospital care and management included two national capacity-building programmes on hospital care and management for public hospital managers. A model for training master trainers was developed for rolling out the programme on hospital care and management. The model will be used to replicate this programme in the Region in 2018.

Available data from the WHO emergency care system assessment collected from 12 countries shows critical organizational and implementation gaps in the Region. A new initiative was developed to strengthen the capacity of hospital managers in hospital emergency preparedness and response, with the first national training conducted in Sudan. This course will be replicated in countries in emergencies during 2018. An assessment of national policies for the hospital sector was conducted in 2017 in order to develop a regional framework for the hospital sector.

Member States were supported in different areas related to quality and safety, including in the development of national quality policies and strategies and in technical review and guidance for national health care accreditation programmes. A regional study on mapping health care accreditation programmes was conducted and the report is being finalized. At the primary care level, a framework was developed that includes a set of 34 core indicators for quality of care for countries to use in assessing, improving and monitoring the quality of care at primary health care level. Member States were also supported in implementing the WHO maternal and newborn health framework for quality of care, and of patient safety interventions, including the launch and expansion of the Patient Safety Friendly Hospital Initiative in more countries. Other key activities included the integration of the WHO patient safety curriculum in 21 health care-related academic institutions in Oman as well as the implementation of the WHO core components of infection prevention and control in Qatar.

Health information systems

Implementation of the regional framework for health information systems and core indicators remains one of the key priorities for technical support in the Region. Key Sustainable Development Goal (SDG) indicators are incorporated in the regional core indicators list to provide countries with a unified approach for reporting health-related indicators. Intensive work with Member States in strengthening 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 2014–2017. In 16 out of 22 countries, the reporting of core indicators ranges from 76% to 95%; whereas in the remaining six countries reporting ranges from 62% to 75%.

As part of efforts to enhance the capacity of countries to report on indicators that are mainly generated from population-based surveys, a consultative meeting was held in December to discuss priority national population-based surveys, recommended survey modules and national survey plans to support the generation of data for key SDG indicators and effective monitoring of progress towards universal health coverage. In 2018, the results will be adopted to the context of the countries for use in national plans.

In 2017, comprehensive assessments of national health information systems were conducted in Libya and Pakistan as part of efforts to strengthen these systems. In Libya, the assessment was followed by the development of a costed national health information system strategy. A national health information system strategy was also developed in Jordan based on the results of its 2016 assessment. Three countries (Pakistan, Sudan and Syrian Arab Republic) were supported to pilot the district health information system, version 2 (DHIS2) to enhance the collection, processing, analysis and reporting of health data. A regional workshop was conducted in Jordan to build the capacity of national managers of maternal and child health programmes and health information systems in setting SDG-related targets for reproductive, maternal, newborn, child and adolescent health indicators.

Strengthening collection and improving the quality of data from civil registration and vital statistics (CRVS) systems remains a key priority in the Region. During 2017, regional activities focused on building capacity for improved coverage and quality of mortality data. The WHO automated verbal autopsy questionnaire was introduced for the first time in a workshop for seven countries. In collaboration with Melbourne University and the Bloomberg Data for Health Initiative, a workshop was conducted to build the capacity of Member States in using ANACONDA, an electronic tool to assess the accuracy and completeness of mortality and cause-of-death data. To promote utilization of the electronic application for notification of deaths and causes of deaths (DHIS2-SMoL), a workshop for DHIS2 customization was organized for all countries in the Region. A regional orientation workshop on the International Classification of Diseases (ICD-11) was conducted in collaboration with the WHO Collaborating Centre for the WHO Family of International Classifications in Kuwait. National workshops were also conducted in four countries to build national capacity in certification of deaths and ICD-10 coding. A workshop on advanced ICD-10 coding using decision tables was conducted for the first time in the Region with the collaboration of the Bahrain Supreme Council of Health. WHO also supported workshops in several countries to evaluate progress in implementing CRVS improvement plans. During 2017, 12 countries reported mortality data using ICD-10 and one country used ICD-9.

Future work will focus on supporting Member States to address the remaining challenges with health information systems. In particular, countries will be supported to develop national survey plans to promote regular and focused implementation of population-based surveys. Piloting of DHIS-2 to enhance the collection, processing, analysis and reporting of health data is planned in Libya, and a comprehensive assessment of the health information system is planned in Afghanistan. The protracted emergencies in the Region and limited resources continue to affect efforts to improve health information systems, including CRVS systems. Further efforts are also needed to improve the quality of certification of deaths using ICD-10 compliant certification forms.

Research development and innovation

WHO support focused on building the capacity of health care and academic institutions in the use of health information resources, by promoting the Hinari Access to Research for Health programme and conducting national training workshops. The Eastern Mediterranean Health Journal continued its regular monthly publication, including a special issue on substance use.

In the area of eHealth, a regional situation analysis was conducted on national health priorities, potential opportunities and barriers for eHealth applications. In December, the first regional workshop on the development of national eHealth strategies was conducted jointly with the International Telecommunications Union. A scaled-up smoking cessation mobile eHealth (mHealth) application was launched in Tunisia. Implementation of other evidence-based mobile eHealth applications continued in Tunisia (diabetes control) and Egypt (diabetes control, smoking cessation).

In coordination with UNESCO, a regional summit of national ethics and bioethics committees was held in Oman in April with the aim of fostering regional cooperation to address emerging issues related to bioethics.

In October, the 64th session of the Regional Committee issued a resolution calling for the establishment of regional mechanisms to support the bridging of gaps between relevant research institutions and policy-makers and the translation of research evidence into health policy statements. An expert consultation on evidence-based health policy-making, held in November, highlighted the need to support 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.

Tropical disease research projects from six countries were completed, while 10 grants for research priorities in public health in eight countries were also fulfilled. WHO continued to support capacity-building for research through regional workshops on implementation research and on good health research practices. In 2017, there were 46 WHO collaborating centres supporting WHO activities in the Region.