The cornerstone of an effective health system is primary health care (PHC), and WHO is working with our Member States to support them in developing PHC and ensuring that it is effectively integrated with other elements of the health system.

PHC Measurement and Improvement (PHCMI) is a flagship initiative in the Region which was launched on World Health Day, 7 April 2019, as part of efforts to emphasize the link between PHC and universal health coverage. It offers a step-by-step approach to help countries enhance their PHC provision, beginning with standardized, in-depth assessment of each country’s PHC system to establish a baseline and identify key gaps and challenges. Countries will then be supported to develop strategic, tailored interventions to achieve measurable improvements.

A suite of information products are being developed to support the initiative, notably PHC country profiles and vital signs profiles giving an at-a-glance picture of provision in each country. A consultative meeting in December 2019 brought together 19 countries to discuss their profiles.

Meanwhile, WHO continued working to identify priority benefit packages – the core of essential promotive, preventive, curative, rehabilitative and palliative services that should be available and accessible to all people in the country without risk of financial hardship. A draft regional package of essential services has been developed and will be published in 2020.

The private sector plays a major role in the financing and provision of health care in the Region. In line with the pioneering framework for action adopted by the Regional Committee in October 2018, WHO is seeking to support countries in engaging with the private sector and harnessing it to help expand health coverage.

A necessary step in this long-term project is intensive work to analyse and understand the private health sector in different countries, since information systems, monitoring and regulatory regimes are often underdeveloped. Seventeen countries have now completed in-depth private health sector assessments using a tool developed by WHO, and the regional team also began preparing a series of eight thematic reports to help identify gaps and priorities going forward.

Further activities include important collaboration with UNICEF and USAID to develop a policy dialogue workshop, and with partners under the Global Action Plan for Healthy Lives and Well-being for All.

Research has shown that 18% of hospital admissions in the Eastern Mediterranean Region are associated with adverse events, 83% of which could have been prevented. WHO’s work to address this problem centres on implementation of the Patient Safety Friendly Hospital Initiative (PSFHI), a tool to support hospital managers and staff in adopting best practice in their institutions.

More than 280 hospitals across the Region have now adopted the PSFHI. A new edition of the Patient safety assessment manual, which includes detailed criteria and procedures to guide implementation of the PSFHI, is in preparation and will be published in 2020. The substantive content of the manual aligns with the requirements of the International Society of Quality (ISQua) and was validated at a meeting in July 2019.

Work is also ongoing to enhance service quality in other parts of the health system. In 2019, several countries were supported in developing and implementing a national quality policy and strategy. The process involves extensive consultation with stakeholders to articulate a shared vision and priorities which will then inform the selection of evidence- based interventions linked with national health plans.

In addition, four countries were supported to adopt a set of 34 quality indicators specifically for PHC.

WHO works extensively to foster informed discussion of health- related issues among legislators in the Region. Partnerships have been established focusing on several specific issues, including reproductive and child health, road safety and tobacco control, and a further landmark was reached with the launch of the Parliamentary Forum for Health and Well-being in June 2019.

The Forum brings together parliamentarians from across the Region with technical support from WHO. The aim is to strengthen their engagement in advancing health and well-being and facilitate a more holistic, whole- of-government approach to health issues. In so doing, it should support policy-makers in achieving their national goals while also encouraging collaboration at regional level.

Just a few months later, in October 2019, WHO coordinated the first annual meeting of the regional chapter of the Health Systems Governance Collaborative, which brings together a wide range of stakeholders, including parliamentarians and other policy-makers, practitioners, civil society representatives, academics and researchers.

These initiatives were complemented by ongoing efforts to support improvements in health system governance and financing and build capacity within countries. Extensive technical support on institutionalizing health accounts was provided to 11 countries; professionals from seven countries received training on measuring financial health protection; and work began on developing a framework to enable the systematic analysis of health system governance at national and subnational levels in the Region.

Routine immunization is the backbone of efforts to prevent and control communicable diseases. Coverage of the third dose of pertussis, diphtheria and tetanus (DTP3)-containing vaccine increased to 82% in 2018 (the latest reported year) – meaning a year-on-year decrease of about 6% in the number of infants unvaccinated for DTP. Fourteen countries in the Region have maintained the achieved target of DTP3 vaccine coverage above 90%, and routine immunization services continued to be provided in fragile and conflict-affected countries.

Meanwhile, more new vaccines were introduced in countries of the Region in 2019, including pneumococcal conjugate vaccine (PCV) in Tunisia and human papilloma virus (HPV) vaccine in United Arab Emirates. Pakistan became the first country in the world to introduce typhoid conjugate vaccine. Currently, Haemophilus influenzae type B (Hib) and inactivated polio (IPV) vaccines are in use in the national Expanded Programme on Immunization (EPI) in all countries, pneumococcus- containing vaccine in 17 and rotavirus vaccine in 15 countries. In addition, a national policy and decision to introduce rotavirus vaccine was taken in the Islamic Republic of Iran, and preparations for its introduction are underway. The national immunization technical advisory group (NITAG) in Yemen has recommended introduction of a booster dose of DTP vaccines and birth dose of hepatitis B vaccine.

Encouraging milestones were recorded in the fight against measles and rubella. The overall reported incidence of measles in the Region fell from 54.2 cases per million in 2017 to 22.5 per million in 2019, and the regional verification commission for measles and rubella elimination declared that measles and rubella had been eliminated in Bahrain, the Islamic Republic of Iran and Oman. Another six countries now have an incidence rate of fewer than 0.5 cases per 100 000 population.

Underpinning these successes were strong efforts in surveillance and immunization. Measles and rubella case-based surveillance was initiated with the support of WHO in 2004 and is now fully functioning in 20 of the Region’s 22 countries. It is supported by a network of WHO-accredited national measles and rubella laboratories and three regional and subregional reference laboratories. System performance indicators show 17 countries meeting the main elimination surveillance standards.

To boost population immunity, around 90 million people between the ages of 6 months and 14 years in nine countries were vaccinated against measles through vaccination campaigns in 2018–2019, with an average coverage rate of around 96%.

In 2019, Pakistan experienced an unprecedented outbreak of HIV affecting more than 1000 children in Sindh province, mainly through substandard health care injections. WHO coordinated technical support to investigate and respond to the outbreak, including infection control, supply of diagnostics and medicines, as well as delivery of quality diagnosis and treatment services.

More generally, the regional team focused efforts on interventions to increase access to HIV diagnosis and treatment. Regional as well as national activities in the Islamic Republic of Iran, Morocco and Pakistan helped to expedite the introduction of HIV self-testing (HIVST) as a strategic approach to increase access to HIV testing services. Client- centred approaches using integrated and differentiated service delivery models were supported in the Islamic Republic of Iran and Pakistan to improve linkage to treatment services after diagnosis and to enhance retention in treatment, particularly for key populations at increased risk of HIV. Other efforts to provide HIV services for refugees and other displaced persons included supporting the mobilization and implementation of resources from the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Work to tackle tuberculosis (TB) sought to build on global momentum following the first-ever High-level Meeting on the Fight to End TB of the United Nations General Assembly and its landmark Political Declaration in October 2018. WHO’s regional team advocated to obtain corresponding commitments from Member States to accelerate progress to end TB by 2030.

The President of Pakistan declared the Pakistan TB-free Initiative in 2019 and the Ministry of Health of Morocco announced a National Initiative for Ending TB. Both countries redoubled efforts to involve non health sector partners in the fight against TB, in line with the global multisectoral accountability framework.

The regional TB team also worked with countries and partners to enable rapid adaptation and use of new WHO guidelines on the treatment of isoniazid-resistant TB and updated guidelines for the treatment of multidrug- and rifampicin-resistant TB (MDR/RR-TB), with 17 countries plus other partners attending a workshop in May. Afghanistan, Iraq, Lebanon, Pakistan and Qatar were supported to develop national strategic plans, while Jordan, the Syrian Arab Republic and Yemen were supported to update their national guidelines.

Noncommunicable diseases (NCDs) such as cancer and cardiovascular disease and mental disorders account for around two thirds of all deaths in the Region and pose a heavy burden of chronic disease.

Effective surveillance systems are crucial to prevent and manage NCDs. WHO is working to support countries in implementing and integrating NCD monitoring and tracking within their national health information systems. The WHO Global Monitoring Framework identifies three pillars for NCD surveillance: 1) monitoring of mortality (with a specific focus on premature mortality from cardiovascular diseases, cancer, diabetes and chronic respiratory disease) and morbidity (cancer incidence); 2) monitoring of risk factors; and 3) monitoring of national system response (a core component of which is health system response and capacity). In 2019, attention was given to scaling up existing sources of data collection on mortality and morbidity, risk factors and health system response. The resulting information will help countries in setting priorities and developing targeted interventions to reverse the NCD epidemic.

Meanwhile, agreements and memoranda of understanding were renewed with the United States CDC and the CDC Foundation to continue implementation of the Global Tobacco Surveillance System in the Region, specifically the Global Youth Tobacco Survey, the Global Adult Tobacco Survey and Tobacco Questions for Surveys. Collaboration continued with the International Agency for Research on Cancer (IARC), WHO’s sister agency, to strengthen cancer surveillance and capacities in the area of research on cancer.

Data on progress made in tackling NCDs at country level were featured in a new regional report, Assessing national capacity for the prevention and control of NCDs. The survey aims to further support countries by identifying progress to date and remaining gaps, highlighting lessons learned and recommending opportunities for improvement.

Mental, neurological and substance use disorders are highly prevalent in the Region, and are major contributors to disease, premature death and disability. They are also frequently associated with high levels of stigma and human rights violations, particularly in low- and middle-income countries.

There have been some welcome signs of progress in recent years. For example, suicide rates have fallen significantly (see Fig. 3). Unfortunately, however, there is still a large gap between the resources available and the resources urgently needed to address the burden of mental disorders. WHO is working with countries to close that gap and help people with mental disorders get the support they need. In 2019, we produced a set of factsheets in both Arabic and English giving basic information about a range of disorders to raise awareness among the general public. We also worked to scale up the mental health gap action programme (mhGAP), which aims to bridge the treatment gap for priority mental health problems through integration within each country’s PHC system.