Universal health coverage

In 2013, WHO advocated with its Member States the move towards universal health coverage in order to expand population coverage, ensure the availability and accessibility of needed health services, and improve financial protection for those who use health care services. The move towards universal health coverage has created many opportunities for Member States to accelerate progress but has also highlighted gaps and challenges in the different health system components that will need to be addressed to accelerate the move. 

In its 60th session, the WHO Regional Committee for the Eastern Mediterranean discussed the challenges and opportunities with regard to moving towards universal health coverage and endorsed a vision, strategy and roadmap (EM/RC60/R.2) for Member States. Short health system profiles were developed for each country which provide an overview of health system performance and a summary of the challenges and priorities for health system strengthening towards universal health coverage. 

This was followed by an international event at which high-level representatives from 20 countries of the Region, as well as international and regional experts and development partners, such as the World Bank, endorsed a framework for action that will guide future support to countries in moving towards universal health coverage. Activities to build health system capacity to accelerate progress towards universal health coverage included workshops for the sub-regional group of Gulf Cooperation Council, G5 countries, and countries eligible for support from the GAVI Alliance. 

Work in 2014 and beyond will focus on supporting Member States to implement the framework for action and assessing the progress that countries make in achieving universal health coverage.

Health financing

As noted in last year’s annual report, the Region is characterized by a high share of direct out-of-pocket expenditures for health, which is a major impediment to the move towards universal health coverage. Many countries in all three groups of countries in the Region  continue to lack a clear vision as to how to improve their health financing systems. There is inadequate understanding of health financing concepts and similar lack of capacity in the conducting of health financing studies and tools, particularly national health accounts, OASIS (Organizational assessment for improving and strengthening health financing), household health expenditure and utilization surveys, and cost–effectiveness studies, and the application of these tools to inform decision-making. 

Several activities were held to build national and regional capacities in promoting concepts and the use of health financing tools to engage countries in discussions around strengthening national health financing systems. Global experiences in progress towards universal health coverage were shared at the high-level event on accelerating progress towards universal health coverage. Over 100 delegates participated, including ministers of health and policy-makers, development partners, civil society organizations and global experts. A high-level seminar was held in early 2013 on options for health care financing in the Region followed by a sub-regional meeting on health financing for the member states of the Gulf Cooperation Council (GCC), which comprise the group 1 countries. Among other issues, the particular case of expatriate populations was discussed and options   on how to cover them were reviewed. Two regional capacity-building activities on national health accounts and costing using the one health costing tool were conducted. In addition, country-specific health financing workshops were held in three countries and a national health system conference was supported in Morocco, aimed at developing the vision for the future of the health system. Several policy papers were developed on key topics around universal health coverage, including multi-sectorality, and the role of strategic purchasing. 

Needless to say, much work is needed in this area. Our plan is to continue to reinforce WHO’s technical capacity in health financing to respond to the need to provide advice and build capacity in Member States in the development and implementation of  sound health financing policies to achieve universal health coverage. 

Health governance

Improving governance in health remains a major issue for all countries as they work towards increasing equity and fairness in health care delivery, updating public health laws and legislation, and improving accountability. The right to health – or health as a human right – is not yet a routine part of policy-making. As health assumes increasing importance in the global development agenda, there is an increasing realization of the need to develop capacities in health diplomacy and reinforce coordination with the foreign policy and other sectors. The second regional health diplomacy seminar was conducted for officials in foreign affairs and health to promote coordination between the two sectors in addressing health challenges that require political solutions and skills. 

Support for improving governance, accountability and transparency included assessments in 12 countries to better understand the policy and planning function of the Ministry of Health. Technical support was provided to four countries to review their respective national health policies and strategies. Two assessment tools were developed to support health system development. The first was used to assess the status of the right to health in four countries, and the second to assess public health legislation in five countries. An expert meeting identified gaps in public health law in the Region and galvanized action to respond to these gaps, including the setting up of a regional network of experts on public health law. Work will continue in 2014 and beyond to develop clear guidance for countries in strengthening health legislation. Special emphasis will be given in 2014 to the prevention of noncommunicable diseases.

Of particular concern in the Region is the presence of political crisis and social unrest in several countries, a situation which has led to a domination of emergency-oriented activities in the health sector. This has contributed to further weakening of government institutions in some countries and their ability to increase and improve the predictability of external assistance, and their alignment and harmonization with government priorities. 

Health workforce development

The major challenges facing countries in the area of health workforce development include shortages and maldistribution, especially of nurses, midwives and allied health professionals, training and continuing education, and retention of competent professionals. In several countries in groups 2 and 3, human resources management systems are weak and coordination in health workforce development is inadequate. An important region-wide concern is the need to ensure that the migration, movement, rights and obligations of the health workforce are consistent with the WHO global code of practice on the international recruitment of health personnel. 

While the gaps in the development of the health workforce are clear, solutions to address these gaps are not always evident to Member States. To respond to this challenge, work started in 2013 to develop a comprehensive strategy to guide countries in implementing effective approaches in the production, distribution, training and retention of health professionals. The strategy, which will be based on a review of regional and international experience, will be discussed in an intercountry meeting in 2014.

It is evident from working closely with countries that most Member States do not have adequate capacity in public health. Supporting countries in this area is considered a priority by the Regional Office. Experience and skills in public health are essential for national health development. A regional consultation reviewed options for improving public health capacity, and discussed ways to develop a regional public health leadership programme and improve the quality of public health education and training, addressing the dichotomy between teaching and practice, and improve investment in public health research. We are now working with other international public health institutions in establishing a public health leadership programme which will be open to mid-level public health managers in Member States starting in 2014.

Nursing and midwifery is another area that requires greater attention. A consultation on nursing education was convened to review and update the regional standards for nursing and midwifery education, and develop a regional framework for nursing specialization. A prototype curriculum for pre-service nursing education and a post-basic specialty mental health nursing prototype curriculum were developed. 

WHO support was provided to build national capacity in areas such as leadership and management for nurses and midwives and how to conduct a health workforce projection. Nursing and midwifery regulation was strengthened in three countries. In Afghanistan, a strategic national plan for human resources for health and a strategic plan for the ten institutes of health sciences to promote educational development of nursing, midwifery and allied health sciences and increase production were finalized. 

The regional fellowships programme benefited 94 fellows from countries across the Region. 

We believe that WHO’s work in strengthening medical education has not received adequate attention in recent years despite the important challenges that countries currently face in this area. In scaling up, we first need to conduct an accurate situation analysis, identify constraints and agree on priorities for action. For this reason, a major study on medical education in countries of the Region has been initiated in coordination with the World Federation of Medical Education. The purpose is to review the quality and appropriateness of medical education programmes across the Region, share best practices and identify areas for improvement. Our plan is to provide clear strategic directions for this area of work in 2014.

At the Third Global Forum on Human Resources for Health, 14 Member States made commitments and agreed to monitor and report progress on these. The forum is organized by the Global Health Workforce Alliance, which is hosted by WHO.

Essential medicines and technologies

Access to medical products, including essential medicines, vaccines, blood products, diagnostics and medical devices remains a challenge that is exacerbated for many countries by the failure to fully implement the use of quality-assured generic medicines, irrational use of medicines and inefficient procurement and distribution systems. In addition, countries have not fully used available tools (such as health technology assessment) to help them make informed decisions in relation to investments in health technology. Underpinning the challenges in the area of essential medicines and health technologies is the need to strengthen national regulatory authorities in most countries. 

Important steps were taken in advancing the use of health technology assessment in the Region with an intercountry meeting on health technology assessment attended by 18 countries. The meeting triggered the initiation of a health technology assessment network of regional and international experts, as well as the setting up of national programmes and the mapping of existing national and region-wide health technology assessment resources. 

National medicines policy documents were updated in two countries and capacity was strengthened in 18 countries to conduct surveys to assess the national pharmaceutical sector by using WHO level II methodology. 

The work in strengthening access to medicines and health technology included building up regulatory capacity. Although training was conducted for some countries in 2013, this area requires intensive work in WHO to reinforce technical support to Member States in 2014 and beyond. Capacity-building continued under the WHO good governance for medicines programme. 

Integrated service delivery

The three groups of countries face varying health system challenges. The predominant challenges in the area of health service delivery are expanding access, improving quality of care and strengthening referral systems In addition to the need for improved training, deployment, distribution and development of the health workforce, capacity of health care providers in managing financial and human resources will have to be reinforced. Poor management capacity is compounded by the lack of effective hospital autonomy and public–private partnerships. 

The quality of care and the level of patient safety need to be improved. Studies in some countries have shown the prevalence of adverse events to be as high as 18% of hospital admissions. 

Several studies were conducted to deepen understanding of health service delivery challenges in countries. For the first time a regional analysis of the private health sector was conducted and presented during the pre-session of the Regional Committee. An assessment of the main characteristics of general operations, internal control structures and service delivery aspects of public sector hospitals was completed in all countries. The findings showed that the average length of inpatient stay across the Region is almost 5 days (range 3 to 8 days) and the average bed occupancy is 85% (range 33–100%). A mapping study on accreditation of health care institutions was also carried out in the Region. 

Several tools and guidelines were developed or updated. These include a conceptual and strategic approach for establishing family practice programmes, guidelines to scale up the community health workers’ programme in countries as an approach for moving towards universal health coverage, guidelines for establishing home health care programmes for the elderly, and a manual on community-based disaster risk reduction, developed in collaboration with the regional programme on emergency and humanitarian response. In addition, the patient safety assessment tool was revised and the patient safety curriculum for medical schools translated into Arabic and widely disseminated. 

All countries require support in building and sustaining effective family medicine programmes. This area will be given priority in 2014 by conducting an assessment of the current status of family practice in countries of the Region together with a review of international experience and development of approaches to strengthen family medicine to achieve universal health coverage.

Health information systems

The situation with regard to health information systems in the Region is highly variable. Many countries have several areas that require strengthening, including policy and legislation, human and material resources, indicators for monitoring and evaluation, and skills to collect, analyse and disseminate accurate and timely information to inform decision-making. Following the endorsement in 2012 of resolution EM/RC59/R.3 on health system strengthening, concerted efforts to support countries to improve their health information systems were undertaken. A situation analysis of civil registration and vital statistics was undertaken in all countries using a rapid assessment approach to identify major gaps and challenges. The results were discussed in a regional meeting of stakeholders with the aim of reaching consensus on ways and means to improve the level and quality of registration of births and deaths. Further in-depth assessments were conducted in nearly half of the countries, and the results were used to develop a regional strategy to strengthen civil registration and vital statistics which was endorsed by the Regional Committee (EM/RC60/R.7). 

In order to help countries to strengthen their health information systems, a core list of indicators covering three key areas – health risks and determinants, health status and health system performance – was developed. This was discussed in an intercountry meeting and the initiative of having an agreed list of indicators was subsequently endorsed by the Regional Committee. The current status in countries was reviewed in relation to each core indicator, in terms of data collection, data generation, analysis, dissemination and use for policy development and evaluation. The gaps identified in these areas will be discussed with countries in an intercountry meeting planned for 2014. A regional health observatory was launched to ensure that all health-related information are is accessible and used for better planning at both regional and country level, and this core list of indicators will be included in it. Some Member States have repeatedly reported differences between mortality estimates produced by the United Nations agencies and figures reported nationally. In order to reduce inconsistencies and to ensure timely and transparent consultation with national authorities, a meeting was held with countries on the maternal and child mortality estimates produced by the UN inter-agency groups for monitoring MDGs 4 and 5.

eHealth

There is only limited use of eHealth within health systems in the Region at present. National eHealth strategies need to be developed to meet the financial challenges to health systems, increasing demand for efficiency and higher expectations from citizens. The World Health Assembly (resolution WHA 66.24) has urged Member States to develop national policies and to plan for appropriate eHealth services and implementation of health data standards in their countries.

While several countries have embarked on initiatives of one kind or another, there is a recognized gap in national capacities to manage the development of national strategies and policies. Progress in the adoption and implementation of health data standards is slow and the lack of national networks to support flow of information within the health system is an impediment to the development of eHealth. 

The key considerations in developing a national strategy were highlighted at a regional meeting which also saw the launch of the HealthNet initiative to establish dedicated, reliable, operational national health networks. The Regional Office coordinated with national focal points to complete a survey on eHealth and innovation in women and children’s health conducted by the WHO Global Observatory on eHealth. Preliminary analysis shows that two of the nine countries concerned have partially implemented national eHealth policies, which now need updating, seven have at least one electronic information system to collect and report health data at the district level, and three have major women’s and children’s health initiatives that are supported by eHealth. 

The life course approach

Health is the outcome of all policies, including those related to social determinants of health, gender and equity, nutrition, injury prevention and disabilities. In 2015, WHO continued its efforts to protect and promote the health, safety and well-being of the population in the Region, across the life course. From conception to old age, diverse population health needs were addressed, while focusing on maternal and child health as a strategic priority.

Maternal, reproductive and child health

Considerable progress was achieved towards Millennium Development Goals (MDGs) 4 and 5 in the Eastern Mediterranean Region. Between 1990 and 2015, maternal mortality ratio decreased from 362 to 166 per 100 000 live births, and under-5 child mortality rate from 181 to 91 per 1000 live births (see Fig. 1 and 2). Eight countries achieved MDG 4 and three achieved MDG 5. Following the regional initiative on saving the lives of mothers and children, launched in 2013, the reduction in maternal mortality ratio improved by 12 points from 42% (2012) to 54% (2015).

Source: Trends in maternal mortality: 1990-2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015.

Fig. 1 Regional trend in maternal mortality, 1990–2015

Source: Levels and trends in child mortality. Report 2015. Estimates developed by the UN inter-agency group for child mortality estimation. Geneva: World Health Organization; 2015.

Fig. 2 Regional trends in child and newborn mortality, 1990–2015

The high levels of maternal, newborn and child mortality at regional level are mainly due to weak health systems. There are insufficient numbers of well trained human resources, essential drugs and commodities are often lacking or inadequate, referral systems do not function well and the quality of care for mothers and children at the referral hospitals is inadequate. Most national programmes do not target the main causes of maternal, neonatal, and child death by implementing the evidence-based, cost-effective and high impact interventions (best buys) that are available to them. Political will and commitment to maternal and child health need are not always translated into concrete action and financing mechanisms to ensure universal coverage with maternal and child health services are inadequate. The situation is most critical in the countries affected by political instability, social unrest, acute and chronic protracted crises.

WHO maintained its support to reproductive, maternal, neonatal, child and adolescent health, with specific focus on addressing the main causes of maternal, neonatal, child deaths and targeting quality of care. The regional initiative on saving the lives of mothers and children continued to target the main challenges in countries with a high burden of maternal and child deaths, jointly with UNFPA and UNICEF, and in close collaboration with Member States and key stakeholders. Launching the maternal and child health acceleration plans strengthened national ownership and leadership towards achieving the MDG targets, and prepared the way for the new Sustainable Development Goals (SDGs).

To ensure the implementation of the acceleration plans was of sufficient quality and to address the gaps identified through the regional surveys, special attention was given to health system-related elements. These included access to and delivery of high impact interventions, the health workforce, assessment of quality and infection control services, and identifying knowledge gaps to be able to determine research priorities. Technical support to Member States was focused on building national capacity in strategic planning for the period 2016–2020 in line with the global strategy and the SDGs.

Priority was given to the adoption of key evidence-based, cost-effective and high impact interventions by all countries of the Region. At a meeting held jointly with UNFPA and UNICEF, national programme managers identified priority maternal, neonatal and child health and mental health interventions with high impact, focused on the health systems challenges to be addressed and determined strategic directions in preparation for the SDGs. The strategic directions are in line with the United Nations global strategy for women’s, children’s and adolescents’ health, endorsed by the UN General Assembly in September 2015. The following month, the Regional Committee (resolution EM/RC62/1) urged all Member States to develop or update national reproductive, maternal, neonatal, child health strategic plans in accordance with the global strategy.

Supporting countries in establishing and strengthening preconception care, as part of the continuum of care, is another priority that will further improve maternal, neonatal and child health outcomes in the Region. A meeting held with Member States, with support from UNFPA, UNICEF and international and regional experts, resulted in consensus on a set of core interventions, a regional operational framework and service delivery channels for preconception care. Further work was conducted during the year, which resulted in a regional package of evidence-based interventions and programmatic steps for promoting preconception care within countries. The package of preconception care is currently being integrated into a broader package that covers care during pregnancy and after birth with special focus on the prevention and care of common congenital disorders.

Reproductive, maternal, neonatal and child health will continue to be a regional and national health priority in the post-2015 development agenda. WHO will focus on building capacity in countries to end preventable deaths among women, children and adolescents. Implementation of the United Nations global strategy on women’s, children’s and adolescents’ health and the SDGs will require integrated and multisectoral approaches backed by well defined targets and sustainable financing mechanisms

Nutrition

The situation with regard to malnutrition in the Region has seen some general improvement since 1990 but the progress is insufficient and the situation remains very serious in many countries of the Region, including those suffering from major crises. Much more work is needed to ensure that all mothers and children in all countries are adequately nourished to maintain health and development. According to the latest data from WHO and other UN organizations, on average, the prevalence of undernourishment in the Region decreased from 22.1% in 1990 to 13.7% in 2014. Since 1990, 13 out of 22 countries of the Region have reached MDG 1 with regard to halving the proportion of people who suffer from hunger. The estimated prevalence of children under 5 years of age affected by stunting was reduced from 39.8% in 1990 to 16.9% in 2014 as a result of economic and social development, especially in high- and middle-income countries, while the estimated prevalence of wasting increased from 9.6% in 1991 to 10.1 % in 2011, due to natural and manmade disasters and political instability in Afghanistan, Djibouti, Iraq, Pakistan, Somalia, Syrian Arab Republic and Yemen.

In 2015, a regional roadmap was developed for countries to implement the global targets set by the World Health Assembly in 2012 and the recommendations of the Second International Conference on Nutrition (ICN-2). National strategies and/or national action plans for post-2015 were developed by most countries of the Region.

The regional policy statement on the urgent need to fully implement the International Code of Marketing of Breast Milk Substitutes was promoted. Most countries in emergency situations expanded the number of nutrition stabilization centres for treatment of severe and complex cases of malnutrition. Supplementation and food fortification with essential micronutrients are provided in almost all countries.

The Region continues to face major challenges in tackling nutrition issues. These include the lack of quality nutrition data and indicators, as well as of national capacity to support countries in data collection and analysis, and the need for effective nutrition surveillance and a monitoring and evaluation system to enable policy-making and programme implementation. Finally, the demand for action to address malnutrition is high, while the financial resources to do so are limited.

The Regional Office is working with countries to develop a regional framework to scale up action on nutrition, with focus on cost-effective interventions. Technical support is being provided to countries to establish national targets and monitor national action plans, promote interagency and multisectoral coordination, promote a healthy diet, as well as food and nutrition security, at national and regional levels, and introduce and apply innovative approaches for delivering effective nutrition actions, including implementation of food standards and WHO guidelines.

Health of special groups

The situation prevailing in several countries is exposing the life and well-being of many older persons and schoolchildren to various levels of risk, and their unmet needs and health status should be of great concern in the provision of health support during emergencies. Despite this, the health programmes concerned with these special groups face strong competition from many other priorities.

Nevertheless, several countries were active in reviewing the draft world report on ageing and health and providing case studies, as well as the draft global strategy and action plan on ageing and health. The regional launch of the world report was organized in collaboration with Sharjah Health Authority, United Arab Emirates, during the celebration of the International Day of Older Persons (1 October). The city of Sharjah is heading firmly towards being an age-friendly city. Several countries continued activities to build capacity and multisectoral collaboration in ageing and health.

Focusing on the school setting as an important entry point for health promotion throughout the life course, the active role of countries in institutionalization of the Global School Health Initiative was reviewed in a consultation for developing updated and evidence-based criteria and an executive framework for health promoting schools. The plan is to continue this work in 2016 and to launch the new criteria in a special initiative on health-promoting schools in 2017.

One of the important steps in the way forward is to put the unmet needs of older persons and schoolchildren at the centre of relief efforts and programmes in countries in emergency situations.

Violence, injuries and disabilities

In 2015 WHO published the Global status report on road safety 2015, which presented the most recent data from countries across the world, including the Eastern Mediterranean Region. The report showed that road traffic injury continues to be a grave concern in the Region despite the decrease in the regional road traffic fatality rate from 21.3 to 19.9 per 100 000 population between 2010 and 2013. This fatality rate remains higher than the global rate, and still puts the Eastern Mediterranean among the WHO regions with highest fatality rates. The vast majority of deaths occur in the middle-income countries. The overall death rate in the high-income countries exceeds that of the less affluent countries and is more than double the rate of other high-income countries in the world. Despite the gravity of the issue, serious gaps persist in the comprehensive implementation of proven cost-effective interventions based on a whole safe system approach. Some aspects of these interventions have been implemented in most countries in the Region. However they have not been implemented as a package that covers all essential elements, which seriously affects their effectiveness.

In addition, 2015 marked the mid-point in the Decade of Action for Road Safety 2011–2020 and two road safety-related targets were included in the SDGs. The Brasilia Declaration on Road Safety was endorsed by the Second Global High-level Conference on Road Safety, held in November 2015. This Declaration describes the global roadmap towards achieving the targets of the Decade of Action and the SDGs, which can only be achieved through concerted efforts across all countries.

WHO continued its efforts on different aspects of road traffic injury prevention and control from data to care. A standardized methodology for estimation of the cost of road traffic injuries was developed and piloted in the Islamic Republic of Iran. The regional instrument to profile trauma care systems was finalized based on piloting in Djibouti, Islamic Republic of Iran and Pakistan. A report documenting the exercise was prepared and peer-reviewed for publication; it recommends actions to address existing gaps and will pave the way for expansion of the exercise to other countries. A more comprehensive exercise for strengthening trauma care services was also done in Iraq.

A regional high-level ministerial meeting on road safety is planned for 2017, to increase political commitment and to agree on concrete actions for accelerated progress in the second half of the Decade of Action. In preparation, an expert consultation was held in January 2016 to review an in-depth analysis of the current burden road traffic injuries and related risk factors in the Region prepared by WHO with Johns Hopkins Bloomberg School of Public Health. Based on this analysis, experts will provide their views on the development of a specific framework for action at country level. This will guide the development of a resource document for the ministerial meeting outlining packages of essential cost-effective interventions for the three groups of countries in the Region, building on WHO related work, and taking into consideration recent global and regional developments.

In terms of child injury prevention, a literature review on child injuries in the Region was done. Based on this, the regional strategic framework for child and adolescent injury prevention was updated and finalized.

In the area of violence prevention, the Global status report on violence prevention 2014, in which 16 countries of the Region participated, revealed that the Region’s low- and middle-income countries rank third (7 per 100 000 population) in terms of homicide rate, among similar countries in all WHO regions. Many of the surveyed prevention strategies are available in participating countries of the Region. However their implementation has not been evaluated. A regional consultation was organized to review the draft global action plan for strengthening the health system’s role in addressing interpersonal violence, in particular against women and girls, and against children, to ensure that regional and country perspectives were reflected in the final version. Prior to the consultation, a preparatory coordination meeting was held with concerned United Nations agencies and the League of Arab States to initiate discussion on a sustainable regional inter-agency coordination mechanism for the implementation of the plan.

A number of major challenges confront effective violence and injury prevention and control. Declared political commitment is not always translated into sufficient action at country level. Enforcement, implementation and evaluation of policy and legislative frameworks are weak. Coordination and multisectoral action remain insufficient. Furthermore the adoption of a whole safe system approach is inadequate, with more focus needed on individual behaviour issues. In the area of disability, several countries developed national disability strategies and action plans. Thirteen countries participated in the global survey on developing the WHO priority list of assistive products. The subject will be discussed during the forthcoming session of the Regional Committee.

WHO continued to support countries in the prevention and management of avoidable blindness in line with WHO’s global initiative VISION 2020: The Right to Sight. Primary eye care activities are being integrated into the primary health care system in some countries and this is contributing to the decline in vision loss and visual impairment through early case finding, referral and eye health education. However, despite the the considerable burden of visual impairment in many countries of the Region and the increase in potentially blinding age-related eye diseases as people live longer, investment in blindness prevention remains low. Reaching the goal of eliminating avoidable blindness by 2020 will depend on the ability of health systems to scale up efforts

Health education and promotion

In 2015, WHO focused on building capacity in the development of multisectoral national plans of action on physical activity and of social marketing and mass media campaign plans. In partnership with the WHO Collaborating Centre on Physical Activity, Nutrition and Obesity, Sydney, Australia, a training package was developed on mass media and social marketing to support countries in implementation of the best buys related to promoting physical activity and healthy diet. Participants from both health and non-health sectors worked together to develop provisional social marketing and mass media plans which will be launched in 2016.

A toolkit was developed to guide the inclusion of physical activity in primary health care. The toolkit was developed through a systematic review and meta-analysis, which showed that primary health care is instrumental in promoting physical activity and thus it is crucial to ensure that primary health care services are adequately resourced and fit to play a major role in getting a population more active. The toolkit was reviewed by countries to ensure regional relevance and practicality based on country context. The next step is to pilot test the instrument in eight selected countries.

A bi-regional workshop to build legal capacity and advance action on the WHO recommendations on marketing of food and non-alcoholic beverages to children was held in collaboration with the Regional Office for Europe, WHO headquarters and the University of Liverpool. Participants from nine countries attended and developed a provisional roadmap to advance actions in addressing marketing of unhealthy foods in their countries.

As part of an initiative to address unopposed marketing, a series of activities was organized to sensitize the non-health sector to the issue and obtain innovative ideas in creating a social movement. A key event was an open forum which was attended by mainstream media outlets, regional celebrities and media experts and representatives of civil society organizations, including Consumer International, and which resulted in a set of actions to be promoted to non-health sectors. The biggest challenges to health promotion concerns countries’ capacity to mobilize non-health sectors and work intersectorally to implement objectives, the need for research and advocacy, and the need to mobilize experts with legal backgrounds in support of the regional objectives. WHO will continue to build capacity to work with the different sectors.

Social determinants of health and gender

Focus continued to be placed on the implementation of the Rio Political Declaration on Social Determinants of Health; effective integration of social determinants of health and gender within health programmes; and strengthening country capacity to implement health-in-all policies, intersectoral action and social participation to address social determinants of health and gender. Countries agreed to implement an action framework developed at a regional consultation on reducing inequalities through action on social determinants of health, organized in 2015. In this regard four countries conducted in-depth assessments with a view to developing action plans. The results of these assessments were presented to the Regional Committee which urged Member States to assess inequalities in health and their related social determinants, identify priority actions and monitor progress (resolution EM/RC62/R.1). Several countries have undertaken specific actions on social determinants of health.

Health and the environment

With the support of the Regional Centre for Environmental Health Action (CEHA), many countries implemented programmes and activities pertinent to health protection and the environment. Implementation of the regional strategy on health and environment and its framework of action (2014-2019) began, and several countries have taken concrete steps to develop their national strategic frameworks for action. Field missions to assess the environmental health situation and delineate priorities were undertaken in several countries.

The WHO guidelines on drinking-water quality and wastewater reuse were promoted. So far, 16 countries have updated their national standards for drinking-water quality in accordance with the guidelines, and Jordan issued national standards on irrigation water quality in line with the WHO guidelines on safe use of treated wastewater in agriculture. With WHO support, eight countries have adopted preventive water and sanitation safety management plans and 11 countries have published their national profiles under the framework of the UN-Water Global Analysis and Assessment of Sanitation and Water. All countries are participating in the WHO/UNICEF Joint Monitoring Programme. The public health risk of natural radiation in groundwater is being tackled in two countries.

Member States of the Region participated in the negotiations and adoption of World Health Assembly resolution WHA68.8 on the health impact of air pollution, to discussions on the road map for implementation. The special air quality needs of the Region, such as the health impact of sand and airborne dust, were addressed in a regional meeting of experts with the United Nations Environment Programme (UNEP) and World Meteorological Organization (WMO). Capacity-building was supported in the area of air pollution and health. In collaboration with the Jordan University of Science and Technology, CEHA reviewed and compiled the knowledge of all the countries of the Region in the fields of air pollution and climate change.

Joining the WHO delegation to the United Nations Framework Convention on Climate Change (UNFCCC) COP21, the Regional Office advocated with its Member States positioning of public health at the centre of climate change debate and contributed to the successful global agreement concluded in Paris in December 2015. Four countries developed, with WHO support, climate change and health national profiles which were presented at the Paris conference and several others are in process. A regional network of climate change and health experts was established.

The institutional capacity of countries in management of health care waste was strengthened and technical support extended to several countries. In response to the solid waste crisis in Lebanon, a series of technical consultations were held and briefings on solid waste management master planning, landfill assessment and public health impacts of refuse were shared with stakeholders. A scientific protocol to assess the potential health effects of solid waste, and interventions, on the population in Lebanon was finalized.

A regional food safety assessment initiative was launched and national profiling missions were conducted by WHO staff and experts in 15 countries and the results, which demonstrated major gaps, were presented to the Regional Committee. The aim was to assess strengths and weaknesses in the national food safety systems and to identify the priority actions required to address gaps identified. This “farm-to-fork” initiative will augment the capacity of countries to prevent, detect and manage foodborne health risks and outbreaks. WHO and countries are following up on the results and regional action plan to strengthen food safety systems is being developed.

Environmental health support was provided to all countries in emergency situations. Emergency support was provided in 10 countries, including a multi-stakeholder regional meeting; technical missions and training. CEHA established a regional revolving stock for environmental health supplies to support emergencies in the Region. Capacity-building was supported for health service providers in several countries on response to chemical accidents and trauma care. National preparedness and response capacities for chemical, radio-nuclear and food safety events were strengthened in line with the International Health Regulations (2005).