- Governing bodies
- Health policy and management
- Health systems and services development
- Promotion and protection of health
- Integrated control of disease
- Administrative services

4.1 Reproductive, family and community health and population issues

Promotion of reproductive health and family planning
Child and adolescent health
Protection and promotion of adolescent health
Protection and promotion of women's health
Protection and promotion of health of the elderly
Protection and promotion of occupational health
Protection and promotion of school health

Promotion of reproductive health and family planning

The launch of WHO's Making Pregnancy Safer (MPS) initiative in 2000 was a significant step towards reducing maternal and neonatal ill-health. The MPS philosophy is country-oriented, building on existing successful efforts, supporting governments through ministries of health so as to determine clear and comprehensive national strategies, complemented by realistic action plans, and contributing to the most effective partnerships at both national and international levels in order to ensure strategy funding and support for implementation. Ten countries having high levels of maternal and neonatal mortality, but strong political commitment, were selected from around the world by WHO to implement this initiative in 2000-01, including Sudan from the Eastern Mediterranean Region. In October 2000, a joint planning meeting was held in the Regional Office with the participation of MPS officials from WHO headquarters and regional and country levels as well as representatives from the Federal Ministry of Health in Sudan. The meeting provided an excellent opportunity to learn national expectations and emphasize WHO's role and commitment to MPS. The meeting concluded with a framework for providing support to national safe motherhood programmes and activities in countries of the Region, with specific focus on Sudan.

In continuation of building national capacity in safe motherhood surveillance in countries of the Region, technical preparations for a training course on data use for decision-making in maternal and perinatal health were made in 2000. The training course took place to in Cairo, Egypt, in January 2001, in collaboration with the US Centers for Disease Control and Prevention and the University of Nebraska Medical Center. The focus of this training is on identifying and screening appropriate data sources, managing the limitations of the data and translating the analysis results into programme and policy recommendations.

In support to reproductive health research in the Eastern Mediterranean Region, the Regional Office maintained close collaboration with the World Bank Special Programme on Research, Development and Research Training. In follow-up to the recommendations of a 1999 intercountry workshop on adolescents' needs and perspectives in reproductive health, the Regional Office, in collaboration with the Special Programme, organized a training course on research in reproductive health of adolescents in the Eastern Mediterranean Region in Damascus, Syrian Arab Republic, in September 2000. The training course aimed at developing regional capacity in reproductive health research and improving the use of the available data on the reproductive health of adolescents for training and managerial purposes.

The Gulf Family Health Survey Project (GFHS) was concluded in 2000. The survey was implemented by the Executive Board of the Council of the Health Ministers for the GCC States in collaboration with the Regional Office, AGFUND, UNICEF, UNFPA, UN Statistics Office and Arab Fund for Social and Economic Development. The survey demonstrated an excellent model of collaboration among UN agencies and international organizations with the GCC states and provided a database for developing family health programmes in the GCC countries.

Technical preparations for the Pan Arab Project for Family Health (PAPFAM) were finalized in 2000. The project is executed by the League of Arab States in collaboration with the Regional Office, along with other UN agencies and international organizations, and is to be implemented in 12 countries of the Region in 2001-04. The key objective of this project is to provide detailed information on the health, social and environmental status of the family and their underlying determinants. This information will be used as a basis for an accurate and reliable database on family health, which will help in determining priority areas and hence in developing national strategies and programmes to meet with identified priority areas in the participating countries.

At the country level, expanding the availability of emergency obstetric care in the community was given specific attention. Essential obstetric health care supplies and equipment were provided for four district hospitals and training on clean and safe delivery techniques was provided for different categories of health staff in Afghanistan and Somalia. National experts were recruited to develop guidelines for standard obstetric care in Sudan. In support to maternal health surveillance at country level, technical assistance and training were provided to the Libyan Arab Jamahiriya and Tunisia.

The Regional Office continued to extend its technical support to several reproductive health projects funded by UNFPA in Iraq, Lebanon, Somalia, Syrian Arab Republic and Republic of Yemen. Extensive consultations, local and international training of health staff and community awareness activities were executed in these countries in collaboration with UNFPA.

Child and adolescent health

Integrated management of childhood illness

The integrated management of childhood illness (IMCI) strategy has been adopted by the Region in order to improve the chances of survival of infants and children, to improve the quality of child health care and to emphasize the provision of essential information to the family as a basis for better child care at home and also to direct concern to the psychosocial development of the child.

Currently, three of those countries are in the expansion phase (Egypt, Morocco and Sudan), two countries in the early implementation phase (Pakistan and Syrian Arab Republic), and seven countries in the introduction phase (Afghanistan, Islamic Republic of Iran, Iraq, Saudi Arabia, Tunisia and Republic of Yemen) (see Figure 4.1).

Evidence is accumulating in the Region that IMCI implementation is changing the quality of care provided in health facilities through improved health care providers' skills, better organization of work, more efficient distribution of tasks, availability and rational use of drugs and strengthened facility support. It is also making change by building the intersectoral partnership through mobilizing partners at all levels, organizing them around a common framework for improving child health. Change has also been made in strengthening the health system by stimulating policy development and implementation (essential drug policy, human resource policy and health system research), as well as changes in family and community practices.

In Morocco, an evaluation of IMCI impact on health providers' performance and caretakers' knowledge in health facilities implementing IMCI, compared with the health providers' performance and caretakers' knowledge in other health facilities. Results showed great evidence that IMCI works, as shown in Table 4.1.

Preliminary evaluation of family responses to recommendations of referral and follow-up under the IMCI strategy conducted in Sudan, also showed positive results in compliance to follow up and referral recommendations.

The IMCI regional consultation was the main IMCI event of the year. It convened 55 participants from the 12 IMCI countries, together with staff from the World Bank, USAID, UNICEF and WHO. During this meeting, in Alexandria, Egypt, the participants made two field visits, which offered them the opportunity to observe and discuss the Egyptian IMCI implementation experience, both at the health facility level and at the university level. The participants of the meeting concluded that IMCI is not just a programme but is an approach for improving the quality of health care in the health system and at home, building upon existing programmes and interventions.

In 2000, four IMCI general orientation meetings and preliminary planning workshops were conducted in Palestine, Saudi Arabia, Syrian Arab Republic and Tunisia, and one planning and adaptation workshop was conducted in the Syrian Arab Republic in late 2000. Training in IMCI clinical skills and facilitation skills were conducted in four countries (Egypt, Morocco, Pakistan and Sudan).

Improving health providers' skills

The Regional Office emphasizes IMCI pre-service training in medical and nursing schools. This activity, it is hoped, will ensure sustainability of IMCI. During 2000, teaching of IMCI was introduced at three universities in Egypt, two universities in Morocco and one nursing institute in Morocco.

Follow-up activities were conducted one month after each district course, in order to facilitate transfer of the skills gained during the course to the daily work at the health facilities. These activities provided clear evidence that IMCI produces positive changes in health providers' performance and the quality of care children receive, and the way health services are organized. This was shown in Morocco by comparing the results of the health providers' performance after the first (one month after each district course) and second follow-up visits (6 months later), as shown in Table 4.2.

Improvement of health system support

IMCI implementation has been linked to health sector reform activities, for example in Egypt and the Republic of Yemen supported by World Bank, and to the health district project in the Syrian Arab Republic. The essential drug list has been reviewed and revised in Egypt, Sudan and Syrian Arab Republic. Close monitoring of drug use after IMCI implementation showed evidence of rational use of drugs, especially antibiotics. Improvement of recording and reporting systems, health information systems and referral system have been among the most important elements of the second IMCI component.

Improvement of community and family practices

The development and implementation of activities to improve community and family practices does not show the same progress as other IMCI activities. During 2000, identification of existing projects to which improvement of community and family practices can be linked was a major achievement in the countries of the Region; for example, healthy villages and child-friendly housing in Syrian Arab Republic, the better parenting initiative in Tunisia and a basic development needs project in Morocco.

Operational research

There are two ongoing operational research projects in the Region. In Egypt, outcome of IMCI case management 11-day course versus the IMCI case management 6-day course is being completed. In Sudan, family responses to recommendations of referral and follow-up under the IMCI strategy is being evaluated.

Protection and promotion of adolescent health

In recognition of the special importance of adolescence as an area of strategic priority for health protection and promotion, the Regional Office maintained close dialogue with WHO headquarters in the process of formulating of a WHO global strategy on adolescent health and development during the year 2000. The developed strategy statement is planned to be finalized in 2001 and is expected to provide a model for national strategic planning for adolescent health and development. In support to strategy implementation at country level, the Regional Office adopted a set of adolescent health and development programming guidelines, which were developed by WHO headquarters in 2000, and plans to field-test them in selected countries, including Iraq, in 2001. The guidelines address how a country should best plan a needs assessment for adolescent health and how to create a comprehensive approach to meeting those needs.

Support to the programme for measurement of protective and risk factors to adolescent health was another area of close collaboration with WHO headquarters in 2000. The programme is being implemented worldwide in collaboration with UNICEF in selected countries, including Egypt from the Eastern Mediterranean Region.

In follow-up to the recommendations of the consultative meeting on building national capacity for protection and promotion of adolescent health and development in the Eastern Mediterranean Region held in Hammamat, Tunisia, in October 1999, the Regional Office initiated the formulation of regional guidelines for strategy development in the Eastern Mediterranean countries. The developed tools are planned to be available to countries of the Region in 2001.

As in previous years, the Regional Office maintained close collaboration with the Arab Regional Office for the World Organization of the Scout Movement. In December 2000, a joint plan of action was developed with this organization in a step to further expand the scope of collaboration in areas of joint interest including adolescent health in 2001.

At the country level, the second stage of district surveys on reproductive health services available for school adolescents in Tunisia was initiated in collaboration with WHO headquarters and the Ministry of Public Health. Technical assistance was provided by the Regional Office in support of national efforts in various facets of adolescent health including research and studies in Islamic Republic of Iran, Oman, Syrian Arab Republic and United Arab Emirates.

Protection and promotion of women's health

The year 2000 witnessed extensive collaborative efforts between the Regional Office and WHO headquarters in the process of developing a WHO global policy statement on women's health. The key objective of this statement is to clarify the broad parameters of women's health, to set out the overall goal of the WHO's work in the field and to set strategic actions to achieve that goal. At the same time, recognizing that women's health is context-specific and is influenced by both personal and local cultural, economic and other factors, the implementation of the policy is intended to be adjusted to local conditions.

In support of national efforts in identifying major determinants of women's health, and hence establishing appropriate national strategies and programmes for promoting women's health, software was developed by the Regional Office in 2000 to serve as a model for developing women's health country profiles. The software was field-tested by the Regional Office in collaboration with Ministry of Health in Oman in 2000, and is planned to be available to countries of the Region in 2001.

Female genital mutilation (FGM), which involves partial or total removal of the external female genitalia, is a cruel practice that causes grave damage to girls and women. WHO estimated in 1996 that around the world there are still between 100 and 132 million girls and women who have been subjected to FGM, with a further 2 millions who are at risk of this dreadful practice every year. This evil custom is still practised in some countries in the Eastern Mediterranean Region, albeit with wide variations in terms of its prevalence and severity. Realizing the need for a systematic, evidence-based approach for eliminating practices harmful to women, with specific focus on FGM, an intercountry workshop to strengthen national capacity towards eventual elimination of harmful practices to women in the Eastern Mediterranean Region was organized by the Regional Office in Sharm El Sheikh, Egypt, in 2000. The workshop provided an excellent opportunity for assessing the extent of activities undertaken toward the elimination of FGM in the affected countries of the Region, achieving better understanding of the perceptions and beliefs of communities with regard to FGM and identifying feasible and effective approaches towards its elimination.

Domestic violence against women is increasingly regarded as an important public health problem. Following a 1997 regional meeting at which domestic violence against women was presented as an issue for the first time in the Region, several countries started to address the subject. Participants from Egypt, Jordan, Islamic Republic of Iran, Lebanon, Morocco and Pakistan presented their country initiatives regarding violence and health in a joint regional consultation of the Regional Offices for the Eastern Mediterranean and Europe and WHO headquarters, which convened in Copenhagen, Denmark, in 2000 on the World report on violence and health, to be published by WHO's Violence and Injury Prevention Department in late 2001.

At country level, many women's health-related activities were technically assisted by the Regional Office in several countries. Training on early detection of breast and cervical cancers was provided for health staff in the Islamic Republic of Iran and the United Arab Emirates. Technical assistance was provided to Jordan, Oman and Syrian Arab Republic in women's health data collection.

Women in health and development

During 2000, an intercountry meeting was organized jointly by the Regional Office and the International Planned Parenthood Federation on strengthening the role of women in community-based programmes in the Eastern Mediterranean Region. The aim was to review and discuss achievements and constraints related to the Beijing Platform for Action for women's empowerment (1995) at the country level in the areas of health and development. Participants, who represented both governmental and nongovernmental organizations, reaffirmed the importance of partnership between the two sectors.

The meeting resulted in a set of recommendations, which stressed a holistic approach to addressing issues regarding women's health and socioeconomic development. The holistic approach calls for more cooperation between the various institutions that are involved with women's issues. For the sustainability of any programme, whether sponsored by government, private sector or nongovernmental organization, community involvement is essential at all levels, starting at the grass roots. The recommendations covered the areas of policy, strategy, education and training, power and decision-making, health services, research and information systems, and advocacy.

Gender mainstreaming was introduced in a workshop for revising and updating technical and administrative tools for systematic implementation of basic development needs activities among the countries of the Region.

The Regional Office also participated in a headquarters-sponsored meeting on gender analysis and health, where discussion took place on the conclusions from research studies conducted by scientists from around the globe addressing 14 different diseases and conditions from a gender perspective. The aim was to arrive at better understanding of the causes of ill health, which can result in more effective interventions to improve health according to the needs of both men and women.

The Regional Office continued to support the women in health and development programmes in countries of the Region. Technical support continued to be given to the Alexandria Healthy City and Women's Development programme with an emphasis on the role of women in environmental protection and on fighting harmful traditional practices, particularly female genital mutilation. The project was expanded to other squatter areas with the financial support of UNDP. It is interesting to note that what started as an experiment at the local level is now feeding into national policy and the Egyptian national environmental action plan: the Regional Office was invited to a national workshop to update the plan.

A new AGFUND-supported project was implemented in Abu Qir, near Alexandria, Egypt, which focuses on nosocomial infection within a community-integrated management framework, where the role of women in environmental protection is stressed. The project has successfully gone through the first phase and is now entering its second phase.

The Alliance for Arab Women, together with the League of Arab States and the newly established Egyptian National Council for Women, held a regional conference for Arab nongovernmental organizations in order to formulate work plans and projects relating to women's issues for the next five years. The Regional Office participated in this important conference. During a workshop on girls' education organized by UNDP, the Regional Office proposed to integrate an additional unit addressing harmful traditional practices, particularly female genital mutilation, in the prototype action-oriented school health curriculum. The proposal was well received.

In Jordan, the women's health and environment project, which started in November 1999 as a joint project between the Regional Office, CEHA and Princess Basma Women's Resource Centre, continued during 2000. The project aims to produce a training manual addressing 10 environmental health priorities in Jordan in order to train master trainers in Jordanian communities and to build their capacity to train other women, especially in rural areas, in order to raise their awareness of environmental and health-related issues.

A fellowship was awarded to a staff member of Queen Zein Al Sharaf Institute for Development to attend a training course at the Social Research Center at the American University in Cairo. This training will enable the participant to prepare a profile on women's health and development for Jordan.

Technical support was given to the department of reproductive health of the Ministry of Health in Oman to prepare a profile on reproductive health based on survey data. A WHO consultant went to Oman to assist with this activity, which was funded by UNICEF.

In Djibouti a profile on women's health and development was completed in 2000 and is being used as a tool for fund-raising and policy formulation.

Protection and promotion of health of the elderly

The population projections for most countries of the East Mediterranean Region indicate the percentage of the population that is elderly will reach about 8% to 10% of the total by 2020. Taking this fact into consideration, the Regional Office continues its catalytic role to enhance regional and country efforts being exerted to protect and promote the health of elderly people.

In support of the development of national and regional capacities, and in collaboration with the Centre for Elderly Care, Helwan University, Cairo, Egypt, the first regional conference on care for the elderly.

In collaboration with the Pakistan Medical Research Council a survey on health and living conditions of the elderly population was conducted in six pilot areas. The preliminary results show that senior citizens are going to emerge as a significant consumer of health services in the population structure of Pakistan.

Several countries were supported in: obtaining references and publications about the health of the elderly (Islamic Republic of Iran); conducting training activities on care of the elderly (Bahrain, Egypt, Morocco, Syrian Arab Republic); printing and updating manuals and brochures (Morocco, Syrian Arab Republic); analysing data on the elderly and preparing a draft national plan (Sudan); and holding a national seminar on the use of technical guidelines on the care of the elderly (Tunisia).

Short-term consultants carried out missions in Bahrain, Libyan Arab Jamahiriya and Republic of Yemen to assist in developing of country profiles and formulating of national policies and plans of action for the care of the elderly, and to conduct training courses.

A consultation was held in April 2001 in Beirut which looked holistically at all aspects of the health of the elderly in order to develop a strategy addressing their mental and physical health, nutrition, exercise and other issues.

Protection and promotion of occupational health

The provision of technical assistance in capacity-building and strengthening national strategies and programmes on occupational health (OCH) and work safety in the Region continued to be one of the important aspects of the Regional Office support to the countries of the Region. In the period under review, 12 collaborative programmes on occupational health and work safety existed in 17 countries.

In national training activities that were implemented as part of these collaborative programmes, special attention was giving to: occupational health surveillance, occupational health in existing industries, epidemiology of work-related diseases, the outcome of national health surveys, ergonomic principles, occupational hygiene and occupational safety for health inspectors.

Short-term consultants carried out many country missions, including: reviewing, comparing with other experiences and advising on laws governing OCH and dealing with occupational injuries and disabilities in Kuwait; preparing a plan of action for promotion of ergonomic activities in the Islamic Republic of Iran; and reviewing the occupational health situation in Lebanon.

Contractual services were issued to develop awareness materials and translate training booklets on occupational health. Funding was allocated for OCH surveys (Iraq); supervisory visits and printing of guidelines and education materials (Sudan); and printing of occupational health and safety regulations (Republic of Yemen). Supplies and equipment were provided to help build up the infrastructure of occupational health services in the countries of the Region. Also, books, journals, periodicals, and references were provided.

The Regional Office provided technical support to the Ministry of Labour and Social Affairs in Bahrain in conducting a seminar on heat stress and its impact on the work environment, held in Manama in May 2000, and to the Egyptian Ministry of Insurance and Social Affairs through participating in a seminar on youth at risk, in June 2000 in Cairo. The seminar discussed various aspects of hazards endangering the health and well-being of neglected groups of at-risk children: street children and working children.

The Tunisian WHO collaborating centre on occupational safety and health organized an international forum on international labour legislation in occupational safety and health in collaboration with the International Labour Organisation in May 2000.

Close technical collaboration was maintained with the Arab Institute for Occupational Health and Safety (an affiliate of the Arab Labour Organization and the League of Arab States). The Regional Office provided technical support to the pan-Arab countries symposium on occupational diseases among air-crew workers, organized by this institute in Damascus, Syrian Arab Republic, in November 2000.

In order to expand the role of occupational epidemiology in developing occupational health services and research in the Region, the Regional Office provided technical and financial support to the Fifth International Epidemiological Association Eastern Mediterranean Regional Scientific Meeting on Occupational Epidemiology, held in October 2000 in Bahrain.

As a part of global efforts to strengthen occupational health, the Regional Office participated in the WHO occupational health regional advisers' meeting during the 26th International Congress on Occupational Health, convened in Singapore in August 2000. The regional advisers' meeting aimed to discuss the current headquarters and regional work plans and activities and explore approaches to further coordinate them.

Protection and promotion of school health

Technical support was provided to the eighth international congress of the Union of Arab Paediatric Societies and the third international congress of the Lebanese Pediatric Society, held in November 2000 in Beirut, Lebanon.

The Regional Office provided supplies and equipment to the Islamic Republic of Iran to strengthen the infrastructure for screening of schoolchildren's vision and hearing, and technical assistance to establish school health services as an independent health programme in Qatar. A workshop for the expansion of school health to new states was organized in Sudan, and supplies and equipment were provided. A survey of school health services was conducted in the Syrian Arab Republic and local training courses were organized. A guide for school medical examinations (prepared in Arabic) was developed by the Lebanese Ministry of Public Health and the Ministry of Education in cooperation with Al Makased Islamic Charitable Society and UNICEF.