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Strengthening health systems for universal health coverage PDF Print

Universal health coverage

In 2016, the framework for action on advancing universal health coverage in the Eastern Mediterranean Region was updated. The framework provides a clear roadmap for Member States to transform their health systems to progress on the three dimensions of universal health coverage, and specifies the type of support that WHO and other development partners can provide.

In 2016, guided by the framework, five countries (Islamic Republic of Iran, Iraq, Pakistan, Palestine and Saudi Arabia) took concrete steps to review and reform their health systems in line with the goals of universal health coverage. In addition, Sudan finalized several specific health strategies to reform the health system and endorsed the Khartoum Declaration on universal health coverage in January 2017. The framework also influenced the development of a framework for action for universal health coverage in Africa, developed jointly with the World Bank, Japan International Cooperation Agency, the African Development Bank and others.

In 2016, the second round of the leadership for health programme took place, with 30 policy-makers and mid- and high-level managers from the Region taking part. The programme, developed in collaboration with the Harvard School of Public Health and the Graduate Institute of International and Development Studies in Geneva, aims to strengthen the leadership function of the ministries of health in the Region to pursue the health agenda, including universal health coverage.

Health financing

Functioning health financing systems are critical to achieve the goals of universal health coverage. Such systems are often compromised by insufficient public funding, lack of equitable financial protection and inefficient use of resources in the Region.

In 2016, WHO supported countries to identify ways to reform revenue raising, and pooling and purchasing arrangements. Attention focused on developing health financing strategies for universal health coverage. Nine countries were guided to develop their health financing strategies through capacity-building, in-depth analysis, experience-sharing and policy dialogue. Attention was also given to institutionalizing health accounting, with a focus on disease distribution. Training was provided to 16 countries on the system of health accounts 2011, including on estimating expenditure by disease groups. A new area of work was started to enhance alignment between public financial management and health financing, with a first assessment conducted in Sudan. Efforts were intensified to develop benefit packages for universal health coverage, as part of an ongoing collaboration with the Disease Control Priorities Network. A high-level policy forum was held to establish a region-specific list of highest priority interventions for countries to consider when developing their own essential health services packages.

In 2017, assessment of the health financing systems in the Region will continue in order to identify challenges and ways to tackle them. Development of universal health coverage packages and public financial management will also continue, with a focus on capacity-building and institutional development. Particular attention will be given to the health financing requirements of specific health programmes, including noncommunicable diseases, essential public health functions and emergencies.

Health governance and human rights

National health policies, strategies and plans guide a country to define its priorities for improving the health and well-being of its people and achieving universal health coverage. Ongoing efforts to evaluate the status of national health planning included an assessment of health policy and planning functions in the ministries of health in preparation for a workshop on health sector strategic planning. As part of the regional effort to encourage countries to adopt the Health-in-All-Policies approach to achieve the health-related Sustainable Development Goals (SDGs), a related workshop is being planned in collaboration with the Social Research Center of the American University in Cairo. A main focus of the 2030 Agenda is leaving no one behind. Efforts are therefore being made to reinforce health equity and human rights in WHO work as part of the actions to achieve the Sustainable Development Goals.

Weak health governance, accountability and transparency remain obstacles to strengthening health systems performance in the Region. In collaboration with the UNDP Regional Bureau for Arab States, the Regional Office is working to strengthen health system accountability and reduce the risk of corruption in the health sector. Additionally, a regional accountability assessment framework and capacity-building tool for enhancing accountability and governance functions of health systems has been developed. 

To strengthen national capacities to support health legislation and regulation, an introductory course on the role of law in health system strengthening in the Region was developed and delivered to experts from five countries. In addition, in collaboration with the O’Neill Institute, Georgetown University, 10 priority legal interventions for noncommunicable diseases were identified and policy briefs were developed to be shared with the countries. 

During 2017, focus will continue to be placed on adapting and applying the established know-how to the regional setting. Particular attention will be given to policy development and health legislation, capacity-building, and the integration of health equity and human rights in all policies and health programmes.  

Global health initiatives 

The global health initiatives collaborative work in the Region covers several areas: AIDS, tuberculosis and malaria, immunization programmes, maternal and child health, tobacco use, human resources, emerging diseases, nutrition, health promotion and health system strengthening. The Global Fund and Gavi, the Vaccine Alliance are the main institutions that provide substantial funding to eligible countries in the Region. Seven countries – Afghanistan, Djibouti, Pakistan, Somalia, Sudan, Syrian Arab Republic and Yemen – are eligible for Gavi support on immunization and health system strengthening, and 12 are eligible for Global Fund grants, including the seven supported by Gavi.

Protracted social and political unrest in most grant-recipient countries continues to be a major challenge. Insecurity in many places hampers access to social services with the health sector being the worst affected, and the loss of human capital has severely weakened health services and systems in affected countries. Furthermore, global health initiatives have created parallel systems that undermine the holistic approach for health system development, and the principles of external aid, such as ownership and harmonization, are not adequately applied.

In 2016, in collaboration with the Global Fund, regional training was conducted to strengthen the role of country staff in securing partnership with the Global Fund. In addition, joint appraisal missions to Gavi-supported countries were carried out to review grant implementation, identify challenges, assess grant management and propose priorities for 2017. 

In 2017, capacity development on an integrated approach for health system strengthening will be organized for relevant country focal points. The regional vision and strategy for strengthening partnerships for universal health coverage will be finalized. Support will be given to improving reports and records with a focus on country experiences with global health initiatives.

Health workforce development 

Tackling health workforce challenges remains a pressing priority in the Region. Overall health workforce shortages continue in addition to concerns about the quality, relevance and performance of health workers. The need for an adequate and competent health workforce is acknowledged as a critical element in moving towards universal health coverage and achieving the SDGs. 

To respond to the health workforce challenges in the Region, an action framework for health workforce development 2017–2030 has been developed and is being finalized to guide countries to enhance their health workforce. Capacity-building for health workforce governance was undertaken through a regional workshop organized in collaboration with the World Bank, and a health workforce planning and management workshop for Jordanian officials in Amman. 

In 2016, further efforts were made to strengthen medical education through implementation of the framework for action on reforming medical education. An expert consultation on health profession education allowed further dissemination of the framework, highlighted the priorities and outlined the way forward. A regional guide for the development of nursing specialist practice in the Region was prepared which explains a nurse specialist, the educational requirements for designating a nursing specialty and the necessary regulatory mechanisms. At the country level, the Council of Accreditation for Medical Colleges in Iraq launched its national standards for accreditation of medical education in August 2016.

The regional framework for strengthening nursing and midwifery in the Region 2016–2025 was finalized in 2016 and shared with ministers of health. The framework guided the development of the Iraq and Pakistan nursing and midwifery strategies, and the Somali midwifery strategy. 

A number of countries face protracted crises, which have led to shortages of health workers and jeopardized their safety and security. The remaining health workers have had to deal with the existing and emerging conditions, including mental health problems. A short course on mental health nursing in emergencies was developed with the first training provided in the Syrian Arab Republic in August 2016. The fellowship programme has continued to support countries to build national capacities in the five regional priority areas and 50 fellowships were awarded in 2016 in the Region. 

In 2017, WHO will continue to provide technical assistance to countries to develop strategies and plans to tackle health workforce challenges. These will take account of population needs and the dynamics of the labour market. Assistance will also be given to build governance capacity for implementation of health workforce strategies. Emphasis will be placed on strengthening the primary care workforce, especially a team approach in family practice. With the increasing involvement of the private sector in education and employment of the health workforce, health workforce regulation requires greater attention. Efforts will continue to tackle the health workforce challenges in countries with protracted crises so as to ensure access to care.

Essential medicines and technologies 

Within the context of health system development and universal health coverage, sustainable access to medical products (medicines, vaccines and medical devices) and health technologies is essential. To achieve this, countries should be supported to improve policies on health technology research, regulation, assessment and management. 

Member States are showing more commitment to increasing transparency and accountability in the pharmaceutical sector through the good governance for medicines programme. A subregional meeting was held in 2016 for countries who are currently developing policies and action plans to improve governance of medicines, Afghanistan, Egypt, Islamic Republic of Iran, Oman, Pakistan, Palestine, Sudan and Tunisia. The transparency evaluation reports for three of these countries have already been reviewed and published.

A survey on availability of essential medicines in the Region showed that shortages were increasingly frequent in most countries. Medicines in short supply are mostly products that are old, off-patent or difficult to formulate, or produced by a few or a sole manufacturer. Some of the reasons for shortages relate to production and marketing (e.g. lack of raw materials or fragmented markets), and others to characteristics of the supply chain system.

Countries were supported in the implementation of WHO’s global action plan on antimicrobial resistance. Planned training courses in 2017 will support the provision of reliable data on national consumption of antimicrobials, which is a prerequisite for understanding the epidemiology of antibiotic resistance.

Regional challenges in accessing controlled medicines for therapeutic use are wide-ranging and include regulatory, legal, policy, awareness and economic factors. The Regional Office is planning to develop a regional strategy to achieve balance in access to and regulation of controlled medicines in 2017.

Pakistan was supported to determine the scope of traditional/alternative treatment and to review the education system for traditional medicine. Technical guidance on intellectual property rights and their implications for research and development of medical products continued in 2016. A national workshop was organized in Egypt to discuss intellectual property rights and patency in Egypt, as well as legislation and law enforcement for counterfeit medicines.

Regulation of medical products, in particular medicines and medical devices, is a priority in countries of the Region. Through the WHO national regulatory authorities benchmarking tool, assessments of the regulatory capacity of Egypt, Iraq, Lebanon, Saudi Arabia and Syrian Arab Republic were conducted and performance gaps were identified. Accordingly, detailed institutional development plans for their regulatory authorities were developed. The Eastern Mediterranean Drug Regulatory Authority Conference was held in Tunisia in 2016 to enhance cooperation between regulatory authorities in the Region. 

A regional publication on developing regulation on medical devices and integrating it into the existing functions of regulatory authorities was prepared and shared with countries during the intercountry meeting on strengthening medical devices regulation in the Region, held in Saudi Arabia in 2016. The meeting resulted in the development of roadmaps for designing and implementing a regulatory programme for medical devices in 15 countries. Currently, Bahrain, Sudan and Egypt are being assisted in the development/enhancement of their regulatory functions for medical devices. It is expected that more countries will be supported in 2017. 

Technical support was provided in 2016 to: the development of a global model on medical devices regulation; the regulatory harmonization efforts in countries in the Intergovernmental Authority on Development which include Djibouti, Somalia and Sudan from the Eastern Mediterranean Region; and the Jordan Food and Drug Administration in its first international congress for drug regulators.

The regional health technology assessment network continues as an active platform for information exchange and knowledge sharing. Technical support was provided to the Islamic Republic of Iran, Oman and Tunisia to enhance or establish national health technology assessment programmes in their national health systems. Contribution was made to the development of a list of noncommunicable disease medicines and medical supplies for inclusion in a new emergency health kit for the management of noncommunicable diseases in humanitarian disasters and emergencies in the Region. In addition, a list of supplies for family planning/reproductive health/maternal health was also developed for inclusion in the interagency emergency health kit.

In the area of health technology management, a tool was developed that can be used by countries to prioritize medical devices based on their public health needs. The next step is to share findings with manufacturers and donors to explore the possibility of reducing manufacturing costs for priority medical devices to make them available to the regional population. The tool is expected to be finalized and shared with countries in 2017.

To increase access to and better management of assistive technologies, an assessment tool was developed which collects baseline information on national systems used for the provision and management of products for mobility, vision, hearing, personal care, communication and cognition assistance. The results of the assessment, which will be shared in 2017, will help improve coverage, policies and finances, increase availability and affordability, and enhance staff capacity and service provision.

Integrated service delivery

During 2016, support to countries in 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. Within this context, WHO carried out a situation analysis out on service provision focusing on the family practice approach, assisted countries to build capacities in hospital care management and to increase access to comprehensive and quality health care services, provided evidence-based policy options, and monitored service provision in moving towards universal health coverage. 

Experiences from other regions and good practices related to integrated people-centred health services were shared with the countries in several regional meetings. Guidance on strengthening emergency health care services was developed based on a situation analysis that was conducted in 12 countries of the Region. 

In view of the importance of service delivery to universal health coverage, the 63rd session of the Regional Committee for the Eastern Mediterranean in 2016 adopted a resolution for scaling up family practice. In response to this, the Regional Office in collaboration with American University of Beirut developed a six-month online course on improving knowledge of the general physicians. An advocacy video on family practice was made and shared with countries on different occasions including during the world and regional conferences for family doctors in Brazil and United Arab Emirates. Several activities aimed at embedding quality of care within health care delivery in countries of the Region were carried out in 2016. These include: the development of a quality framework for primary care with 34 indicators, which has been piloted in four countries of the Region; technical support on patient and community engagement for quality as part of the people-centred integrated service delivery; the establishment of a patient safety system at the health care facility level based on the WHO improvement tool kit. In addition, technical assistance was provided to countries on the development of national policies and a strategy for quality as well as the mapping and review of health care accreditation programmes. 

An assessment tool was developed on engagement of the private health sector in service delivery which will be tested in three countries of the Region: Jordan, Oman and Pakistan. Family practice profiles were developed for countries and distributed at the 63rd Regional Committee to inform country strategies to expand family practice. Pakistan initiated a hospital reform process in Punjab province with WHO technical support, and two model districts were selected for implementation of the family practice approach. Patient safety and quality of care remain a challenge in many countries, particularly those facing emergencies because of fragmentation of the health system.

During 2017, WHO will continue to provide technical support to Member States on scaling up service provision based on the family practice approach. This includes organizing short training courses to strengthen the capacities of general physicians in four countries, establishing family practice training centres in three countries, developing a model of primary health care service for countries in emergencies, establishing a family practice advisory group, and implementing tools and guides on assessment of private sector performance and private sector regulation, contracting and partnership. Countries will be assisted to establish their national quality policy and strategy and ensure better institutionalization of effective quality and safety programmes, particularly at the primary health care level, and to expand the WHO patient safety friendly hospital initiative. A consultation will be organized to develop a guide for accreditation of health care facilities. A hospital management training course is being planned. In addition, WHO will support countries in crisis to enhance health system resilience and strengthen service delivery through community health workers and outreach teams.

Health information systems

As part of efforts to strengthen country health data and measurement systems and in line with the political momentum around data as part of the 2030 agenda for sustainable development, a technical package, with interventions proven to be highly effective in strengthening country health data systems, was developed in collaboration with WHO headquarters, international nongovernmental organizations, and country and regional experts.

In addition, to support routine health information systems and enable countries to report on the 68 regional core indicators (endorsed by the Regional Committee in 2014) and the SDGs, and following the intercountry workshop conducted in 2016 and technical discussions prior to 63rd session of the Regional Committee, key SDG indicators are incorporated in the regional core indicators list. Comprehensive reviews of the health information system were conducted in Jordan, Libya and Pakistan to support the ministries of health in strengthening the current systems that provide health-related information. Comprehensive health profiles of the current situation, challenges, gaps, opportunities and way forward for each country and health programme were published. 

The implementation of the regional strategy for the improvement of civil registration and vital statistics (CRVS) remains one of the key priorities of technical support to strengthen the collection and quality of vital statistics and causes of deaths in the Region. Two more countries, Bahrain and Saudi Arabia, conducted comprehensive assessments of their CRVS systems. Twenty-one countries now have complete assessments, CRVS road maps and national plans of action for CRVS system improvement. Moreover, Syrian Arab Republic also evaluated progress in the implementation of its CRVS improvement plan. During 2016, WHO headquarters launched an ICD-10 startup mortality list (SMoL) in conjunction with a DHIS2 platform. DHIS2-SMoL is an electronic application to facilitate cause of death collection and coding. It was introduced to countries during national CRVS implementation workshops and training was conducted in Libya. In the same context of improving the quality of ICD-10 coding of deaths, the Regional Office introduced Iris automated coding of deaths for the very first time ever in the Region. Sixteen countries which produce annual mortality statistics were invited to the Iris workshop. Towards more partner coordination and harmonization, the Regional Office collaborated with the United Nations Economic and Social Commission for Asia and the Pacific and for West Asia, United Nations Economic Commission for Africa and the League of Arab States in support of CRVS strengthening. 

To address the major gaps in reporting indicators that are mainly generated from population-based surveys, a new type of health examination survey was developed by WHO that focuses on behavioural and biological risk factors, health care utilization, health status and household expenditure. The first of these was conducted in Tunisia with government support.

Several challenges remain within health information systems. Population-based surveys and health information systems assessments need to be conducted on a regular basis in many countries. The ongoing conflicts in the Region and lack of resources continue to be among the main challenges to the improvement of CRVS systems. Intensive efforts are required for capacity building among physicians in high quality certification of deaths. Several capacity-building workshops on the DHIS2-SMoL are planned for 2017 and countries will be encouraged to introduce ICD-10 compliant certification of deaths in their undergraduate medical education.

Research development and innovation

WHO continued to support capacity building for research through workshops on: data management, interpretation and implementation strategy; good health research practices; and developing policy briefs. A research priority-setting exercise was conducted and the results used in a call for proposals for the tropical disease research small grants scheme. In 2016, calls for proposals for the scheme resulted in support for 8 priority research projects from six countries, and grants for research priorities in public health resulted in support for 10 research projects in eight countries. The Eastern Mediterranean Research Ethics Review Committee met to discuss ethical review of research funded by WHO and involving human subjects. In 2016, 47 WHO collaborating centres were supporting WHO activities in the Region. 

The Eastern Mediterranean Health Journal continued its regular monthly publication, including a special issue on influenza and emerging respiratory infections in the Eastern Mediterranean Region. The Journal received its first impact factor in 2016, a measure of the yearly number of citations to recent articles in that journal. 

In the area of eHealth, profiles were developed for each Member State based on results of an eHealth survey conducted in 2015–2016. Evidence-based mobile eHealth (mHealth) applications were initiated and implemented in Tunisia (smoking cessation, diabetes control) and Egypt (diabetes control, smoking cessation, eLearning and telemedicine). 

The way forward will focus on supporting 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. 
 
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Antimicrobial resistance and cross-cutting programmes – Resources

Key resources on AMR

  1. Operational approach to antimicrobial stewardship in the WHO Eastern Mediterranean Region | French
  2. WHO Investment case deep dive: antimicrobial resistance. Investment case 2025–2028. Geneva: World Health Organization; 2024.
  3. Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries. A WHO practical toolkit. Geneva: World Health Organization; 2019.  
  4. Global database for tracking antimicrobial resistance (AMR) country self-assessment survey (TrACSS) [online database]. Geneva: World Health Organization; 2023.
  5. GRAM Project [online database]. University of Oxford; 2024.
  6. GLASS dashboard [online database]. World Health Organization; 2024.
  7. Health workers’ education and training on antimicrobial resistance: curricula guide. Geneva: World Health Organization; 2019.
  8. WHO AWaRe (Access, Watch, Reserve) antibiotic book. Geneva: World Health Organization; 2022.
  9. WHO competency framework for health workers’ education and training on antimicrobial resistance. Geneva: World Health Organization; 2018.  
  10. WHO implementation handbook for national action plans on antimicrobial resistance: guidance for the human health sector. Geneva: World Health Organization; 2022.
  11. WHO policy guidance on integrated antimicrobial stewardship activities. Geneva: World Health Organization; 2021.

Key resources on TB

  1. Factsheet: Antimicrobial resistance and tuberculosis
  2. WHO consolidated guidelines on tuberculosis. Module 3: Diagnosis – rapid diagnostics for tuberculosis detection 2021 update. (Geneva: World Health Organization; 2021).
  3. WHO consolidated guidelines on tuberculosis. Module 4: Treatment – drug-resistant tuberculosis treatment, 2022 update. (Geneva: World Health Organization; 2022).
  4. WHO operational handbook on tuberculosis. Module 4: treatment – drug-resistant tuberculosis treatment, 2022 update.

Key resources on addressing AMR and IPC in health emergencies

  1. Factsheet: Addressing antimicrobial resistance in emergencies
  2. The WHO AWaRe (Access, Watch, Reserve) antibiotic book.
    Geneva: World Health Organization; 2022.
  3. Managing meningitis epidemics in Africa: A quick reference guide for health authorities and health-care workers.
    Geneva: World Health Organization; 2022.
  4. WHO Recommendations for prevention and treatment of maternal peripartum infections. Geneva: World Health Organization; 2016.
  5. Therapeutics and COVID-19: living guideline.
    (Geneva: World Health Organization; 2023).
  6. Guidelines for the clinical management of severe illness from influenza virus infections.
    (Geneva: World Health Organization; 2022).
  7. Global WASH Cluster. Delivering humanitarian WASH at scale, anywhere and ANY TIME, Road Map 2020–2025.
    Geneva: UNICEF; 2020.

Key resources on HIV

  1. Factsheet: HIV and antimicrobial resistance
  2. Global AIDS update 2024. Geneva: UNAIDS; 2024
  3. HIV drug resistance: brief report 2024. Geneva: World Health Organization; 2024
  4. HIV drug resistance report 2021. Geneva: World Health Organization; 2021
  5. The role of HIV viral suppression in improving individual health and reducing transmission. Geneva: World Health Organization; 2023
  6. Surveillance of acquired HIV drug resistance in populations receiving ART. Geneva: World Health Organization; 2023
References
  1. HIV drug resistance: brief report 2024. Geneva: World Health Organization; 2024
  2. HIV drug resistance report 2021. Geneva: World Health Organization; 2021

Key resources on immunization

  1. Factsheet: How immunization strengthens the fight against antimicrobial resistance
  2. The Immunization Agenda 2030 [website]. Geneva: World Health Organization.
  3. Guidelines for developing a national immunization strategy. Geneva: World Health Organization; 2021.
  4. Immunization dashboard [website]. Geneva: World Health Organization.
  5. The big catch up. [website]. Geneva: World Health Organization; 2023.
  6. WHO recommendations for routine immunization - summary tables [website]. Geneva: World Health Organization.
  7. Introduction of new vaccines [website]. Geneva: World Health Organization.
  8. Measles and rubella strategic framework: 2021-2030. Geneva: World Health Organization; 2020.

References

  1. Kim C, Holm M, Frost I, Hasso-Agopsowicz M, Abbas K. Global and regional burden of attributable and associated bacterial antimicrobial resistance avertable by vaccination: modelling study. BMJ Glob Health. 2023; 8(7):e011341.
  2. Leveraging vaccines to reduce antibiotic use and prevent antimicrobial resistance. Geneva: World Health Organization; 2021.

Key resources on cancer

  1. Factsheet: Antimicrobial resistance and cancer care
  2. Framework for action on cancer prevention and control in the WHO Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean; 2019.
  3. Cancer control. Kuwait City: Eastern Mediterranean NCD alliance; 2022.
  4. Report on the Regional workshop on empowering progress: strengthening implementation of the WHO Global Initiative for Childhood Cancer in the Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean; 2024.
  5. Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva: World Health Organization; 2020.
  6. Regional cervical cancer elimination strategy for the Eastern Mediterranean. Cairo: WHO Regional Office for the Eastern Mediterranean; 2023.
  7. The global initiative for childhood cancer [website]. Geneva: World Health Organization; 2021.
  8. The global breast cancer initiative [website]. Geneva: World Health Organization.
  9. Global cancer observatory [website]. Lyon: International Agency for Research on Cancer.
  10. Pourghazian N, Krakauer E, Salama S, Fadhil I, Osman H. The Eastern Mediterranean regional palliative care expert network: Designing a roadmap for palliative care development in the region. East Mediterr Health J. 2022;27(8):610–613.

Key resources on IPC

  1. Factsheet: Antimicrobial resistance and infection prevention and control
  2. Core competencies for infection prevention and control professionals. Geneva: World Health Organization; 2020 
  3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016. 
  4.  Minimum requirements for infection prevention and control programmes. Geneva: World Health Organization; 2019 
  5. Global report on infection prevention and control. Geneva: World Health Organization; 2022.
  6. Global strategy on infection prevention and control. Geneva: World Health Organization; 2023 

Key resources on WASH

  1. Factsheet: Water, sanitation and hygiene and antimicrobial resistance
  2. Technical brief on water, sanitation, hygiene (WASH) and wastewater management to prevent infections and reduce the spread of antimicrobial resistance (AMR). Geneva: World Health Organization; 2020. 
  3. Combatting Antimicrobial resistance through water, sanitation and hygiene and infection prevention and control in health care. Geneva: World Health Organization; 2020  
  4. WHO/UNICEF Joint Monitoring Programme. Progress on household drinking water, sanitation and hygiene 2000-2022: special focus on gender. New York: United Nations Children’s Fund, 2023.  
  5. WHO/UNICEF Joint Monitoring Programme. Progress on WASH in health care facilities 2000–2021: special focus on WASH and infection prevention and control (IPC). New York: United Nations Children’s Fund, 2023. 

Key resources on diabetes

  1. Factsheet: Antimicrobial resistance and diabetes
  2. Global action plan for the prevention and control of NCD 2013–2020 [extended to 2030]. Geneva, WHO; 2013
  3. Framework for action to implement the UN Political Declaration on NCDs, including indicators to assess country progress by 2030.
    Cairo: WHO EMRO; 2019.
  4. Framework for action on diabetes prevention and control in the WHO Eastern Mediterranean Region.
    Cairo: WHO Regional Office for the Eastern Mediterranean; 2021.
  5. WHO package of essential noncommunicable (PEN) disease interventions for primary health care.
    Geneva, World Health Organization; 2020.
  6. Guideline for the pharmacological treatment of hypertension in adults.
    Geneva, World Health Organization; 2021.

References

  1. Number of deaths attributed to non-communicable diseases, by type of disease and sex. Geneva, World Health Organization; 2024.
  2. Diabetes in Middle-East & North Africa – 2021. Brussels: International Diabetes Federation.
  3. Epidemiological status of type 2 diabetes mellitus in the Middle East and North Africa, 1990–2019. Moradinazar M, Babakhani M, Rostami R, Shakiba M, Moradi A, Shakiba E. East Mediterr Health J. 2022;28(7):478–488.
  4. Addressing diabetes as a public health challenge in the Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean; 2021.
  5. Antimicrobial resistance patterns in diabetic foot infections, an epidemiological study in northeastern Italy. Boschetti G, Sgarabotto D, Meloni M, Bruseghin M, Whisstock C, Marin M, et al. Antibiotics. 2021;10(10):1241.
  6. Antimicrobial resistance pattern among diabetic patients with urinary tract infection at Bangladesh. Mohammad Saifuddin FC, Selim S, Uddin N, Pathan F. Endocr Pract. 2016;22:61.
  7. Aspects of the antimicrobial resistance profile in infections with Escherichia coli and Klebsiella pneumoniae in diabetic patients. Petrovici CG, Dorobăţ C, Matei M, Teodor A, Luca V, Miftode E. Rev Med-chir Soc Med Nat Iasi. 2011 Jul;115(3):769–775.
  8. Human gut antibiotic resistome and progression of diabetes. Shuai M, Zhang G, Zeng FF, Fu Y, Liang X, Yuan L, et al. Adv Sci. 2022;9(11):2104965.
  9. HEARTS D: Diagnosis and management of type 2 diabetes. Geneva, World Health Organization; 2020.

Key resources on malaria

  1. Factsheet: Antimicrobial resistance and malaria
  2. Antimalarial drug efficacy and resistance in malaria-endemic countries in HANMAT-PIAMnet countries of the Eastern Mediterranean Region 2016–2020: Clinical and genetic studies. Adam M, Nahzat S, Kakar Q, Assada M, Witkowski B, Tag Eldin Elshafie Am et al. Trop Med Int Health. 2023;28(10):817–829.
  3. Strategy to respond to antimalarial drug resistance in Africa. Geneva: World Health Organization; 2022.
  4. Malaria action plan for the Eastern Mediterranean Region, 2022–2030. Cairo: WHO Regional Office for the Eastern Mediterranean; 2023.
  5. World malaria report 2023. Geneva: World Health Organization; 2023.
  6. المباديء التوجيهية لمنظمة الصحة العالمية بشأن الملاريا – 3 حزيران/يونيو [WHO guidelines for malaria - 3 June 2022]. Geneva: World Health Organization; 2022 (in Arabic).
  7. WHO Guidelines for malaria. Geneva: World Health Organization; 2023.
  8. Malaria [website]. Geneva: World Health Organization.

Key resources on child health

  1. Factsheet: Antimicrobial resistance and child health
  2. Early essential newborn care: clinical practice pocket guide, second edition. Geneva: World Health Organization; 2022.
  3. Child and adolescent health in humanitarian settings [pdf]; interactive. Geneva: World Health Organization; 2021.
  4. Pocket book of hospital care for children, second edition. Geneva: World Health Organization; 2013.
  5. The urgent threat of drug-resistant infections protecting children worldwide. New York: United Nations Children’s Fund; 2023.
  6. Integrated management of childhood illness. United Nations Children’s Fund, World Health Organization. Geneva: WHO; 1995.

Resources

  1. Early essential newborn care: clinical practice pocket guide, second edition. Geneva: World Health Organization; 2022.
  2. Child and adolescent health in humanitarian settings [pdf]; interactive version. Geneva: World Health Organization; 2021.
  3. Pocket book of hospital care for children, second edition. Geneva: World Health Organization; 2013.
  4. The urgent threat of drug-resistant infections protecting children worldwide. New York: United Nations Children’s Fund; 2023.
  5. Integrated management of childhood illness. United Nations Children’s Fund, World Health Organization. Geneva: WHO; 1995.

Key resources on access to antibiotics

Key resources on access to medicines

  1. Factsheet: Antimicrobial resistance and access to antibiotics
  2. Sixty-seventh World Health Assembly, Agenda item 15.4, 24 May 2014: Access to essential medicines. Geneva: World Health Organization (WHA67.22).
  3. Wirtz VJ, Hogerzeil HV, Gray AL, Bigdeli M, de Joncheere CP, Ewen MA, et al. Essential medicines for universal health coverage. Lancet. 2017; 389.10067:403–476.
  4. WHO methodology for a global programme on surveillance of antimicrobial consumption. Geneva: World Health Organization; 2017.
  5. The WHO AWaRe (Access, Watch, Reserve) antibiotic book. Geneva: World Health Organization; 2022.
  6. GLASS guide for national surveillance systems for monitoring antimicrobial consumption in hospitals. Geneva: World Health Organization; 2020

References

  1. Access to medicines: making market forces serve. In: Ten years in public health 2007–2017: report by Dr Margaret Chan, Director-General. Geneva: World Health Organization; 2017.
  2. Regional strategy to improve access to medicines and vaccines in the Eastern Mediterranean, 2020–2030, including lessons from the COVID-19 pandemic. October 2020.
  3. Mahmood RK, Gillani SW, Alzaabi MJ, Gulam SM. Evaluation of inappropriate antibiotic prescribing and management through pharmacist-led antimicrobial stewardship programmes: a meta-analysis of evidence. Eur J Hosp Pharm. 2022;29(1):2–7.
  4. Alagha H. Dispensing antibiotics without prescription in the Arab world: a narrative review of the prevalence, appropriateness, facilitators and preventive interventions. Bull Pharm Sci Assiut. 46. 399-420.
 
Strengthening health systems for universal health coverage PDF Print

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.
 
Awards PDF Print

Every year, the World Health Organization (WHO) presents awards to key people and/or organizations that have made valuable contributions to tobacco control and have helped make World No Tobacco Day and its theme a great success. These awards are an expression of WHO's appreciation of the great time and effort that these contributors have invested in the campaigns, as well as in fighting tobacco.

This year, six World No Tobacco Day awards were presented to:

Ms Samira Ali Higo, Focal Point for the Tobacco Control Programme, Ministry of Health, Djibouti

Dr Nasr El Sayed, Minister’s Assistant for Preventive Affairs, Primary Health Care and Family Planning, Ministry of Health and Population, Egypt

Dr Mostafa Ghaffari, Secretariat for National Tobacco Control, Ministry of Health and Medical Education, Islamic Republic of Iran

Dr Javid A. Khan, Chair of the National Alliance for Tobacco Control, Pakistan

Dr Tawfik Ahmed Khoja, Director General of the Executive Board, Health Ministers’ Council for Gulf Cooperation Council States, Saudi Arabia

His Excellency Mr Mondher Zenaidi, Minister of Public Health, Ministry of Public Health, Tunisia

These individuals are strong advocates for tobacco control and have been instrumental in pushing for the inclusion of pictorial health warnings in tobacco control laws at national level and their implementation on tobacco product packaging. They have also been particularly active in creating alliances and promoting multisectoral collaboration to ensure effective implementation of the WHO Framework Convention on Tobacco Control at country level.
 
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