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Noncommunicable diseases

Regional framework for action

Despite declared political commitment to implement the Political Declaration of the High-Level Meeting of the United Nations General Assembly on the Prevention and Control of Non-Communicable Diseases, many countries are experiencing challenges in moving to concrete action. The response to the 2011 UN political declaration and to the regional framework for action which was endorsed by the Regional Committee in 2012 has been patchy and uneven. Factors responsible for this situation vary from one country to another but generally include inadequate political commitment at the highest level, competing priorities particularly in crisis-stricken countries, weak engagement of non-health sectors whose action is essential in the implementation of key measures, weak health systems including fragmented health information systems, opposing forces including the tobacco industry and the unopposed marketing of unhealthy foods, and the absence of an effective civil society movement.

In 2015, focus continued to be placed on scaling up the implementation of the regional framework for action. Since its endorsement by the Regional Committee, in 2012, the framework has been updated annually and a set of process indicators, intended to guide Member States in measuring progress in implementing the strategic interventions, has been developed.

We continued to hold annual regional meetings on noncommunicable diseases to provide an opportunity for Member States to review the progress made with international and regional experts and to respond to their needs for technical support. In addition the Regional Office continued in 2015 and 2016 to develop concrete technical guidance that will enable countries to implement measures recommended in the four areas of the regional framework (governance, surveillance, prevention and health care) based on evidence, international experience and best practice.

Governance

High-level advocacy was carried out throughout 2015 at various forums, including the World Health Assembly and the Regional Committee, to promote collaboration across sectors outside health and between government and non-state actors. Only six countries now have an operational multisectoral strategy and/or action plan, and four have set targets for 2025 based on WHO guidance. Countries of the Region are at various stages of implementation of their action plans and WHO continues to monitor the situation in collaboration with them, based on the process indicators of the regional framework.

An innovative initiative was the development, in collaboration with the WHO Collaborating Centre at Georgetown University, of a dashboard and policy briefs on best practices in health legislation, based on global evidence. The work provides a guide for countries to take appropriate legislative action to tackle key risk factors in the areas of tobacco control, diet, physical activity and governance. Each of the priority interventions identified is outlined through an individual legal brief that contains tangible recommendations applicable to countries, drawing from global, regional and national experiences, and adaptable to the local economic, social and legal context.

Prevention and control of risk factors

Industry interference with tobacco control policies and the limited involvement of non-health actors continue to be major challenges to operationalizing the interventions in the area of prevention and control of risk factors for noncommunicable diseases. Sixteen countries have adopted a national level target for reducing tobacco use by 30% by 2025 and 17 countries are in the process of implementing taxation increases based on the guidelines to Article 6 of the WHO Framework Convention on Tobacco Control (WHO FCTC). Support was also provided to countries for updating tobacco control legislation, specifically on the aspects of tobacco-free public places, pictorial health warnings, and banning of advertising, promotion and sponsorship.

One of the main activities undertaken was the raising of political awareness on tobacco control issues, particularly on the WHO FCTC protocol and the industry’s influence on tobacco advertising, promotion and sponsorship in drama (TAPS). In this context, six projects were funded for implementation by nongovernmental organizations and completed, tackling different aspects of tobacco use in dramas aired on the regional language networks. Two countries (Yemen and United Arab Emirates) were cited in the WHO Report on the Global Tobacco Epidemic, 2015 as among the highest achieving countries in terms of banning TAPS, and Saudi Arabia was cited as one of the countries that had achieved full compliance with banning tobacco use in public places. Technical support was provided for capacity-building on smoking cessation and ratification of the WHO FCTC protocol in the Gulf Cooperation Council (GCC) countries. Saudi Arabia and Iraq became parties to the WHO FCTC protocol and three new countries joined the highest achieving countries in terms of monitoring (Kuwait, Pakistan and Qatar).

The burden of overweight, obesity and diet-related chronic diseases continues to increase due to nutrition transition, especially in high-income and middle-income countries. Seventeen countries have adopted the International Code of Marketing of Breast-milk Substitutes, and are monitoring its application. Nevertheless the progress on implementation is uneven. A number of policy guidance documents were developed to support the adoption of sustainable multisectoral approaches. These included policy statements and recommended actions for reducing salt, fat and sugar intakes and a protocol for measuring salt intake using 24 hour-urine collection.

Current salt intakes in the Region are very high, with an average intake of 10 g per person per day in most countries. Implementation of salt reduction strategies is progressing in several countries, and multisectoral national committees have been established in some countries with an authority to strategize and monitor implementation of salt reduction activities. Intake estimates for saturated fatty acids are also high, with most countries exceeding the 10% upper limit. Initiatives aimed at reducing total and saturated fat in food products have been undertaken in several countries (Egypt, Iraq, Islamic Republic of Iran and GCC countries). In most countries, industry participation remains voluntary and timid. Food labelling for total fat, saturated fatty acids, transfat and salt in all food imported or locally produced became mandatory in GCC countries. In Egypt, the first steps were taken to reduce palm oil intake with the circulation of a draft standard on subsidized cooking oil. In several countries, private industry moved towards voluntary production of low fat and fat-free dairy products.

A draft nutrient profiling model was developed to guide countries in categorizing foods and beverages into ‘healthy’ and ‘unhealthy’. Support was provided, in collaboration with the WHO Regional Office for Europe, WHO headquarters and Liverpool University, to several countries to develop a provisional roadmap to speed up action on marketing of unhealthy foods through building capacity for legal interventions. A series of sensitization activities culminated in an open forum attended by mainstream media outlets, regional celebrities, media experts and representatives of civil society organizations which resulted in recommendations for non-health sectors to address marketing of unhealthy foods to children.

In order to promote physical activity, capacity development was supported in mass media and social marketing, in partnership with the WHO Collaborating Centre on Physical Activity, Nutrition and Obesity, Sydney, Australia. The first round, in which nine countries participated, resulted in development by representatives of both health and non-health sectors of provisional social marketing and mass media plans. Distance mentoring on implementation was started with four countries (Islamic Republic of Iran, Kuwait, Oman and Morocco). In addition, a toolkit was developed to guide inclusion of physical activity in primary health care.

Surveillance, monitoring and evaluation

The key priority is for Member States to implement the NCD surveillance framework with its three components (monitoring risk factors and determinants, tracking morbidity and premature cause-specific mortality, and assessing health system response and performance). The indicators included under each of the three components will enable Member States to monitor their progress in achieving the targets of the global action plan endorsed by the World Health Assembly.. A training module has been developed and will be offered to countries to build capacity in NCD surveillance and a training course for trainers is expected to be conducted before the end of 2016.

A number of surveys were completed as part of monitoring risk factors. Almost all countries completed the 2015 country capacity survey for noncommunicable diseases, and several countries are engaged at various stages of the STEPS survey to monitor the burden and trends of risk factors, the Global Adult Tobacco Survey and the Global Youth Tobacco Survey. Capacity-building in cancer surveillance was conducted in collaboration with the International Agency for Research on Cancer (IARC), with a focus on establishing population-based cancer registries in countries, while a regional course to further strengthen capacity in surveillance was piloted and is being revised. This was further supported by setting up a standardized assessment tool to identify obstacles and opportunities for countries to scale up surveillance.

Health care

The reorientation of health systems towards the integration of management of noncommunicable diseases into primary health care is a key priority. Building on the recommendations of a regional meeting held in 2014, a guide was developed for assessment of the health systems components underlying effective integration. In addition, a review of global evidence was conducted to support the development of a matrix of policy options, based on WHO health systems building blocks and tailored according to country needs. A core set of quality indicators for management of noncommunicable diseases was developed, as part of a regional initiative on quality measures in primary health care.

A regional situation analysis of care of noncommunicable diseases in emergencies was conducted in five countries focusing on refugees and displaced persons from the Syrian Arab Republic. The findings of the analysis emphasized the importance of a consistent primary health care approach to provision of care, even in emergency contexts. Experiences in the Region have also revealed the need for a standardized set, and timely provision, of core essential medicines and technologies. An emergency health kit for management of noncommunicable diseases was therefore developed, complementing the Interagency Emergency Health Kit.

Country profiles were developed showing where each country stands in addressing the five strategic areas of cancer prevention and control. Work focused on building capacity, first, in establishing or assessing cancer registries, and second, in the development of palliative care. Many countries have invested substantially in organizing nationwide breast cancer screening and public health awareness campaigns. In 2015 WHO provided technical support for the development of screening programmes and for evaluation of public awareness campaigns.

In 2015 the Regional Office led, and played an important role in, advocacy for an accountability framework to measure progress. The contribution of countries was substantial in ensuring that the 10 indicators crafted to measure progress were aligned with the indicators of the regional framework for action. Countries are now better able to monitor and report on progress, and to meet their commitment in implementing the time-bound commitments of Member States: by 2015, to set national targets, and develop/strengthen national multisectoral action plans; and by 2016, to reduce risk factors, and strengthen health systems.

WHO will continue to work with Member States to accelerate progress, which will be measured by the progress indicators during the next United Nations review in 2018. Focus will be placed on raising political awareness and increasing the level of multisectoral involvement in implementing the provisions of the regional framework through a whole-of-government approach and on providing technical support to countries.

Mental health

Mental, neurological and substance disorders account for the loss of 7.4% of disability-adjusted life-years, and for 22.9% of the years lived with disability globally. Illicit drug use accounts for 0·9% of DALYs lost globally. The age-standardized prevalence of drug dependence for cannabis (0.19%), amphetamines (0.25%), cocaine (0.10%) and opioids (0.22%) in the Region are similar to global estimates. However, the Region has the highest prevalence of mental disorders, specifically depressive illness and anxiety disorders, of all WHO regions. This is almost wholly accounted for by the complex emergency situations prevailing within the Region. While all countries have made some progress, irrespective of national income level, a huge treatment gap remains, ranging from 76% to 85% for severe mental disorders.

Despite the great burden, mental health continues to have a low political and public health profile while the stigma attached to it cuts across all aspects of mental health care, with widespread discrimination that has major impact on service development, delivery and utilization. Mental health has suffered chronic under-funding and consequently there is a paucity of specialist staff and services. The skills of both general health workers and mental health leaders are largely limited to the delivery of care.

Institutional care is still the dominant model of care in the majority of countries. This constrains the capacity for development of mental health staff and has led to human rights abuses. There is a lack of research evidence and information from within the Region to underpin strategic planning and service development. Nevertheless, mental health and substance abuse are starting to attract more attention, both globally and regionally, and the number of countries experiencing complex emergency situations is driving up the need and demand for support services.

In 2015, the Regional Committee endorsed an evidence-based regional framework which was developed between 2014 and 2015 by the Regional Office in consultation with Member States and top international and regional experts. The aim of the framework is to scale up action on mental health and operationalize the Comprehensive mental health action plan 2013–2020. Four domains of action were identified by the regional framework: governance, prevention, health care and surveillance.

Good progress has been made by some countries. In the area of governance, some countries (Kuwait, Lebanon, Oman, Qatar, Somalia, United Arab Emirates) developed or updated their mental health strategies in accordance with the global targets and indicators. Three countries (Afghanistan, Saudi Arabia and United Arab Emirates) reviewed their mental health legislation and regulations in accordance with provisions of the United Nations Convention for the Rights of Persons with Disabilities (UNCRPD). The curriculum for a regional course in leadership in mental health was developed and the first course was hosted by American University in Cairo (AUC) t in September 2015.

In the area of health care, support was provided in a number of areas. More than half the countries now have functioning mhGAP programmes aimed at bridging the treatment gap for priority mental health problems through integration within primary health care. So far three countries (Afghanistan, Jordan, Libya) have initiated the Quality and Rights project based on the provisions of the UNCRPD to ensure quality of services and observance of patient’s rights in psychiatric facilities. Services for substance use disorders were strengthened in Iraq and Pakistan through capacity-building and support for the setting up of centres, in collaboration with the United Nations Office on Drugs and Crime (UNODC). Opium substitution treatment services were established in Pakistan and expanded in other countries, while a harm reduction protocol was developed in Oman.

Support was provided, in collaboration with WHO headquarters and international nongovernmental organizations, to countries undergoing humanitarian crises in mental health and psychosocial support in emergencies, through strengthening the technical capacities of the country offices, as well as direct support. The Arabic version of a training package for psychological first aid was published, and a psychosocial intervention package to be delivered through non-specialized health workers in emergencies is being field-tested.

In the area of prevention, the Arabic version of the global report on suicide was published and launched in 2014. An assessment of resources and capacities available for diagnosis and management of autism spectrum disorders was conducted in collaboration with the Italian Public health Institute and the organization Autism Speaks. A training package on mental health for schools was finalized and is in the process of piloting in selected countries, while life skills education materials and parenting skills training materials for autism spectrum disorders are also being finalized.

Guidance was published on setting up systems for suicide registration and substance use treatment information. A core set of quality indicators for mental health care in primary health care was developed, as part of a regional initiative on primary health care quality measures.

WHO will strengthen its linkages and collaboration with regional and global partners to implement the provisions of the regional framework for action in the Region and operationalize the provisions of the global action plan 2013–2020. It will enhance its ability to provide support to countries for reviewing and developing national policies and strategies in line with the global action plan and focus on enhancing the specialist and non-specialist workforce for the integrated delivery of quality mental health care. It will also lead the development of a mental health literacy package and campaign to combat the stigma attached to mental health and substance abuse. It will continue to support countries to scale up mental health and psychosocial support in emergencies and will also promote mental health through school mental health, suicide prevention and mental health literacy programmes.

Promoting health across the life course

The life course approach

Promoting health across the life course addresses key influences on health such as family, social networks, social support, relationships, employment, income, health beliefs, and access to health care and health information. It cuts across all areas of WHO’s work including the health of women before, during and after pregnancy, and of newborns, children, adolescents, and older people, taking into account environmental risks, social determinants of health, gender, equity, and human rights. By identifying critical stages in the life course that influence health, opportunities for health promotion can be recognized and addressed along the continuum of care.

Maternal, reproductive and child health

In 2016, building on the achievements made through the implementation of maternal and child health acceleration plans in countries with a high burden of maternal and child deaths, WHO in collaboration with UNICEF and UNFPA focused on supporting Member States to address the main causes of maternal, neonatal and child deaths by adopting cost-effective, high impact interventions, prioritizing maternal and neonatal health quality of care, and strengthening the promotion of preconception care.

Technical support was provided to national efforts to develop or strengthen strategic plans for reproductive, maternal, neonatal, child and adolescent health. Strategic directions were determined and plans of action developed by all Member States who attended the intercountry meeting on the Every Newborn Action Plan (ENAP) in Amman, Jordan in April 2016. A regional workshop on promoting maternal and neonatal quality of health care was held in Morocco and attended by eight countries with a high burden of maternal and neonatal mortality. The participants were trained on using WHO tools to get a rapid overview of the situation at national and district levels, including a landscaping checklist and analysis framework. Plans of action for promoting the quality of maternal and neonatal health care were developed for implementation to begin in 2017.

Member States were supported to establish preconception care to improve the health outcomes of childbirth. WHO has identified evidence-based core and additional interventions and programmatic steps to facilitate efforts to develop preconception care in countries. In addition, country profiles were developed to foster national efforts in the prevention and management of congenital and genetic disorders.

To improve midwifery competencies in line with WHO norms, standards and guidelines, a national workshop on strengthening the Somali midwifery strategy was conducted with UNFPA in October 2016. The workshop helped in prioritizing the main gaps that need to be addressed to strengthen the Somali midwifery programme and integrate evidence-based interventions in the national midwifery care strategy. Similar activities are planned in Libya, Morocco and Tunisia to strengthen their national strategic frameworks for midwifery care.

A consultative meeting, conducted in collaboration with the Islamic Advisory Group, emphasized the role of religious leaders in raising awareness on issues related to reproductive, maternal and child health and immunization. A plan of action was developed focusing on breastfeeding, immunization, birth spacing, hygiene and sanitation, and care-seeking behaviour (especially for pregnant mothers).

A training workshop on strengthening family planning services through evidence-based guidelines and best practices, held in Tunisia, was attended by 18 Member States who developed national plans of action to ensure the provision of quality family planning services. Building national capacity in family planning is expected to contribute greatly to maternal and neonatal health protection and promotion. An expert consultation to identify core mental health interventions for integration in maternal, child and adolescent health service delivery platforms was held in December 2016.

In terms of child health, in-depth reviews of the integrated management of childhood illness (IMCI) were carried out in the Islamic Republic of Iran and Yemen and four success stories in implementation of IMCI in the Region were documented as part of a global strategic review. Innovative options for IMCI training were introduced to the Region through building the capacities of Member States in the computerized adaptation and training tool and distance learning. Core facilitators from seven targeted Member States were trained in newborn care at home. Member States were supported in the development of the newborn, child and adolescent health component of national reproductive, maternal, neonatal, child and adolescent health strategic plans. The managerial capacity of child health managers at national and subnational levels in Afghanistan was strengthened

WHO is providing technical support to Member States to maintain their commitment to reproductive, maternal, neonatal, child and adolescent health, building close partnerships with concerned United Nations agencies and key stakeholders, and mobilizing the resources required for universal health coverage of women and children.

Nutrition

Deficiencies of essential micronutrients such as vitamin A, iron, folate, zinc and iodine, continue to be widespread and have significant adverse effects on child survival, growth and development, as well as on women’s health and well-being. The regional prevalence of stunting, wasting and underweight is 28%, 9% and 18%, respectively. The countries with the highest burden of stunting are Afghanistan, Djibouti, Pakistan, Sudan and Yemen. However, many countries are on track to meet the 2025 target for stunting set by the World Health Assembly. The prevalence of overweight and obesity in adults in the Region is 27% and 24.4%, respectively, and 16.5% and 4.8%, respectively, in school age children, with the highest levels of obesity in Bahrain, Kuwait, Qatar and United Arab Emirates.

There remains a need in the Region for effective nutrition surveillance and monitoring and evaluation systems, essential for policy-making, accountability and effective programme implementation. Integrating nutrition within health systems is a challenge in many countries, particularly those where the population has limited access to health services including disease prevention, treatment and rehabilitation. Moreover, available financial resources are very limited. These issues are compounded in countries experiencing conflict and humanitarian crises.

Most Member States of the Region have now developed or reviewed national action plans in line with global WHO nutrition policies and strategies. More than 17 countries have also developed full or partial legal documents relating to the Code of Marketing for Breast Milk Substitutes, but implementation remains a challenge. In 2016, development of food-based dietary guidelines was expanded in the Region to include Afghanistan, Egypt, Islamic Republic of Iran, Lebanon, Oman, Qatar and Saudi Arabia. Egypt was the first country in the Region to conduct a landscape analysis on its readiness to accelerate action in nutrition as part of a global project supported by WHO and UNICEF.

Bahrain, Egypt, Jordan, Kuwait, Oman, Qatar and Saudi Arabia have made tremendous progress and are on track for the sustainable elimination of iodine deficiency disorders. In Afghanistan, Syrian Arab Republic and Yemen, WHO supported the establishment of health facility nutrition surveillance and the management of acute malnutrition in therapeutic feeding centres and through mobile nutrition teams. Pakistan, Somalia, Sudan and Yemen became members of the Scaling Up Nutrition (SUN) Movement, providing a great opportunity to galvanize action to ensure country progress in their efforts to reach the targets of the SDGs, particularly SDGs 1, 2 and 3. There is now supplementation and food fortification with essential micronutrients in nearly all countries of the Region.

The development of a roadmap for action to address nutrition-related noncommunicable disease risk factors such as through salt and fat intake reduction is a priority for the Region. WHO will continue to support the adoption and implementation of the United Nations Decade of Action on Nutrition (2016–2030) and encourage coordinated and comprehensive implementation of strategies by Member States to address the double burden of malnutrition. WHO is working with Member States to develop a framework of action for scaling up work on nutrition with more focus on cost-effective interventions and to support the establishment of national targets and monitoring national action plans.

WHO will continue to provide expertise at country level in specialized areas such as the adoption of legal instruments that ensure national application of international norms and standards and evidence-based interventions, engage in capacity-building for high-burden countries on prevention, management and treatment of malnutrition and support national training on healthy growth monitoring and the prevention, management and treatment of malnutrition for children under five years of age.

Health of special groups

In 2016, WHO continued to provide support to countries on ageing and health, focusing on developing policies and strategies that foster healthy and active ageing, delivering integrated person-centred services that respond to the needs of older people, and strengthening the evidence-base and monitoring and evaluation mechanisms to address key issues relevant to the health of older people. However, the prevailing humanitarian crises and limited financial resources in many countries has meant that only seven Member States have allocated funds this biennium to support the implementation of relevant activities.

WHO worked closely with local authorities in United Arab Emirates in the area of age-friendly cities and supported the organization of the Fifth Forum for Elderly Services held in Sharjah in September. Sharjah has since been declared an age-friendly city, part of the global network of age-friendly cities.

WHO will continue to support implementation of the Global strategy and action plan on ageing and health 2016–2020 in countries. Effective partnership and coordination among concerned stakeholders will be needed to overcome the limited resources in this area. The unmet needs of older persons need to be at the centre of relief efforts and programmes in countries in emergency situations.

Violence, injuries and disabilities

The Eastern Mediterranean Region has the second highest road traffic fatality rate (19.9 per 100 000 population) among WHO regions. Middle-income countries account for the vast majority of deaths, while the Region’s high-income countries have an overall fatality rate that is more than double the average rate of high-income countries globally. Efforts have been undertaken in countries to implement proven cost-effective interventions, but these are not pursued within a whole safe system approach, limiting their effectiveness. The global road traffic injury-related targets of the Decade of Action on Road Safety 2011–2020 and the SDGs (targets 3.6 and 11.2) provide important opportunities to build on existing country efforts to strengthen collective action for road safety in the Region.

In 2016, WHO continued to play its normative technical role through its work on different aspects of road traffic injury prevention and control from data to care. Expert consultations were organized to seek the input of key regional and global experts on strengthening action for road traffic injury prevention and emergency care in the Region. Together with Johns Hopkins Bloomberg School of Public Health, a regional road safety report was developed comprising an in-depth analysis of the burden of road traffic injuries in the Region and related risk factors, with proposed recommendations for countries. Implementation of a standard methodology for estimation of the cost of road traffic injuries in the Region was initiated in two countries (Egypt and Tunisia) and assessments of existing emergency care systems were completed in the Islamic Republic of Iran, Libya and Tunisia. The participation of countries of the Region in global road safety events was supported and a regional meeting held on essential services for emergency care at the primary and first level referral hospital levels. Work continues to integrate injury prevention and control in ongoing initiatives. The WHO child injury prevention policy assessment tool was piloted in the Islamic Republic of Iran as part of a global exercise in different WHO regions.

In the area of violence prevention, coordination continued with concerned United Nations agencies and the Arab League to ensure consistent messaging and sustainable interagency coordination of technical support. Mapping of health sector protocols and guidelines to address violence against women in countries was completed and focused support was maintained to strengthen the health sector response to gender-based violence in Afghanistan and Pakistan. In collaboration with the national family safety programme, Saudi Arabia, the WHO child maltreatment prevention readiness assessment tool was implemented in GCC countries.

The WHO Regional Committee for the Eastern Mediterranean issued resolution EM/RC63/R.3 on improving access to assistive technology, a landmark in the area of disability and rehabilitation. As a result, a rapid situation assessment of assistive technology provision at a system level in countries of the Region was initiated. The WHO/World Bank model disability survey was started in Pakistan and Qatar and support was provided to Oman and Sudan to develop and implement disability action plans, and to the Syrian Arab Republic to strengthen the delivery of rehabilitation services.

The average prevalence of blindness in countries ranges from 0.5% to 1.5%, with Afghanistan, Egypt, Djibouti, Somalia and Yemen having the highest prevalence. The WHO global action plan on universal eye health 2014–2019 aims to support efforts by Member States to achieve a measurable reduction of 25% (compared to 2010) of avoidable visual impairment by 2019, with special focus on developing national action plans in line with the WHO framework for action for strengthening health systems. During 2016, Afghanistan, Lebanon and Yemen developed and revised their five-year national action plans on eye health in line with the global action plan, making a total of 16 countries who have so far developed national action plans in the Region. A database was developed based on global action plan indicators to monitor the implementation of eye health national action plans in the countries of the Region, while country profiles were updated on eye and ear health, and trachoma mapped in endemic countries (Afghanistan, Egypt, Pakistan, Somalia, Sudan and Yemen).

Assessments were undertaken on the status of eye care services in seven countries and diabetic retinopathy and diabetes management systems in eight. WHO continued to build the capacity of countries to integrate eye and ear health into primary health care and national health information systems, and to promote evidence-based advocacy and planning for eye and ear health as part of the overall health system. This approach is now being adopted in most countries in the Region.

The prevalence of disabling hearing loss in the Region is estimated at between 2.7% and 4.4%, with adults accounting for 91% and children 9%. In approximately 50% of adults and 60% of children, hearing loss is avoidable through prevention and early detection. In 2016, support was provided to eight countries (Bahrain, Djibouti, Jordan, Kuwait, Morocco, Oman, Qatar, Saudi Arabia) that have undertaken surveys to estimate the prevalence of hearing loss, have national plans for ear and hearing care in varying stages of development and implementation, and have screening programmes to detect hearing loss for newborns and school children.

Major challenges that continue to impede effective action to address violence, injuries and disabilities include insufficient financial and human resources at regional and country levels. In terms of road safety and injury prevention, efforts are fragmented in the absence of a whole safe system approach, while coordination and multisectoral action are not based on sustainable mechanisms. Enforcement, implementation and evaluation of policy and legislative frameworks are insufficient, while data systems are weak and fragmented with widespread under-reporting. Significant gaps continue to exist in post-injury emergency and trauma care and rehabilitation services. In terms of disability, challenges include finding space for eye and ear health indicators in national health information systems, and integrating and delivering primary eye and ear care in primary health care. Contextual challenges also persist, including crisis and post-crisis situations in many countries.

Health education and promotion

Insufficient physical activity is one of the 10 leading risk factors for global mortality, causing some 3.2 million deaths each year. Globally, the Region has the second highest prevalence of physical inactivity (31%), although with wide variation across the Region. In 2016, there was a focus on building national capacities in the development of national multisectoral plans of action on physical activity and plans for social marketing and mass media campaigns. A survey assessing national capacity to develop and implement physical activity policies and programmes was expanded from 12 to 16 countries. In an effort to curb the rising levels of physical inactivity, 48% of countries in the Region implemented at least one national public awareness programme on physical activity in 2016. The biggest challenges facing countries are their limited capacity to mobilize non-health sectors to implement World Health Assembly recommendations on physical activity and the lack of coordination between different sectors.

Regionally, progress in implementing the recommendations on controlling unhealthy food in children has been slow, despite clear commitment by countries, while expenditure on promoting energy-dense diets has grown considerably in recent years. Only 19% of countries in the Region have implemented WHO recommendations on the marketing of foods and non-alcoholic beverages to children.

Following on from the concerns expressed by the ministerial panel discussion on the prevention of noncommunicable diseases held during the Sixty-first session of the WHO Regional Committee for the Eastern Mediterranean in 2014 and the forum on addressing unopposed marketing of unhealthy foods and beverages to children held in Jordan in 2015, an expert meeting was held to finalize a regional roadmap to address unopposed marketing of unhealthy foods and beverages to children and a survey on food marketing was initiated.

Social determinants of health and gender

In 2016, there was regional participation in the global technical meeting on measuring and monitoring action on the social determinants of health in response to the Rio Political Declaration on Social Determinants of Health. The meeting, held in June in Ottawa, Canada, focused on harmonization of monitoring systems and review of the core indicators proposed by WHO. Also in 2016, the Health-in-All-Policies (HiAP) training manual was translated into Arabic to maximize its use in the Region, and preparations were begun for a regional multisectoral consultation on HiAP. An in-depth assessment of the social determinants of health was initiated in Oman as a first step in developing national and subnational action plans.

Regional adaptation, piloting and implementation of WHO tools to support the integration of gender, equity and human rights in national policies and planning was carried out in 2016. Close cooperation continued with concerned United Nations agencies and the Arab League to promote health and human rights and gender in the Arab world, while health protocols and guidelines on gender-based violence were piloted in Afghanistan and Pakistan, involving the adaptation of WHO instruments, capacity-building and health care facility assessment.

Ongoing challenges include insufficient dedicated human resources and funding at regional and country levels, inadequate national capacity, and the security situation and ongoing conflicts in many countries of the Region.

Health and the environment

Environmental health is an area of growing importance for the Region, with environmental risk factors, such as air, water and soil pollution, chemical exposures, climate change and radiation, contributing to more than 100 diseases and injuries. The health impact of environmental risks is reflected in both communicable and noncommunicable diseases in all countries in the Region, with environmental hazards responsible for about 22% of the total burden of disease. The top environmental health-related causes of death in the Region are heart disease, stroke, respiratory infections and diarrhoeal diseases, targeting the most vulnerable, including children and the elderly. It is estimated that more than 850 000 people die prematurely every year as a result of living or working in unhealthy environments – nearly 1 in 5 of total regional deaths, with 72% of these the result of noncommunicable diseases and injuries.

About one half of environmentally-caused premature deaths are attributable to air pollution, with the rest due to chemical exposures, lack of access to water and sanitation, and other environmental hazards. Air pollution with particulate matter reaches alarming levels in many cities of the Region, with about 98% of the urban population breathing air exceeding WHO safe levels by up to 12-fold, causing about 400 000 annual deaths.

In 2016, national plans of action to implement the regional strategy on health and the environment and its related framework for action (2014–2019) were developed and adopted by many countries, and WHO was instrumental in the finalization of the strategy on health and the environment in the Arab Region (2017–2030). All countries of the Region endorsed the global roadmap on the health impacts of air pollution on health, while 82 cities in 16 countries report their air quality data to a WHO database, improving burden of disease estimates and highlighting regional specificities, such as natural dust pollution. Status reports on water and sanitation were generated for all countries and country profiles on water, sanitation and health enablers issued for 11 countries.

The needs of the Region were reflected in several global and regional processes, including WHO drinking-water quality guidelines, guidance on managing radioactivity, and the global water, sanitation and health strategy. Development of a compendium of national standards on drinking-water quality is under way. Normative and technical support was provided to countries on drinking-water quality management and sanitation/wastewater use, and training provided on water and sanitation safety management and addressing chemical and liquid waste in health care facilities.

A draft regional plan of action for food safety was developed to enable countries to fulfil the recommendations of their national food safety assessments and national profiling in order to control risk and reduce the burden of foodborne diseases, including zoonotic diseases linked to food safety. A training workshop for improving food safety laboratory was conducted, and a regional guidance document on food safety laws and regulations completed. Technical support was also provided on chemical safety in the Region. To address the heath aspects of the Minamata Convention on Mercury, participants from 12 countries of the Region were trained on phasing out mercury in the health sector.

The impact of environmental risks and the lack of environmental health services on morbidity and mortality rates is exacerbated during emergencies. Addressing the environmental health aspects of emergencies requires WHO to work with all countries to invest in vulnerability and risk assessment, preparedness, response and recovery planning.

In 2016, capacity-building in the areas of water, sanitation and health, chemical safety, food safety and waste management was undertaken for emergency-struck and neighbouring countries. A technical training workshop on environmental health services in conflicts was conducted for Syrian health personnel and United Nations staff and a field assessment of the environmental health impact of the crises in the Syrian Arab Republic was carried out, resulting in a comprehensive report with practical recommendations. Technical support and emergency supplies were provided to countries to respond to cholera outbreaks, and to the Syrian Arab Republic for securing drinking-water sources and groundwater wells near health care facilities.

Health personnel and first responders were trained on chemical exposure and trauma care, and factsheets on chemical exposure made available in local languages for the countries in conflict. Technical support was also provided to help several countries in responding to air pollution emergencies, including (with the United Nations Environment Programme) an assessment of the health impact of an Israeli industrial zone on the Palestinian population.

Climate change poses serious, but preventable, risks to public health. In the Region, it is producing more frequent and more intense heat waves, floods, droughts and dust storms. Its effects are being seen in increasing mortality and morbidity rates, including airborne respiratory diseases, water and foodborne diseases, vector-borne diseases, malnutrition, heat stress and occupational injuries. The Regional Office was instrumentally involved in the preparation for 22nd session of the Conference of the Parties to the United Nations Framework Convention on Climate Change in Marrakesh, Morocco and the WHO Second Global Conference on Climate and Health in Paris, France. With the support of WHO, eight countries developed national profiles on climate and health, tackling vulnerability, adaptation and mitigation.

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Promoting health across the life course

The life-course approach

Promoting health and well-being across the life-course cuts across all areas of WHO’s work, including the health of women before, during and after pregnancy, newborns, children, adolescents and older people. The aim is to reduce mortality and morbidity, and address the social, economic and commercial determinants of health of the population. By identifying critical stages in the life-course that influence health, opportunities for health promotion can be recognized and addressed along the continuum of care.

Reproductive, maternal, newborn, child and adolescent health

Reproductive, maternal, newborn, child and adolescent health has been recognized as a priority in the roadmap for WHO’s work in the Eastern Mediterranean Region (2017–2021). It is the cornerstone of the United Nations Global strategy for women’s, children’s and adolescent’s health (2016–2030) and a prerequisite for achieving the SDGs by 2030. Maternal, neonatal and child mortality levels, and meeting the need for family planning, are core indicators in monitoring the progress being made by the reproductive, maternal, newborn, child and adolescent health programmes in Member States. Unfortunately, progress remains uneven, with clear setbacks in countries affected by humanitarian crises.

In 2017, WHO maintained technical support for national strategic planning. Iraq, United Arab Emirates and Yemen launched strategic plans, good progress was made in Afghanistan, Egypt, Libya, Morocco, Pakistan and Saudi Arabia, and focused support was provided for national efforts in Syrian Arab Republic and Tunisia. In September, WHO, jointly with the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF), held the third annual intercountry meeting of maternal and child health programme managers in the Region. The 19 participating countries developed plans of action to scale up national programmes towards achieving the health-related SDG targets and promoting the transfer of knowledge and expertise to Member States. The meeting released a joint statement expressing the commitment of the H6 global health partnership to the health of women, children and adolescents. The H6 partnership pulls together six United Nations agencies, related organizations and programmes to improve the health and save the lives of women and children, namely WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS), UNFPA, UNICEF, the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) and the World Bank.

In response to the specific reproductive and maternal health needs that exist in crisis situations, WHO and UNFPA held an informal consultation in August on improving the existing reproductive health emergency kits. In addition, a project to improve family planning practice in emergency situations was initiated with an assessment of practice in refugee camps in Lebanon based on WHO practice recommendations on safe and effective contraceptive use.

To improve the quality of care for reproductive and maternal health, up-to-date WHO maternal and newborn quality of care standards and tools, including the Standards for improving quality of maternal and newborn care in health facilities (WHO 2016) were introduced to Member States. The Islamic Republic of Iran adapted the existing tools to their local context, providing a model for other countries in the Region. In addition, technical support was provided to Palestine and Sudan on early essential newborn care coaching, and to the Syrian Arab Republic on Integrated Management of Childhood Health (IMCI) and caring for the newborn at home in humanitarian settings.

Throughout 2017, close follow-up with countries was maintained to support the strengthening of family planning services through the implementation of evidence-based guidelines and best practices, with a focus on countries with low contraceptive prevalence rates, to assist them in developing plans of action funded by the Bill & Melinda Gates Foundation. As part of this project, a training-of-trainers course on evidence-based guidelines for strengthening family planning services was conducted for national gynaecology and obstetrics societies and midwifery associations in the Region. This resulted in plans of action to strengthen the role of the private sector in providing family planning services in countries. National training activities were also assisted, such as in Morocco and Tunisia, and WHO disseminated the publication Medical eligibility criteria wheel for contraceptive use (WHO 2015) to Member States to support national capacity-building activities and enhance service quality.

In October 2017, resolution EM/RC64/R.4 on the operationalization of the adolescent health component of the Global strategy for women’s, children’s and adolescents’ health (2016–2030) was endorsed at the 64th session of the Regional Committee. The resolution urged Members States to develop and/or update national adolescent health action plans using the Accelerated Action for the Health of Adolescents (AA-HA!) implementation guidance towards a comprehensive approach to the planning, monitoring and evaluating of adolescent health interventions. Ten Member States received training in the use of the guidance, with Sudan being the first country in the world to apply it in developing a country strategic plan for adolescent health and development. In addition, partnerships with concerned United Nations agencies were strengthened through the implementation, monitoring and evaluation of the Regional framework of joint strategic actions for young people in the Arab States/Middle East and North Africa Region (2016–2017). Meanwhile, a regional implementation framework for newborn, child and adolescent health (2018–2025) and a regional operational field guide for child and adolescent health in humanitarian settings were developed in consultation with Member States.

The roadmap of WHO’s work in the Region provides a solid platform to foster national efforts to improve reproductive, maternal, newborn, child and adolescent health using up-to-date WHO evidence-based interventions. Cross-programme proposals have been developed to support the implementation of priority areas for reproductive, maternal, newborn, child and adolescent health within the roadmap for implementation in 2018–2019. Partnerships, especially with the concerned United Nations sister agencies and key donors, resource mobilization and national capacity-building will remain critical in supporting Member States to achieve the SDGs by 2030.