PDF version

Editorial

Awad Mataria,¹ Richard Brennan,² Arash Rashidian,³ Yvan Hutin,⁴ Asmus Hammerich,⁵ Maha El-Adawy ⁶ and Rana Hajjeh ⁷

1Director, Department for Universal Health Coverage/Health Systems, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Regional Emergency Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 3Director, Department for Science, Information and Dissemination, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 4Director, Department for Universal Health Coverage/Communicable Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 5Director, Department for Universal Health Coverage/Noncommunicable Diseases and Mental Health, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 6Director, Department for Health Protection and Promotion, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 7Director of Programme Management, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. (Correspondence to: Awad Mataria: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Citation: Mataria A; Brennan R; Rashidian A; Hutin Y; Hammerich A; El-Adawy M; et al. ‘Health for All by All’ during a pandemic: ‘Protect Everyone’ and ‘Keep the Promise’ of Universal Health Coverage in the Eastern Mediterranean Region. East Mediterr Health J. 2020;26(12):1436–1439. https://doi.org/10.26719/2020.26.12.1436

Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

---

The Universal Health Coverage (UHC) Day has been commemorated on 12 December every year since 2017 (1). In 2019, the theme of the day was “Keep the Promise”, referring to the Political Declaration on UHC endorsed by Heads of States at the United Nations General Assembly High-Level Meeting on 23 September 2019 (2). In 2020, the theme is “Protect Everyone”, emphasizing global and individual health security in the context of the COVID-19 pandemic, attributed to SARS-CoV 2 – a virus that infected more than 4 million people in the Eastern Mediterranean Region (EMR) and left over 100 000 dead in less than 12 months (6.6% and 7.1% of the global toll, respectively) (3). Keeping the promise of UHC, while ensuring health security, is becoming a priority agenda of policy-makers and practitioners in the EMR in order to save lives, advance health and protect livelihoods (4).

Covering everyone: where are we in the Eastern Mediterranean Region?

Universal health coverage is about ensuring that all individuals and communities have access to their needed health services of good quality and with financial protection (5). Primary Health Care (PHC) is recognized as the most inclusive, effective and efficient approach to promote health and achieve UHC (6). The EMR was the first WHO region to express collective political commitment towards UHC by signing the UHC2030’s Global Compact (7) and endorsing the 2018 Salalah Declaration (8). The latter provides a regional roadmap based on PHC to achieve UHC by 2030 (9). Nevertheless, in 2019 the UHC Global Monitoring Report (10) showed that the EMR is lagging behind in achieving the UHC targets of the Sustainable Development Goals (SDGs): Service Coverage (SDG target 3.8.1) and Financial Protection (SDG target 3.8.2).

Countries in the EMR face a plethora of public health challenges: from high rates of smoking to high intake of sugar and salt, emerging and re-emerging communicable diseases, weak disease surveillance and response, and the unfinished agenda in many countries of high maternal and child mortality (11). The Service Coverage Index in the EMR was estimated at 58 (out of 100) in 2019, below the global average of 66 (out of 100), and behind three other WHO Regions (12). Close to 77 million people in the EMR faced financial hardship in 2015 by spending more than 10% of their resources as direct out-of-pocket payments – 15 million more compared with 2010 (13). These overall indices reflect difficulties in provision of care to key subgroups, countries and geographical areas in the Region. Several vulnerable groups in the EMR remain uncovered by financial protection or without access to their needed quality health care – including communities impacted by conflict and state fragility, refugees, migrants and those in the informal sector (14). The COVID-19 pandemic has amplified all these challenges (15).

Protecting everyone: where are we in the Eastern Mediterranean Region?

Health security is about reducing vulnerability to health threats at individual and collective levels (16). The EMR is prone to emergencies from multiple hazards, including disease outbreaks, natural disasters, conflicts, displacements, and technological disasters. Of particular concern are the multiple conflicts and humanitarian crises across the Region, where major health system disruptions pose enormous obstacles to health service delivery and health security (17). Over 69.6 million people living in the Region require humanitarian assistance, representing 42% of the global total (18). The Region is also source of 64% of the world’s refugees, many of whom remain in the EMR (19).

Between 2016 and 2018, Joint External Evaluations (JEEs) (20) assessed 18 EMR countries in terms of their ability to prevent, prepare for, detect and respond to public health risks, as pertains to International Health Regulations’ implementation (21). The evaluations revealed varying levels of capacities. Accordingly, National Action Plans for Health Security were developed but not adequately implemented. The response to COVID-19 pandemic has exposed additional gaps in emergency preparedness and management across the Region that the JEEs did not fully reveal. After almost one year of the pandemic, the most pressing challenges continue to exist – scaling up proven public health measures, tackling COVID-19 fatigue, balancing the easing of COVID-19 control measures while maintaining suppression of the virus transmission, and establishing a platform for distribution of COVID-19 vaccines (22).

Universal Health Coverage and Health Security – lessons from COVID-19 for the Eastern Mediterranean Region

Dr Adhanom Ghebreyesus Tedros, World Health Organization (WHO) Director-General, has repeatedly indicated that UHC and Health Security are two sides of the same coin (23). COVID-19 unveiled how ill-prepared the world was to face a pandemic of such magnitude and how vulnerable most national health systems are to ensure continuous access to essential health services amid emergencies. A survey conducted in the EMR revealed that about 75% of essential health services had some level of disruption (in 13 out of 22 countries that responded), mostly affecting routine immunizations, dental services, rehabilitation services, and family planning, in addition to chronic disease management, including cancer care (22). Moreover, the pandemic has exposed the fragility of medicine and vaccine supply chains.

The pandemic is projected to cost the world up to US$ 21 trillion; a cost which could have been largely avoided with an adequate investment in emergency preparedness (24). The pandemic has demonstrated the value of decisive and collaborative leadership based on evidence-informed decisions (25). It has also highlighted more than ever the importance of whole-of-society, whole-of-government approaches in formulating policies and ensuring their effective implementation. Furthermore, it reminded us of the key role of health professionals, stressing their chronic universal shortages as previously reiterated by the High-Level Commission on Health Employment and Economic Growth (26). Finally, the pandemic signaled the low investment in Essential Public Health Functions (27) and other Common Goods for Health in building equitable and resilient health systems (28).

How to build a resilient health system that supports the dual goal of Universal Health Coverage and Health Security?

The concept of “health system strengthening” made its way to global public health in the last few decades as key for the effective implementation of global and national health policies. Health systems mean ‘all institutions and activities whose primary purpose is to promote, maintain or restore health’ (29). COVID-19 unveiled gaps in current health systems analytical approaches, calling for a paradigm shift towards developing resilient health systems that ensure health security while advancing UHC based on the PHC approach. The ‘Step 0’ in health system recovery from COVID-19 requires adequate investment in Essential Public Health Functions and other Common Goods for Health (e.g. policy and coordination, taxes and subsidies, regulations and legislations, information, analysis and communication and population services) (30), coupled with rebuilding ‘fit-for-purpose’ institutions towards UHC and health security (31). This calls for integrating health programs’ specificities; e.g. communicable diseases, noncommunicable diseases, mental health, and reproductive, maternal, neonatal, child and adolescent health, in all endeavors that aim for strengthening health systems.

What is needed to protect everyone and keep the promise of Universal Health coverage in the Eastern Mediterranean Region?

Advancing UHC and ensuring health security are two key Regional Strategic Priorities in the EMR Vision 2023 (32). Moving ahead requires building resilient health systems that are able to resist, absorb, accommodate and recover from external shocks in a timely and efficient manner (16). The ‘Turning Vision into Action’ paper (33) endorsed by the 66th Session of Eastern Mediterranean Regional Committee in 2019 identified the Strategic Directions to advance the complementary goals of UHC and Health Security. Prominent among those are: investing in health protection and promotion, evidence-informed policy-making (34), building effective information systems (35) and disease surveillance approaches, strengthening emergency preparedness and response, investing in health workforce and facilitating community engagement. Sustainability can only be ensured by institution building.

We have always known that diseases have no borders and that only collective efforts ensure the safety and security of all. A pandemic is not the time to stall investments in public health. Just the opposite. As we respond to COVID-19, countries must invest more and invest better in strong health systems to ‘Protect Everyone’ – during and after the pandemic. This should include the young and the old, men and women, citizens and residents, refugees, migrants and internally displaced people, etc. WHO together with all health and development partners shall continue to build and rebuild health systems to achieve UHC and Health Security, via technical cooperation, capacity building and experience sharing. ‘Health for All by All’ has been the regional motto since 2018. COVID-19 has underscored its relevance today more than ever.

References

1. United Nations. International Universal Health Coverage Day. New York: United Nations; 2019 (https://universalhealthcoverageday.org/).
2. United Nations. Universal Health Coverage: moving together to build a healthier world – UN high-level meeting on Universal Health Coverage. New York: United Nations; 2019 (https://www.un.org/pga/73/event/universal-health-coverage/).
3. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Eastern Mediterranean Regional Office COVID-19 dashboard. Cairo: WHO/EMRO; 2020 (https://app.powerbi.com/view?r=eyJrIjoiN2ExNWI3ZGQtZDk3My00YzE2LWFjYmQtNGMwZjk0OWQ1MjFhIiwidCI6ImY2MTBjMGI3LWJkMjQtNGIzOS04MTBiLTNkYzI4MGFmYjU5MCIsImMiOjh9).
4. Al-Mandhari A. Public health in the Eastern Mediterranean Region: profound challenges, huge opportunities. Lancet. 2019 Sep 21;394(10203):992-993. doi:10.1016/S0140-6736(19)32138-5.
5. World Health Organization. Universal health coverage (UHC). Geneva: World Health Organization; 2019 (https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)).
6. World Health Organization and the United Nations Children’s Fund (UNICEF). Declaration of Astana. Geneva: WHO & UNICEF; 2018 (https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf).
7. UHC2030. Global compact. Geneva & New York: World Health Organization; 2020 (https://www.uhc2030.org/what-we-do/working-better-together/global-compact/).
8. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Salalah Declaration signals countries’ firm commitment to universal health coverage. Cairo: WHO/EMRO; 2018 (http://www.emro.who.int/media/news/salalah-declaration-signals-countries-firm-commitment-to-universal-health-coverage.html).
9. Al-Mandhari A. Achieving “Health for All by All” in the Eastern Mediterranean Region. East Mediterr Health J. 2019 Oct 13;25(9):595-596. https://doi.org/10.26719/2019.25.9.595.
10. World Health Organization. Health statistics and information systems. Geneva: World Health Organization; 2020 (https://www.who.int/healthinfo/universal_health_coverage/report/2019/en/).
11. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Country health profiles. Cairo: WHO/EMRO; 2020 (http://www.emro.who.int/entity/statistics/country-health-profiles.html).
12. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Monitoring health and health system performance in the Eastern Mediterranean Region. Cairo: WHO/EMRO; 2019 (https://rho.emro.who.int/sites/default/files/booklets/EMR-HIS-and-core-indicators-2019-final_0.pdf%20).
13. World Health Organization. Health statistics and information systems – 2019 monitoring report. Geneva: World Health Organization; 2020 (https://www.who.int/healthinfo/universal_health_coverage/report/2019/en/).
14. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Regional committee technical papers. Cairo: WHO/EMRO; 2018 (https://applications.emro.who.int/docs/RC_Technical_Papers_2018_4_20534_EN.pdf?ua=1).
15. Al-Mandhari A. Coming together in the Region to tackle COVID-19. East Mediterr Health J. 2020 Sep 24;26(9):992-993. https://doi.org/10.26719/2020.26.9.992
16. Kutzin K, Sparkes S. Health systems strengthening, universal health coverage, health security and resilience. Bull World Health Organ. 2016;94:2 http://dx.doi.org/10.2471/BLT.15.165050
17. Brennan R, Hajjeh R, Al-Mandhari A. Responding to health emergencies in the Eastern Mediterranean region in times of conflict. Lancet 2020(2 March). https://doi.org/10.1016/S0140-6736(20)30069-6 (Epub ahead of print).
18. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Global humanitarian overview 2020. New York: OCHA; 2019 (https://www.unocha.org/sites/unocha/files/GHO-2020_v9.1.pdf).
19. United Nations High commissioner for Refugees (UNHCR). UNHCR global trends—forced displacement in 2018. Geneva: UNHCR; (https://www.unhcr.org/5d08d7ee7.pdf).
20. World Health Organization. Strengthening health security by implementing the International Health Regulations (2005) – Joint External Evaluations. Geneva: World Health Organization; 2020 (https://www.who.int/ihr/procedures/joint-external-evaluations/en/0.
21. World Health Organization. International Health Regulations (2005). Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/9789241580410).
22. Al-Mandhari AS, Brennan RJ, Abubakar A, Hajjeh R. Tackling COVID-19 in the Eastern Mediterranean Region. Lancet. 2020(19 November). https://doi.org/10.1016/ S0140-6736(20)32349-7 (In press).
23. Tedros AG. All roads lead to universal health coverage. Geneva: World Health Organization; 2017 (http://www.who.int/news-room/commentaries/detail/all-roads-lead-to-universal-health-coverage).
24. World Health Organization. A world in disorder: Global Preparedness Monitoring Board annual report 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/gpmb/assets/annual_report/GPMB_AR_2020_EN.pdf).
25. Obaid Al Saidi AM, Abikar Nur F, Al-Mandhari AS, El Rabbat M, Hafeez A, Abubakar A. Decisive leadership is a necessity in the COVID-19 response. Lancet 2020;396(10247): 295–98 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333999/).
26. World Health Organization. Health workforce – high-level commission on health employment and economic growth. Geneva: World Health Organization; 2016 (https://www.who.int/hrh/com-heeg/en/).
27. Alwan A, Shideed O, Siddiqi S. Essential public health functions: the experience of the Eastern Mediterranean Region. East Mediterr Health J. 2016 Dec 12;22(9):694-700. https://doi.org/10.26719/2016.22.9.694.
28. Soucat A, Kickbusch I. Global common goods for health: towards a new framework for global financing. Global Policy. 2020;11(5):628-635 (https://onlinelibrary.wiley.com/doi/epdf/10.1111/1758-5899.12875).
29. World Health Organization. The world health report 2000. Geneva: World Health Organization; 2000 (https://www.who.int/whr/2000/en/whr00_en.pdf?ua=1).
30. Soucat A. Financing common goods for health: fundamental for health, the foundation for UHC. Health Systems and Reform. 2019;5(4) (https://www.tandfonline.com/doi/full/10.1080/23288604.2019.1671125).
31. UHC2030. Living with COVID-19: Time to get our act together on health emergencies and UHC. Geneva: World Health Organization; 2020 (https://www.uhc2030.org/fileadmin/uploads/uhc2030/Documents/Key_Issues/Health_emergencies_and_UHC/UHC2030_discussion_paper_on_health_emergencies_and_UHC_-_May_2020.pdf).
32. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO. Vision 2023 Eastern Mediterranean Region. Cairo: WHO/EMRO; 2018 (http://www.emro.who.int/about-who/vision2023/vision-2023.html).
33. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO. WHO’s strategy for the Eastern Mediterranean Region, 2020-2023. Cairo: WHO/EMRO; 2019 (https://applications.emro.who.int/docs/EMRPUB-RDO-014-2019-EN.pdf).
34. Rashidian A, Mandil A, Mahjour J. Improving evidence informed policy-making for health in the Eastern Mediterranean Region. East Mediterr Health J. 2018;23(12):793-794. https://doi.org/10.26719/2017.23.10.793
35. Rashidian A. Effective health information systems for delivering the Sustainable Development Goals and the universal health coverage agenda. East Mediterr Health J. 2019;25(12):849-851. https://doi.org/10.26719/2019.25.12.849