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Emergency preparedness and response |
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Overview
2014 saw an escalation in emergencies and associated health needs of affected populations in a number of countries. A total of 58 million people are affected by emergencies in the Region, including 16 million refugees or internally displaced persons. More than half of the world’s refugees come from three countries of the Eastern Mediterranean Region (Afghanistan, Somalia and Syrian Arabic Republic) and are hosted in just four countries (Islamic Republic of Iran, Jordan, Lebanon and Pakistan). As a result of the Syrian crisis, in 2014 the refugee population in Jordan doubled and that in Lebanon tripled. Today, almost 25% of Lebanon’s total population comprises refugees. The Region also hosts the largest number of internally displaced persons as a result of conflict, with Iraq, Sudan and Syrian Arab Republic among the top five countries globally hosting internally displaced persons.
In Iraq, almost 5.2 million people across the country were in need of humanitarian assistance by May 2015, of whom more than 2.9 million were internally displaced, one of the largest internally displaced populations in the world. In security-compromised governorates an estimated 80% of health facilities were partially functional and 4% were non-functional as of December 2014. The departure of almost half of all health professionals, created a gap in the provision of primary health care, trauma surgery and obstetric care in areas where violence was ongoing. Supplies of medicines and equipment were irregular due to road inaccessibility and power/fuel shortages. In the three governorates forming the Kurdistan region, the rapid and massive influx of internally displaced persons overwhelmed the health system, causing critical medical shortages and overburdening health facilities. Due to the unprecedented scale, urgency and complexity of the conflict, in August 2014 the Inter-Agency Standing Committee declared the Iraq crisis a Grade 3 emergency, representing the highest level of emergency, and the second in the Region following the designation of the crisis in the Syrian Arab Republic as Grade 3 in 2012.
In the Syrian Arab Republic, by December 2014, almost 12.2 million people had been affected inside the country, including 7.6 million internally displaced and 4.8 million living in hard-to-reach or besieged areas. An additional 4 million were refugees taking shelter in Egypt, Iraq, Jordan, Lebanon and Turkey. By the end of March 2015, out of 113 pub¬lic hospitals assessed, 44% were reported fully functioning, 36% par¬tially functioning and 20% non-functioning. Populations had increasingly limited access to basic services, including life-saving health care, and functioning health facilities were unable to cope with the increasing needs of affected populations in conflict areas. Overcrowded living conditions, together with a significant drop in the overall vaccination coverage, left populations increasingly vulnerable to communicable diseases such as measles, typhoid and whooping cough.
In March 2015, the conflict in Yemen escalated, with violence reaching 19 out of Yemen’s 22 governorates. By June, more than 20 million people were affected, with almost 15 million people requiring health care services. The number of internally displaced persons almost doubled in May, reaching more than 1 million people. Serious shortages of medicines and medical supplies, as well as lack of fuel to operate hospital generators and maintain the vaccine cold chain, resulted in a gradual collapse of the health system. Fuel shortages also resulted in an estimated 9.4 million people with no or limited access to safe water. Surges in suspected cases of malaria and dengue fever were reported, with more than 3000 suspected cases and a number of deaths. Lack of access prevented WHO and partners from assessing the situation and providing vector control measures. Significant incidence of diarrhoeal diseases and pneumonia also continued to be reported. Delays and cancellations of vaccination campaigns increased the risk of measles outbreaks, and risked the reintroduction of polio into the country, although as of June, no polio cases were reported. A 5-day humanitarian pause in May allowed WHO and partners to scale up the response around the country. However, calls for a second pause during the month of Ramadan failed.
In Pakistan, military operations in the North Waziristan Agency resulted in the displacement of 500 000 people in June 2014, bringing the total number of displaced persons to 1 million, 74% of whom were women and children. Bad weather conditions, overcrowded housing in host communities, and poor nutrition increased the risk of waterborne diseases, such as cholera, dehydration, diarrhoea and heat stroke, as well as airborne diseases, such as pneumonia and measles.
In Libya, in June 2014, clashes between rival forces erupted in the cities of Tripoli and Benghazi. By December 2014, more than 2.5 million people were in need of humanitarian aid, including 400 000 displaced. Shortages in medicines and medical supplies, together with the evacuation of many of the country’s international health workforce left the health system weak and functioning health facilities overwhelmed.
In Palestine, 51 days of fighting in Gaza during July and August 2014 left 2333 Palestinians dead and 15 788 injured. Half a million people were displaced and up to 22 000 homes were destroyed or rendered uninhabitable, with 100 000 people remaining homeless at the end of the year. The conflict caused widespread damage to infrastructure, including hospitals, clinics and ambulances, as well as water and sanitation facilities, resulting in limited access to basic services.
In Afghanistan, as the armed conflict grew in intensity and geographical scope, the number of people in need of access to health services rose from 3.3 million in 2013 to 5.4 million in 2014, with the conflict continuing to cause critical disruptions to the provision of health services. More than 30% of the population in Afghanistan still has no or difficult access to essential health care.
In Somalia, the United Nations warned in June 2014 of a “looming humanitarian emergency”. Almost half of the country’s population lack access to basic services and about 3.2 million women and men require emergency health services. The health care system remains weak and there is a critical shortage of qualified health workers. The impact of this lack of basic services is felt most strongly among the internally displaced people who continue to be affected by disease outbreaks due to overcrowded and unsanitary living conditions and limited health services.
Natural disasters claimed additional lives. In September 2014, floods in Sudan resulted in the displacement of more than 320 000 men, women and children, while monsoon rains and flash floods in Pakistan affected almost 1.8 million people and resulted in 282 deaths and 489 injuries. More than 42 000 houses were estimated to be damaged or destroyed, while an estimated 2413 million acres of farmland were flooded at a time when crops were almost ready to be harvested. Some areas affected were those that had previously experienced flooding in 2013.
WHO has been fully mobilized in responding to the above mentioned emergencies by leading the work of the humanitarian health cluster and implementing its functions in strengthening disease surveillance and early warning systems, strengthening other public health functions including control of disease outbreaks and immunization and helping to sustain basic health care and life-saving services.
Challenges and WHO response to emergencies in the Region
One of the biggest challenges impeding WHO’s ability to respond is limited access as a result of insecurity. In the Syrian Arab Republic, limited access has required more innovative ways to reach populations in need. In Yemen, restricted access into the country via all ports delayed the delivery of urgently needed health supplies. Inside the country, violence and insecurity made some areas inaccessible, and increased the risk of diseases such as malaria and dengue fever as patients lack access to health care and thus timely diagnosis and treatment. Additional challenges included repeated and targeted attacks on health care workers, health facilities and health infrastructure. In 2014, WHO’s Regional Office publically condemned such attacks in Afghanistan, Iraq, Palestine, Sudan, Syrian Arab Republic and Yemen. Lack of sustainable funding for health in emergency response also posed a key challenge, impeding WHO and health partners’ capacity to respond, and risking the closure of existing health services and health programmes. In 2014, health was funded at 45.6% in the Region while coordination was funded at 84.8% and food at 61.8%. Despite increasing needs, health was only funded at 12.5% for 2015 as of May. There continues to be a heavy dependence by countries in crisis on external humanitarian and financial aid, which may not always arrive when it is most critically needed.
While trauma care needs have increased, there is decreasing capacity among partners to respond due to the insecurity. In the Syrian Arab Republic, where 1 million people were injured in the first quarter of 2015, health partners have been forced to completely withdraw from “hot” areas, leaving a critical gap in the provision of trauma care. Mass population movement, coupled with low immunization rates and vaccine shortages place the entire region at risk of disease outbreaks. The outbreak of polio and measles in the Syrian Arab Republic as a result of the crisis led to the re-introduction of polio in Iraq in 2014 after 14 years of being polio-free.
Operational challenges faced by WHO and health partners included disrupted health systems, an increasing number of patients requiring trauma care (especially in hard-to-reach areas), growing numbers of internally displaced persons, severely reduced health workforces as health staff fled with their families, disrupted referral systems as a result of insecurity and blocked roads, and critical shortages of essential medicines and vaccines. Mass population movements increased the risk of communicable diseases as IDPs sought shelter in overcrowded camps and public spaces, and damaged water and hygiene infrastructure increased the risk of water-borne diseases. Disease surveillance systems were disrupted as a result of limited data and information. Patients with chronic noncommunicable diseases were forced to find alternate locations for treatment as health facilities shut down or reported shortages in essential medicines. As a result of the violence, mental health needs also increased.
Following the Grade 3 designation of the crisis in Iraq, which signified a global organizational response, WHO’s country office was scaled up with the deployment of more than 21 international staff in all areas of expertise, as of May 2015 and WHO hubs and/or focal points were established in all 19 provinces. Through funding from Saudi Arabia, WHO procured and operationalized 10 mobile clinics in northern Iraq covering 300 000 internally displaced people and host communities. The project is part of WHO's broader response of providing a timely basic package of primary and secondary health care services. As of May 2015, 3.5 million people in Iraq had been provided with direct access to essential drugs and medical equipment procured and supplied by WHO.
Two cases of poliomyelitis were confirmed in Iraq in early 2014. Together with national and United Nations health partners, WHO was able to vaccinate more than 5 million children against poliomyelitis in three national immunization campaigns, as of May 2015.
In the Syrian Arab Republic in 2014, WHO delivered more than 13.8 million medical treatments to people in need across the country, with more than 32% of the deliveries distributed to hard-to-reach and opposition-controlled areas. WHO also mobilized more than 17 000 health care workers to vaccinate approximately 2.9 million children against poliomyelitis through 10 immunization campaigns and 1.1 million children immunized against measles.
In Yemen, from March to June 2015, WHO distributed almost 130 tonnes of medicines and medical supplies and more than 500 000 litres of fuel to maintain the functionality of main hospitals, vaccine stores, ambulances, national laboratories, kidney and oncology centres, and health centres in 13 governorates, reaching a total of more than 4.7 million beneficiaries, including 700 000 internally displaced people and 140 000 children under the age of 5 years. WHO also provided safe water and sanitation kits and supplies to health facilities and to internally displaced people hosted in affected communities, as well water trucking services to health facilities and communities with high numbers of internally displaced people. WHO also delivered medicines for tuberculosis and malaria and supported disease outbreak response and control.
During and after the Gaza conflict, WHO facilitated the delivery of medicines and medical supplies to hospitals and health facilities for hundreds of thousands of patients. The health cluster system was reactivated and led by WHO, together with the Ministry of Health. WHO took the lead in conducting the health component of the multi-cluster assessment, and led the health cluster in completing the joint health sector assessment. Despite the conflict, WHO ensured ongoing advocacy for access for patients with referrals abroad, working at a policy level to facilitate access for these patients.
Health risk management
The Regional Committee endorsed the need to strengthen emergency preparedness and response through an all-hazard and multisectoral approach (EM/RC61/R.1) and requested enhanced technical support from WHO to scale up national emergency risk management capacity. By the end of 2014, 19 countries had received support in reviewing their existing national plans for emergency preparedness and response, with a view to adopting the comprehensive approach. Two countries finalized a national plan for all-hazard emergency preparedness and response for health. To support the planning process, the comprehensive all-hazard risk assessment protocol was piloted in the Islamic Republic of Iran, along with comprehensive vulnerability analysis. In Afghanistan mass casualty management capacity was scaled up, in collaboration with partners.
In 2014, WHO’s work in emergencies in the Region was made possible with the support of many donors, including Australia, Canada, China, the European Commission, Finland, Italy, Japan, Korea, Kuwait, Norway, Russian Federation, Saudi Arabia, Switzerland, Turkey, United Arab Emirates, United Kingdom and United States of America.
Implementing the strategies endorsed by the Regional Committee
Progress was made in regard to implementing resolutions endorsed by the Regional Committee. The process of establishing a regional emergency solidarity fund was initiated with the aim of ensuring predictable financing of surge/rapid response to natural and man-made disasters in the Region. This was strengthened by the Regional Committee which urged Member States to contribute to the Fund by allocating to it a minimum of 1% of the WHO country budget, in addition to other voluntary contributions whenever possible.
With the goal of establishing a regional roster of trained experts who are able to quickly and effectively respond to any emergency, including disease outbreaks, capacity-building of emergency focal points was supported on surge training in emergencies , and will continue to be supported each year. To ensure the timely procurement and provision of critical medical supplies and equipment to countries experiencing emergencies in the Region and beyond, WHO has finalized an agreement with the Government of the United Arab Emirates to establish a dedicated WHO humanitarian operations/logistics hub.
WHO will continue to work with Member States to strengthen the capacity of health systems to prevent, mitigate, prepare for, respond to and recover from emergencies and crises following a whole-health and multisectoral approach, with special emphasis on reinforcing technical capacity in preparedness. |
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Implementing WHO management reforms |
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Programmes and priority-setting
WHO continued to strengthen its implementation of reform in programme strategy and priority-setting, with the objective of improving global and regional health outcomes by focusing on its comparative advantages. The Regional Office provided support for the strategic aspects of WHO’s work at country level through regular liaison with WHO country offices and relevant regional stakeholders in developing, monitoring and evaluating the country cooperation strategies (CCS). New CCS guidelines were launched. An initial pilot group of four countries was established and training conducted. The new guidelines advocate for strong national ownership and an inclusive and consultative process of negotiation and development. Development of partnerships was promoted, including with the League of Arab States, the regional United Nations Development Group, the Organization of Islamic Cooperation, and regional UN organizations and institutions. The regional bottom-up operational planning process took place in good time for the WHO Financing Dialogue held in Geneva in November 2015 and was thus operational for an equally early start to implementation for the 2016–2017 biennium.
The outcome of the end-of biennium reporting on the Programme Budget Performance Assessment for 2014–2015 showed that the regional base budget of US$ 268 million had been funded to the level of 84% while the allocated emergency budget of US$ 585 million had been funded at 89%. The base programme budget utilization (expenditures and encumbrances) was 83% and utilization of actual available funding reached 99%. Budget utilization in the emergency programme for the Region as a whole was 85% and utilization of funding was 96%, leaving WHO at the regional level with a high overall funding utilization of 97% at the close of the biennium. The investment in priority work at the country level saw 85% of flexible funding allocated to country priorities.
Delivery of technical outputs was also high, particularly when viewed against the continued efforts of the regional and country offices to respond to and support event-driven emergency situations, with 78% of outputs fully achieved and 22% partially achieved.
The Regional Office was an active partner in the strengthening of the global category and programme area networks which contribute to programmatic and technical coherence at global, regional and country level. Both the category and programme area networks play a key role in harmonizing the priorities from the country level bottom-up planning with commitments emanating inter alia from regional and global resolutions to ensure the comprehensiveness and completeness of work plans.
In anticipation of the adoption in September 2015 by the United Nations General Assembly of the new development agenda for the period 2016–2030 expressed within the 17 Sustainable Development Goals (SDG) including one specific goal (Goal 3) for health with 13 targets, work was initiated to prepare plans for addressing the unfinished MDGs and the integrated SDG agenda. This was presented at the 62nd Session of the Regional Committee.
As part of ongoing periodic programmatic reviews, an expert consultation was held in early 2016 on the Global Arabic Programme. Regional participants with expertise in translation, publishing and public health reviewed the work of the programme and the achievements of the past two decades. Taking into account the current context, the pressure on available resources and the need to streamline the strategic focus of the programme, it was recommended that resources should be concentrated on translation of WHO publications in the strategic priority areas, and on updating of the Unified Medical Dictionary.
Governance
In keeping with the practice of the past few years, a high-level meeting for ministers and representatives of Member States and permanent missions in Geneva was held prior to the World Health Assembly. These meetings continue to provide an opportunity to review, with ministers of health and senior government officials, progress in addressing key priorities since the previous Regional Committee and to strengthen Member States’ engagement in global discussions on health and WHO reform. Daily meetings during the Executive Board meeting and Health Assembly provided additional opportunities for Member States from the Region to interact and agree on common positions that affect the Region.
At its 62nd Session in October, the Regional Committee endorsed five resolutions in relation to the regional strategic priorities. Immediately prior to the session, a day of technical meetings was held to discuss current issues of interest. Where pertinent, the outcome of the discussions was taken forward to the Regional Committee for further discussion. This process, which follows from the revised rules of procedure endorsed by the Regional Committee at its 59th session, has proved to be a useful forum for high-level technical discussion with Member States.
Management
The Regional Office continued to develop essential instruments for the enhancement of the WHO reform process, with special emphasis on managerial reform, working closely with all other levels of the Organization to achieve the goals of the 12th General Programme of Work. It also continued to improve its planning, forecasting, implementation, monitoring and evaluation capacity aimed at more efficient use and distribution of limited resources, with a view to making WHO in the Region more fit for purpose.
The managerial actions associated with the reform process with respect to staff mobility and rotation, performance management and human resources planning and management were complemented by the promotion of an accountability culture.
Accountability and controls continued to be at the heart of improvement efforts with focus on the five compliance areas, which were repeatedly mentioned in internal and external audit observations of preceding years: direct financial cooperation, direct implementation, imprest purchase orders, asset inventories and non-staff contractual arrangements. These areas were closely monitored throughout the year by means of the monthly compliance dashboards. The aim of reducing audit observations to a minimum, and of closing all long-standing audit observations, was fully achieved by year end, with over 230 recommendations closed. This was accomplished while welcoming an unprecedented number of audit missions to the Region (seven, of which two in the Regional Office) within the same year. All audits resulted in satisfactory or partially satisfactory ratings, showing a clear improvement in controls compared to previous years, and a deep commitment to zero tolerance to non-compliance across the Region.
A number of initiatives have been undertaken in the past two biennia that have also proved useful to other regions. These include: a dedicated compliance and risk management role; improved compliance monitoring and reporting through dashboards; accountability compacts with budget centre managers and administrative officers tied in with performance management mechanisms; self-assessment questionnaires for managers in support of the management assertions on internal control; capacity-building initiatives, such an integrated training programme for budget centres, compliance forums and many more outreach initiatives; pilot projects as a basis for programmatic and administrative reviews; establishment of surge support capacity in the Region, with special focus on emergency countries; targeted country visits to provide on-site support; and strengthened managerial support to emergency preparedness and response, including the establishment of a regional solidarity fund.
WHO will address a number of specific challenges in 2016–2017, including the need for: capacity-building in institutions to support Member States in remaining aligned with evolving requirements; strengthening country level perspectives in responding to acute and protracted emergencies; consideration to deploy and deliver on a no-regrets basis; a regional risk register in addition to the corporate risk register; and continual improvement in accountability and control, as embedded in the regulatory frameworks. |
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 WHO experts identify mosquito breeding sites to guide vector control efforts (Photo: WHO).
Zika virus (ZIKV) disease is caused by a virus which is transmitted primarily by Aedes mosquitoes. Most infections are either asymptomatic or cause a mild illness including low fever, skin rash, conjunctivitis, muscle and joint pain, malaise or headache. Zika virus infection during pregnancy can cause microcephaly and other congenital malformations in newborns, known as congenital Zika syndrome. In adults and children it can cause rare but severe neurologic complications induding Guillain-Barré syndrome.
On 1 February 2016, WHO declared that recently reported clusters of microcephaly and neurological disorders potentially associated with ZIKV constituted a Public Health Emergency of International Concern (PHEIC). As of February 2018, 86 countries and territories around the world have reported transmission of Zika virus infection, of which 27 areas have ongoing transmission with new introduction or reintroduction reported since 2015.
As of August 2018, no cases of Zika have been recorded in the Eastern Mediterranean region. However, the Aedes aegypti mosquito is present in 8 countries in the Region (Djibouti, Egypt, Oman, Pakistan, Saudi Arabia, Somalia, Sudan and Yemen), so continued vigilance remains important.
There is no vaccine to prevent Zika virus infection, nor is specific anti-viral treatment currently available. Protection against mosquito bites during the day and early evening is a key measure to prevent Zika virus infection.
WHO is supporting countries to prevent and manage Zika and its complications according to the four main objectives outlined in the Zika Strategic Response Plan: detection, prevention, care and support, and research.
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Health systems strengthening |
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Situation in 2012
The need for strengthening of health systems in the Region was abundantly clear in 2012, and remains so today. Inequities in health are widespread, not just among group 2 and 3 countries but also in group 1 countries . Exposure to health risks is rising, particularly to the key causes of noncommunicable diseases – the Region’s leading killers. Health care costs are increasing and health insurance coverage is low, leading to high out-of-pocket health expenditure which drives many families into poverty. Access to quality health care – and sometimes any health care at all – is beyond the reach of a significant portion of the Region’s population. While modern networks of health infrastructure, skilled health care professionals and advanced medical technologies and pharmaceuticals are fully available to citizens in some countries, this is certainly not the case in all countries. Such differences in the strength of health systems contribute to divergent health outcomes, such as in life expectancy, maternal mortality and infant and child mortality.
Health information systems, including civil registration and vital statistics systems, are failing to capture vital information necessary for health system planning, development and monitoring. This includes reliable data on births, deaths and of causes of death, and key health indicators. While there are variations between countries in the quality of the health information system, all countries lack a comprehensive and fully functioning system that can provide the required information in a timely and reliable manner for planning and policy-making.
Capacity and resources for emergency preparedness and response are inadequate and fragmented. The violence, destruction of infrastructure, including health care infrastructure, and displacement of tens of millions of people, has become a severe crisis for health systems that were inadequately prepared. In direct response to these and other severe health challenges, the Regional Office, working with country offices, ministries of health, WHO headquarters and other partners, began the process of strengthening the health systems of Member States.
In October 2012, the Regional Committee endorsed a resolution (EM/RC59/R.3) on health systems strengthening in countries of the Eastern Mediterranean Region. The resolution, which concluded that improving population health of the Region “can only be realized through well performing national health systems which assure universal access to effective and good quality health care”, urged Member States to focus on seven strategic priorities (Box 1). These became the objectives for strengthening health systems.
Box 1. Priorities for health system strengthening
- Strengthen leadership and governance in health
- Move towards universal health coverage
- Strengthen health information systems
- Promote a balanced and well-managed health workforce
- Improve access to quality health care services
- Engage with the private health sector
- Ensure access to essential technologies, including medicines
Progress 2012-2016
Leadership and governance: The multi-faceted area of health system strengthening began with an in-depth review of the health systems in the Region and the subsequent development of a brief health system profile for each country. The two-page profiles, which are produced annually, in consultation with Member States, provide critical information on each country and a brief assessment of strengths, weaknesses, opportunities, challenges and priorities. They are aimed at helping policy-makers to focus on the assets and challenges within their countries and provide a useful opportunity and entry point for dialogue, especially during missions to countries. A range of capacity development courses to strengthen government policy-making and decision-making, on health legislation and regulation, health and human rights, and health policy and planning, have been offered in parallel.
A major impediment to progress in public health in many countries has been a lack of capacity to develop and implement evidence-based health policies and programmes. As part of the efforts to strengthen leadership, a leadership for health programme was launched to promote skills among mid-level and senior level public health officials in countries. So far, more than 50 future leaders in public health have graduated. The programme, offered in collaboration with the Harvard School of Public Health, aims to develop future leaders who can address, proactively, local and national health problems that have direct impact on population health. Another leading initiative was the assessment of essential public health functions in the Region. Led by the Regional Director and advised by a global committee of renowned experts, this work established for Member States the specific functions of public health that are essential for the health and wellness of their populations. This was followed by the development of tools and self-assessment guides for countries to identify gaps in their public health capacity. The assessment was implemented in two countries as a pilot experience and will be rolled out to other countries of the Region.
In the area of health governance, an initiative was launched to build capacity in health diplomacy. This concerns the negotiations that Member States engage in at global level, in particular, around health issues that affect all countries and that shape the global policy environment surrounding health. Annual seminars have brought together key players from ministries of health and foreign affairs, diplomats, parliamentarians and experts to discuss the key global health issues of the moment and to learn from each other. Year on year this has proved to be a most useful dialogue from which all participants learn and which is contributing to strengthening the relationship between health and foreign policy in the Region. Several countries are implementing national seminars and workshops.
Universal health coverage: The most important goal for strengthening health systems in countries is the achievement of universal health coverage – and that means for everyone, all countries and both citizens and noncitizens. Universal health coverage must include interventions to tackle the most important causes of morbidity and mortality for the whole population, including the marginalized and vulnerable, as well as protection against catastrophic health costs that can cause financial ruin for families. It is an important target of the health goal of the Sustainable Development Goals and vital for ensuring effective response to the growing impact of noncommunicable diseases. The endorsement, in 2012, by the Regional Committee of universal health coverage as the overarching priority led to the development and subsequent endorsement, in 2014, of the Framework for action on advancing universal health coverage (UHC) in the Eastern Mediterranean Region. This is a strategic policy document that will help to achieve this vitally important initiative for every individual and family in the 22 countries of the Region.
The framework includes a set of strategic actions to achieve universal health coverage that are evidence-based, cost-effective and feasible, and all of which would be supported by corresponding actions by WHO. They include, for example, establishing a multisectoral steering mechanism under the stewardship of each Ministry of Health. They also include actions to enhance financial risk protection, which would ultimately help reduce the share of out-of-pocket spending, and thus of catastrophic health expenditure, and impoverishment. The framework also aims to ensure that each country’s social health insurance coverage scheme contains a package of essential services, including preventive and curative services. Finally, it guides countries to expand coverage to vulnerable groups, particularly the poor and those in the informal sector, and to collect data to allow monitoring of progress toward population coverage.
Following the endorsement of the regional framework for universal health coverage, it is now necessary for each country to implement the recommended actions (Box 2.). To that end, WHO has extended support through health system review missions aimed at identifying challenges and opportunities to create national universal health coverage strategies. By mid-2016 in-depth health system reviews had been conducted and national strategies and plans developed in 10 countries. Almost all countries, including group 3 countries, are actively exploring options for universal health coverage, including the important topic of expanding population coverage through social health insurance, and covering the informal and vulnerable groups.
Box 2. Universal health coverage: key commitments of the framework for action
- Developing a vision and strategy
- Enhancing financial risk protection
- Expanding the coverage of needed health services
- Ensuring expansion and monitoring of population coverage
Health information systems: Two interconnected initiatives are being spearheaded by WHO in the Region to address the gaps in, and fragmentation of, health information systems in countries. These initiatives, started in 2012, are vitally important for the future development of evidence-based health policy-making, planning and monitoring.
In the first of these initiatives, WHO has been working intensively with Member States to review and strengthen their health information systems through expert consultations, intercountry meetings and widespread consultation with countries. In 2014, a framework for health information systems was endorsed by the Regional Committee. It provides 68 core indicators to monitor health in three areas: health risks and determinants, health status, including morbidity and mortality, and health system response. For each indicator WHO has provided a detailed analysis of the attributes (meta registry) which covers the source of data, the tool used to generate them and requirements for analysis, use for policy development and dissemination. In the past two years, Member States have started to adopt and report on the core indicators. However, to date, no country is able to report on all of them. Addressing this challenge is essential for all countries. A comprehensive report of the gaps in each country’s data has been shared with ministers of health and a comprehensive assessment is followed to identify the priorities for addressing them. The next step for WHO is to provide technical support to countries, as required, to strengthen their health information systems.
The second initiative, endorsed by the Regional Committee in 2013, focuses on improving civil registration and vital statistics, with specific emphasis on strengthening cause-specific mortality statistics. As a result of the rapid and comprehensive assessments that were conducted in collaboration with the ministries of health and other national stakeholders, there is now a comprehensive picture of the strengths and weaknesses of the civil registration and vital statistics systems in all countries. The gaps are considerable: more than 30% of all births were not registered in this region and just below 20% of deaths were reported with causes specified. The gaps that exist in each country were shared with Member States and technical support has been offered based on the regional strategy endorsed by the Regional Committee. Since the assessments were conducted, the number of countries reporting cause of death statistics from the Region has increased, from 7 in 2012 to 13 in 2016. Still, all countries, irrespective of their current achievement, need to do more to improve the accuracy of cause-specific mortality data, which is essential for monitoring health and also the Sustainable Development Goals.
Health workforce: This initiative involves not only developing the number of health care professionals and other health workers needed in countries but also the quality of the workforce. This is a critical area for health in the Region. Attracting quality health care workers is now very difficult in some countries where there is ongoing instability and conflict and from which many health professionals have been forced to flee with their families. In other countries, pay and working conditions are inadequate to sustain the workforce required. Working in collaboration with ministries of health, several strategies have been pursued to strengthen the health workforce.
A regional framework for health workforce development has been developed in consultation with Member States. The evidence-based framework, which is fully aligned with the global health workforce strategy, provides options for tackling some of the most difficult problems facing countries.
Strengthening medical education is key to health development in the Region. This area of work has been stalled in WHO over the past decade. Intensive work with countries and the International Federation of Medical Education was put into conducting a clear assessment of the situation of medical education in different countries and a regional framework was developed to address existing challenges, based on international experience. The framework is an approach to scaling up the development of quality physicians, beginning with establishing and strengthening the regulatory capacities, providing standards and guidelines for new medical schools, encouraging/strengthening education development centres, building capacity of educational leaders and establishing national independent accreditation programmes. Attracting and retaining competent faculty and developing adequate resources for training are also included. For each priority, short-term and long-term actions by Member States are outlined, matched by specific technical support from WHO.
The development of a regional strategy aimed at strengthening nursing and midwifery has been equally important, since nurses and midwives provide a major proportion of health care services worldwide and in the Region. A significant shortage of nurses and midwives exists in this region, and the strategy recommends strategic actions in five key areas: governance and regulation; workforce management systems; practice and services; access to quality education; and research.
Access to quality health care: Delivery of quality health care services for populations is based on the values and principles of primary health care. Family practice has been promoted as the principal approach for delivering integrated, person-centered primary care in the Region. However, countries have many gaps and challenges in offering full-fledged family practice programmes that are responsive to the changing demographics and disease burden. The major efforts undertaken to strengthen primary health care have included a situation review, strategic guidance to countries, building country capacity and advising on scaling up the production of family physicians. Programmes and tools to improve the quality of care and patient safety have been developed for all levels of patient care. The patient safety assessment manual was updated and a toolkit was developed to support patient safety programmes.
Two new areas of work have been instituted into the strategic priorities of health system strengthening: hospital management and the role of the private health sector.
A situation analysis of public sector hospitals in the Region was conducted and a capacity-building workshop was developed in which senior hospital managers from inside and outside the Region shared best practices on hospital care and management. Subsequently, a network of hospital managers and policy-makers was established to promote collaboration in these areas.
The private health sector is one of the major health providers in most countries. It has expanded rapidly and is often under-regulated. Partnerships with the private sector to deliver publicly financed essential health services can be an important means of population health improvement. For this opportunity to be realized, however, the private health sector needs to be well regulated, based on defined standards and enforcement. Government oversight and stewardship is essential, and a laissez faire approach is not acceptable. The work on the private health sector began with an analysis of the private health sector and was followed by a series of capacity-building workshops and consultations aimed at engaging and regulating private sector health care for universal health coverage.
Essential technologies, including medicines: Access to health technologies, including medicines, vaccines, biologicals and medical devices, can mean the difference between wellness and widespread disease for populations and life and death for individuals. Yet, in many countries, a high percentage of the population lacks regular access to essential technologies, including medicines, while quality assurance is problematic and irrational use is widespread. Government capacity to regulate may be supply-driven, which can result in wasted expenditure and purchase of inappropriate products. There is growing recognition that the weak performance of national health systems in this area is a major constraint to health development.
In response, a robust health technology assessment tool was launched. This assessment is a multidisciplinary decision-making process that uses information about the medical, social, economic, organizational and ethical issues related to use of a health technology. It supports the formulation of safe and effective health policies that are patient-focused and seek to achieve both the best value and best patient outcomes. The tool can provide cost–benefit evaluations to make purchase decisions within a given budget, and can help reduce waste and inefficiencies resulting from inappropriate investments. It also can be valuable to countries working towards universal health coverage.
Pharmaceutical sector profiles were also developed for all countries. The profiles provide a detailed description of the components of the national drug policy, with an indicator score card, as well as the challenges and priorities for action.
Way forward
The framework for universal health coverage and the work with health ministries in collaboration with country offices is very promising and will lead to real progress, if the commitment to this process is maintained and expanded. Special attention will be given to finalizing country-specific roadmaps for universal health coverage, including health financing and service delivery strategies. Experiences and lessons learnt from initiatives both inside and outside the Region will be shared.
Future work in leadership and governance will focus on strengthening of ministries of health, building their capacities for better regulation of the health sector, greater multisectoral involvement, effective decentralization and increased accountability and transparency. Strengthening the capacity of public health in ministries of health is key. The leadership for health programme, which has been successful for two consecutive years, will pay greater dividends as time goes on and as graduates progress in their careers. The programme aims to graduate up to 30 public health leaders from the Region every year. The plan is for the leadership programme to be eventually outsourced to an academic institution in the Region to ensure sustainability.
Accurate data from health information systems is absolutely vital to improve the health of populations. Every country of the Region needs to mobilize high-level political commitment and support from relevant sectors to fulfil the promise of health information system initiatives, especially collection of comprehensive cause-of-death data. Member States have repeatedly expressed concern about the validity of estimates that are used to report on health status in countries. While the methods to generate estimates are improving at the global level, there is no alternative to such estimates unless countries develop reliable data collection and reporting systems. WHO is developing methodologies to assess the validity of the reported indicators so that the results of the assessments will help the countries improve their information systems at a national level. Every country will need to consider the gaps in reporting on the 68 core indicators of the regional health information framework recently provided by WHO and develop a plan. Countries should also consider the areas in their civil registration and vital statistics systems that were identified by the comprehensive assessment and subsequent WHO reports as requiring strengthening.
Health workforce development is critical to every other health initiative. Clear strategies to build the workforce of the future have been developed and will be discussed with Member States at the 63rd session of the Regional Committee. Political and educational leadership at the country level is now necessary to move forward.
The support to medical schools will continue through the implementation of the regional framework for medical education. The framework will be discussed in a ministerial-level meeting for the health and higher education sectors which is planned to take place in the fourth quarter of 2016. Every country is expected to review the nursing and midwifery workforce situation based on the regional framework for action. WHO will provide technical guidance and support through a network of international and regional experts.
Regional programmes for capacity-building and technical support aimed at expanding access to quality health care, including enhancing primary care through expansion of family practice, should be expanded to accelerate progress towards universal health coverage and improve patient safety. Engaging the private health sector is an essential component of the journey to universal health coverage. WHO’s work in 20162017 will continue to provide guidance on strengthening the role of private sector in moving towards universal health coverage and regulating it.
Intercountry meetings on the assessment and regulation of essential technologies have begun with the purpose of establishing guidelines to support Member States. Countries need to finalize, and then implement, action plans to institute health technology assessment and regulation. WHO will continue to provide capacity-building and technical support for every step towards full implementation of the assessment for countries. In addition, international donors are potentially interested in supporting health technology assessment and regulation. |
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Public health measures for scaling up national preparedness for Middle East Respiratory Syndrome (MERS)
