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Promotion and protection of health Reproductive,
family and community health and population issues 4.1 Reproductive, family and community health and population issues Promotion of reproductive health and research Strategic issues Reproductive health is fundamental to individuals, families and the socioeconomic development of communities and nations. Concerned about the slow progress made in improving reproductive health over the past decade, and knowing that the international development goals would not be achieved without renewed commitment by the international community, the Fifty-fifth World Health Assembly adopted resolution WHA 55.19 requesting WHO to design a strategy for accelerating progress towards attainment of the international development goals and targets related to reproductive health. In response to this resolution, and following consultations with Member States and other partners, WHO has developed a strategy that builds upon actions taken by Member States in response to resolution WHA 48.10 (Reproductive health: WHO’s role in the global strategy) which urged Member States to further develop and strengthen their reproductive health programmes and reaffirms the programmes and plans of action agreed by governments at the International Conference on Population and Development (Cairo, 1994) and the United Nations Fourth World Conference on Women (Beijing, 1995). However, the attainment of health for all in some countries of the Region still faces challenges where information on major determinants of reproductive morbidity throughout the life span is still inadequate to enable evidence-based programme development and implementation. Action taken in 2003 and results achieved In January 2002, WHO convened a global meeting entitled: “Challenges in sexual and reproductive health: technical consultation on sexual health”. However, there was an early consensus that a regional adaptation of sexual health-related issues would be needed to develop appropriate future directions that address sexual health as an emerging priority from a regional perspective. In response to this need, and in order to discuss the existing opportunities and challenges in addressing sexual health and identify appropriate mechanisms to develop and operationalize the existing strategies for sexual health, the Regional Office organized, in collaboration with the Joint United Nations Programme on HIV/AIDS (UNAIDS), a regional consultative meeting on promoting reproductive and sexual health in Beirut, Lebanon, in December 2003. The consultative meeting was attended by 44 experts from ministries of health, social affairs and education, UNAIDS and UNRWA, national family planning associations and the International Federation of Medical Students’ Associations (IFMSA). The consultative meeting outlined future directions required to further encourage national efforts to formulate and implement national policies and related strategies in countries of the Region. Among the recommended actions, the participants requested the Regional Office to continue to provide technical support and to establish a taskforce to review, recommend, guide and support reproductive and sexual health programmes as necessary and further facilitate exchange of experiences, information, research findings and success stories in reproductive and sexual health among countries of the Region. Emphasizing the importance of reproductive health research as an area of strategic priority for programme development and implementation, the Regional Office developed, in collaboration with headquarters, a project to establish a directory for reproductive health research. The framework of the reproductive health research directory project consists of two components. The first, which was accomplished in 2003, comprises a database of government, private and nongovernmental institutes, scientific bodies, research agencies, advocacy groups and organizations concerned with and involved in reproductive health research in countries of the Region. The second stage will be focused on gathering information about research activities conducted in the identified research institutes over a specified period of time. This stage is expected to be launched in 2004. The Pan Arab Project for Family Health (PAPFAM), which is executed by the League of Arab States in collaboration with the Regional Office along with AGFUND and other partners, made significant progress. The PAPFAM surveys in Djibouti and Yemen were completed and the preliminary reports of these surveys were published. Meanwhile, the project country agreements were signed in Lebanon and Morocco and the field work of this project is expected to be accomplished in these countries in 2004. Future directions A holistic approach to reproductive health
needs to be advocated to further strengthen and develop national
programmes in countries of the Region. In order to address sexual health
as an emerging priority in reproductive health programmes, integrated
interventions by trained health providers, functioning referral systems,
as well as a supportive legal, policy and regulatory environment will be
required. Understanding and appreciation of sexuality, gender roles and
scientific, evidence-based approaches in designing and providing the
needed services will also be required. Making pregnancy safer Strategic issues Despite the international efforts and commitment of the Safe Motherhood Initiative, the global progress towards achieving the goal of reducing maternal mortality has been insufficient. Globally, more than half a million women and three million neonates continue to die each year as a result of pregnancy and childbirth. Millions more become ill or are left disabled. In order to respond to this inexcusable situation, and because childbearing may become a major barrier to health for women, the international community, in the Millennium Declaration, set ambitious goals and targets affirming those agreed at earlier international consensus meetings. The fifth Millennium Development Goal addresses the need to improve maternal health and sets a target of achieving a 75% reduction in the maternal mortality ratio by 2015 from the level in 1990. It is clear, however, that if the present trend continues, countries will not be able to achieve the targets of the Millennium Development Goals and that accelerated and concerted efforts are urgently needed. Unfortunately, the level of maternal death is still unacceptably high in some countries of the Region. Average maternal mortality ratio was 377 per 100 000 live births in the Region in 2002, representing only a 19% reduction from the level in 1990. Action taken in 2003 and results achieved In response to the urgent need to accelerate the reduction of maternal and neonatal morbidity and mortality, more countries embarked on initiating necessary steps to implement the Making Pregnancy Safer (MPS) strategy, in collaboration with the Regional Office. Special attention was given to countries with high levels of maternal death. Despite the difficult situation in Afghanistan, the Regional Office in collaboration with the Ministry of Public Health and partners made tremendous efforts in order to ensure successful implementation of a project to improve care, funded by the Government of Belgium. The Regional Office provided technical support and closely monitored the implementation of this project in order to ensure optimal achievement of its expected results. One of the major activities implemented under this project was a study of the role of traditional birth attendants in promoting maternal health. The implementation of this study was supported by the Regional Office. Over 90% of deliveries in Afghanistan take place at home and there is urgent need to upgrade and expand maternal and neonatal health care in the country. The study concluded with important lessons which will assist in addressing priority issues and help in developing evidence-based strategies aimed at efficiently responding to the health needs women and children in pregnancy and childbirth. Djibouti and Yemen completed their national surveys on maternal mortality under PAPFAM in order to strengthen the national databases and surveillance systems in a way that enables evidence-based policy formulation and programme implementation. In collaboration with the League of Arab States, the Regional Office organized a technical field mission to Somalia to explore the possibility of undertaking a similar survey in the country. The mission reported encouraging results based on the special interest expressed by the local authorities to conduct this survey. In response to the post-conflict humanitarian situation in Iraq, the Regional Office drew on its technical expertise and knowledge of the country’s health system to develop an operational workplan for the immediate recovery and rehabilitation of the health services, including maternal and child health. The workplan primarily aimed at addressing major health problems threatening the health of women and children in the country and ensuring that they receive essential health services. In order to assist Pakistan in achieving its goal of reducing maternal mortality by 20% within two years in 32 districts, the Federal Ministry of Health in collaboration with the Regional Office held a series of training workshops for midwives, lady health supervisors and lady health visitors located in these districts. The training was aimed at upgrading the knowledge and skills of the trained staff to ensure proper case management, early identification of risk cases and complications and referral to an appropriate health facility, where necessary. This training also assisted in sensitizing the participants about the role of health providers in the implementation of the MPS strategy. Sudan continued to actively implement its plans on Making Pregnancy Safer. A supplementary plan of action for MPS in Sudan was formulated by the Regional Office and successfully implemented in the country in collaboration with the Federal Ministry of Health. The plan included training of the project coordinators in Northern, River Nile and Sinnar States on programme management, training health workers in the use of the standard obstetric care management manual, assessing the application of this manual in three states and strengthening monitoring and evaluation procedures. The Regional Office also provided necessary supplies and equipment in order to support the health services delivered by this project. Future directions The adoption of the MPS strategy and its implementation in Member States, particularly where the levels of maternal mortality are still high, is expected to support and strengthen the efforts being made in countries to reduce maternal and neonatal morbidity and mortality. Further emphasis needs to be placed on strengthening health systems with coordinated policies, strategies and plans, developing human resources and improving referral and supervisory systems. Educating women and their families about the risks they may encounter in pregnancy and childbirth and about the appropriate actions to be taken should danger signals be identified, early identification of mothers and newborn babies with complications and their prompt referral to appropriate medical care, and effective motivation of women and their families to agree to these referrals, can all drastically improve maternal and neonatal health. Provision of appropriate education about consanguinity, premarital medical examination and neonatal screening for inherited diseases are also important factors in promoting the health of newborn babies, and hence reducing infant and child mortality. Protection and promotion of child health Strategic issues 1.5 million children under 5 years of age are still dying every year in our Region, which represents 13.8% of global child mortality. Figure 4.1 shows the contribution of the countries of the Region to child mortality. The traditional major killers (diarrhoea, pneumonia, measles, malaria and malnutrition) of children under 5 remain the major causes of death in most countries, despite some countries having the epidemiological pattern of the industrialized countries, where perinatal mortality, accidents and poisoning are emerging as the major causes of mortality. The Integrated Management of Child Health (IMCI) is the key strategy of the Regional Office in addressing child health with its regional emphasis on addressing health as well as sickness in children. To date, 17 countries have introduced IMCI into their health systems, nine of which (Egypt, Islamic Republic of Iran, Morocco, Oman, Pakistan, Sudan, Syrian Arab Republic, Tunisia and Yemen) are currently implementing IMCI in the field in 474 districts and 1934 health facilities. Throughout this experience, the Regional Office has recognized the strong need to develop national child health policies in countries in order to complement and bring together in one document all the elements and issues related to child care, and to provide long-term direction and commitment. Five countries (Egypt, Morocco, Sudan, Syrian Arab Republic and Tunisia) have expressed interest in joining such a process.
Figure 4.1 Contribution of countries to under-five deaths in the Eastern Mediterranean Region, 2003 Action taken in 2003 and results achieved Technical support in the area of child health focused on capacity-building and health systems support for IMCI. With regard to capacity-building, country-specific guidelines for the standard case management of children under 5 were developed in 11 countries and used in the field to train the health providers dealing with children at primary health care level through the case management courses. To date about 10 000 health providers of different categories are implementing IMCI in the field in those countries, while a pool of 555 facilitators was created to increase the training coverage and accelerate the pace of expansion. Two regional breastfeeding counselling training courses were held to create a pool of consultants and to train the IMCI facilitators in this area using the newly adapted regional material in Arabic. In the area of supervision and planning, supervisory guidelines (Egypt and Sudan) and a district planning guide (Egypt) were developed in collaboration with the Regional Office, to strengthen the capacity of central and district teams in supervision and outcome-based planning using targets and indicators. In order to strengthen the health providers’ skills in the field, IMCI follow-up after training is taking place in seven countries. In the area of pre-service training, 19 medical schools in the Region introduced IMCI into the paediatric and community medicine teaching curricula, as the public health approach to strengthening outpatient paediatric and community medicine teaching, and are at different phases of this implementation. Strengthening elements of health system support has been a major focus since the beginning of IMCI implementation as an essential prerequisite to improving quality of child health services and ensuring successful implementation of IMCI. Among the elements are comprehensive situation analysis and data collection from the areas of IMCI implementation, planning at district level, supervision, strengthening the referral system, strengthening the health information system, distribution of tasks, flow of patients and organization of work at the level of the primary health care facility, and drug availability. With regard to the last element, a model drug management package, in the context of IMCI, was developed in collaboration with the Essential Drugs unit and the Ministry of Health and Population, Egypt. Widening the scope of IMCI implementation, both geographically and by adding new areas of work was a major target. Collaboration with countries included development of a healthy child module with two countries (Syrian Arab Republic and Tunisia) and introduction of the care for development component, which involves the participation of caretakers in stimulating the psychosocial development of children, into the IMCI clinical guidelines of three countries (Oman, Syrian Arab Republic, Tunisia). Issues related to child environmental health were addressed, including the development of guidelines for management of children suffering from poisoning and burns, at the primary health care level.
Figure 4.2 Comparison betweem the performance of IMCI trained and untrained health providers in assessment tasks of sick children, IMCI Health Facility Survey, Sudan 2003 To empower families and communities to play active roles in child care, a planning guide on the IMCI community component was developed, and plans of action were developed by 10 countries in two intercountry workshops. Training materials for volunteers were developed by four countries. For purposes of monitoring and evaluation, IMCI reviews, follow-up visits after training and IMCI health facility surveys on quality of outpatient child health services were conducted in order to collect evidence on the effectiveness of the IMCI strategy in improving child health. The results of these activities showed that IMCI is an effective strategy for improving the quality of child health services delivered at both primary health care level and at home (Figures 4.2 and 4.3). A number of focused intercountry activities were conducted to address the main issues facing the implementation of child health-related interventions. A regional workshop on infant and young child feeding, held in Morocco, conducted in collaboration with the nutrition programme, concluded that child feeding is an integral part of child health and recommended that this area receive more focus from countries. A WHO/UNICEF joint intercountry meeting, held in Tunisia, addressed the issue of IMCI sustainability and scaling up. The maintaining of political commitment to child health in order to accelerate the expansion of effective child health-related interventions, and the development of national child health policy were among the major recommendations of this meeting.
Figure 4.3 Comparison between the performance of IMCI rained and untrained health providers in prescription of antibiotics, IMCI Health Facility Survey, Sudan 2003 Due attention was given to advocacy for child
health and related interventions. Advocacy material was developed and
activities were held in some countries to address key issues related to
child health and to move child health higher up the agenda in terms of
countries’ priorities. Such activities included meetings with ministers
of health and decision-makers, and participation in national child
health week. Among major challenges that impeded the pace of achievements were the lack of financial resources at global and regional levels which is having tremendous adverse effect on the regional support to child-health related strategies and interventions and on development work. Child health is not sufficiently high up on countries’ agendas of priorities and this has led to the shifting of resources to other emerging priorities. The absence of child health-related policies, inadequacy and inconsistency of available data, and low national planning, managerial, supervisory and advocacy skills are also major constraints. Future directions The Regional Office will continue to plan and work closely with countries towards achievement of the Millennium Development Goals, and to support countries to develop national child health policies. It will continue to build and develop the regional child health database and to document evidence on the effectiveness of the IMCI strategy through different evaluation activities and continuous monitoring, as well as to further widen the scope of IMCI, both geographically and technically, and to build national capacity in advocacy management, planning, negotiation and communication skills. More emphasis will be placed on community-based interventions and the role of communities in improving child health. Protection and promotion of adolescent health Strategic issues
Over the past decade, considerable progress has been made in understanding the factors that affect adolescents and in introducing appropriate interventions in order to address their health needs. Nevertheless, many adolescents still lack the support they need for their development, including access to information, skills and health services. Accidental and non-accidental injuries, drug addiction and sexually transmitted infections, including HIV/AIDS, take their toll particularly during the adolescent period. The rapidly changing socioeconomic circumstances in the Region pose considerable challenges to young people in making a safe transition into adulthood through adopting healthy behaviour and avoiding risk factors. Unfortunately, adolescents are generally thought to be healthy. A tragic marker of the consequences of inattention to their health and social needs is that the incidence of HIV infections is rapidly increasing in this age group. Traffic accidents have become the first cause of death of young people in several countries of the Region. Under-nutrition and micronutrient deficiencies in girls are associated with adverse pregnancy outcomes. Action taken in 2003 and
results achieved In view of the great need for data on adolescent health and development, research continued to be considered as a priority for exploring the living conditions of adolescents, informing policy-makers about the major risks adolescents face and developing appropriate strategies and programmes that are relevant to their health and social needs. Priority is also given to the development of key feasible interventions that are useful in promoting adolescent health and development with countries. In support of building national capacity in research on reproductive health of adolescents, and in order to enable evidence-based development of adolescent health programmes in countries, the Regional Office, in collaboration with headquarters, maintained its support to the research projects initiated in the Islamic Republic of Iran, Oman and Syrian Arab Republic. Based on the findings of the quantitative and qualitative studies conducted in 2001 and 2002, respectively, Oman developed a national strategy for adolescent health and development through information, education and communication. The strategy was formulated in collaboration with the Regional Office, and was adopted nationally in a workshop held in the country in April 2003 using the grid approach for prioritizing and planning actions. The Islamic Republic of Iran and Syrian Arab Republic completed their projects and published the reports. In order to upgrade the technical know-how and improve knowledge and skills of health staff and members of the national committee on adolescent health, a training workshop on narrative research was organized by the Regional Office in coordination with the Ministry of Health in Bahrain. This research method was developed by WHO as a tool to identify risky behaviour among adolescents. It facilitates the outlining of appropriate strategies for creating positive attitudes and practices among adolescents, families, school teachers and other partners that will enable them to better understand their needs and set up corrective measures. Participants were provided with the opportunity to learn-by-doing the rationale, approach and methodology required to conduct a narrative research in a manner that is appropriate to local situation. The workshop concluded by developing a draft questionnaire, which was pre-tested on a sample of 34 adolescents aged from 13 to 18 years. The Regional Office maintained its technical support in other areas of adolescent health and development. In Cyprus, health visitors and school physicians were trained in a national workshop to improve their knowledge and skills in adolescent health and development and strengthen their roles in providing youth friendly services in the community. Tunisia initiated a project to revise its national strategy in light of research conducted on adolescent health in the country. In follow-up to the survey on risk behaviour among medical students conducted in Egypt, Kuwait and Lebanon in collaboration with the International Federation for Medical Students’ Associations (IFSMA), and concluded in 2002, the Regional Office maintained close communication with IFMSA, providing technical support for a workshop to be held in 2004. The aim of the workshop is to develop a joint plan of action to be advocated through the IFSMA’s network in the Region. Future directions The development of adolescent health programmes still faces major challenges in some countries of the Region where adolescents are perceived as a healthy population and a non-priority target group. While national adolescent health and development strategies, norms and standards evolve in a few countries, culturally appropriate mechanisms of active listening and guidance need to be developed to reflect the needs and aspirations of adolescents and reinforce their connections with their family, friends and communities. Tremendous efforts are still required to assist countries in realizing priority areas in adolescent health and development programmes and in evidence-based strategic planning. Among the main directions that would be required to promote adolescent health and development in the Region are advocacy for development of national policies and programmes on adolescent health and development; promotion of research activities and situation analyses on the health and development status and living conditions of adolescents; technical support to better equip national health systems to deliver adolescent-friendly health services; and improving the knowledge and awareness of individuals, families and concerned community institutes of the health, social and development needs of adolescents. Protection and promotion of women’s health Strategic issues Despite the fact that women have, on average, longer life expectancy than men, this longer life does not translate into more healthy years. During their late adolescence and middle years, women experience a considerable burden of disease associated with their reproductive functions, as well as threats to their mental and physical health from occupational risks and the burden of their multiple roles in the family, the workplace and community. Overall, the evidence is that women in the Region experience greater morbidity than men and higher levels of disability, both short-term and long-term. This is particularly obvious in the later years of life. The health problems of particular importance to women and warranting special attention can be clustered in five groups: those affecting particularly large numbers of women, such as malnutrition and tuberculosis; those related to sex-specific characteristics, such as maternal mortality and cervical and breast cancers; those having documented intergenerational impact, such as use of certain drugs and tobacco-related health problems; those with noticeably higher burden of disease among women than among men, for example mental health conditions and autoimmune diseases; and those strongly influenced by gender, such as the health impact of violence, exposure to unsafe sex and harmful practices such as female genital mutilation. Action taken in 2003 and results achieved In recent years it has become clear that there is a need for a systematic, evidence-based approach to eliminating practices harmful to women, including female genital mutilation. Following the recommendations of the intercountry workshop to strengthen national capacity towards eventual elimination of practices harmful to women in the Eastern Mediterranean Region held in 2000, the Regional Office, in collaboration with the International Islamic Centre for Population Studies and Research of Al-Azhar University, Cairo, Egypt, published and disseminated to the countries concerned a training manual entitled Towards the elimination of female genital mutilation. The manual was written in accordance with the sociocultural norms and religious values of the Region and in line with the 1997 WHO/UNFPA/UNICEF joint statement on the subject. The manual is expected to help these countries intensify their efforts to eliminate female genital mutilation through evidence-based approaches and use of scientific methods. The manual can also help in developing advocacy activities aimed at increasing the commitment of decision-makers towards the elimination of female genital mutilation and can positively support health and religious awareness and education activities in the community. The Regional Office also completed the translation into Arabic of the teacher’s guide, student’s manual and policy guidelines on female genital mutilation and disseminated these documents to the countries concerned. These training guides are considered to be excellent tools for improving the knowledge and skills of health personnel on female genital mutilation. The Regional Office continued advocating the need for nationwide, disaggregated situation analyses of the health of women. 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, the Regional Office supported the conduct of a survey on the health situation of women in southern Jordan. In view of the difficult situation in Palestine, the collaborative plan of action aimed at establishing a surveillance system and a country profile on the determinants of ill health and well being of women across the life cycle could not be completed. International training on early detection of breast and cervical cancers was provided for national health staff from Qatar, and the development and production of health education materials on women’s health and quality of life was supported, in collaboration with the Women’s General Union in the Syrian Arab Republic. Future directions Three areas relating to protection and promotion of women’s health are considered to be priority issues: the need for an integrated and comprehensive approach to women’s health in order to ensure that women are adequately served throughout the life cycle; the special burdens on women and their health caused by gender discrimination and poverty; and the importance of recognizing and promoting women, as individuals and in groups, as responsible partners in the health enterprise and as consumers and providers of health information, care and service. Despite the fact that considerable progress has been made towards realizing women’s rights and social needs in countries of the Region, national policies and programmes on women’s health need to be reinforced. Among the main directions that would be required to promote women’s health in the Region are preparation of appropriate documents and reports that address the need for protection and promotion of women’s health throughout the life cycle, in order to advocate the specials health needs of women and gain the support of decision-makers at all levels; establishment of gender disaggregated national surveillance systems in order to specify morbidity patterns among women, and prepare evidence-based national strategies that meet with the health needs of women, according to size and severity of the problem and resources available at the country level; training of primary health care workers on management of common women’s health problems, throughout the life cycle; setting up of mechanisms for monitoring and evaluation of the existing services for women’s health in the community; and collaboration with all partners through national councils and bodies in order to coordinate efforts aimed at promoting the status and health of women in countries. Protection and promotion of health of the elderly Strategic issues Development of national capacity to address the health and social needs of the elderly population is one of the most important strategic directions of the Regional Office in relation to strengthening integrated care of older persons. Other important strategic areas are: establishment of national monitoring systems on ageing and health; further development of evidence-based national strategies and plans of action; development of training and advocacy materials; and development of closer partnership with international, regional and local organizations. Action taken in 2003 and results achieved An in-depth study of the status of community care for elderly people in four countries (Bahrain, Egypt, Islamic Republic of Iran and Lebanon) was conducted in order to develop comprehensive country profiles on elderly issues. The lack of such comprehensive profiles inversely affects the cost–effectiveness of any service development for older people. The Regional Office continued to be involved in the project on developing integrated response of health care systems to rapid population ageing (INTRA) in Lebanon, developed by WHO with a grant from the Government of the Netherlands. The next step will be to involve other countries in the project. The Regional Committee adopted a resolution (EM/RC50/R.10) on health care of the elderly, thereby emphasizing the need to establish, develop and improve the integration and coordination of the health, welfare and other concerned sectors to develop comprehensive programmes and services that address effectively the various needs of older persons. Technical support was provided to the Fourth Pan Arab Conference on Elderly Care held in Egypt, which focused on elderly women. Future directions As older people in the Eastern Mediterranean Region become a larger and more visible proportion of the general population, better statistical information on demographic ageing and its causes, consequences and specific regional aspects is urgently needed to guide policies and programmes. The lack of information on the health and social needs of the elderly is an obstacle to development of effective interventions at national and regional levels. WHO will continue to support development of country profiles on health and social issues relating to the elderly. Protection and promotion of occupational health Strategic issues Development of regional and country profiles, strategies and plans of action continue to be important aspects of the regional strategic directions for developing occupational health in the Region. Strengthening of existing collaborative programmes on occupational health and safety and establishment of new ones in other countries is of great importance. WHO support is provided in the fields of capacity-building, establishment and strengthening of surveillance systems, encouraging active occupational health and safety institutions and centres to be WHO collaborating centres, and improvement in quality and coverage of promotive, preventive, curative and rehabilitative occupational health services in health systems. Action taken in 2003 and results achieved A workshop on the national occupational health and safety profile in Egypt was organized as part of the WHO/ILO Joint Efforts on Occupational Health and Safety in Africa. This workshop will be used as a model for other countries in avoiding duplication and reaching consensus on the main structure and content of the national profile on occupational health and safety. Eleven countries have also developed national profiles on occupational health and safety according to a WHO regional questionnaire. A regional consultative meeting on development trends of occupational health and safety in the Eastern Mediterranean Region, held in Damascus, Syrian Arab Republic, discussed those country profiles and provided participants with a good opportunity to share knowledge and experiences. A set of action-oriented recommendations was developed and the general framework of a regional strategy was also discussed. Technical support was provided to Saudi Arabia to organize a training workshop on environmental/occupational hazards and ways of protecting the work environment from occupational health hazards. 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). Technical support was also provided to the expert meeting organized by the Institute on principles and methods of evaluation and measurement of occupational pollutants and hazards in the work environment, held in Damascus, Syrian Arab Republic. Fruitful collaboration was initiated with the Egyptian Society of Infection Control by the technical support provided to the 12th annual conference of this society, in October 2003, in Egypt. The theme of the conference was prevention and control of occupational infections. Future directions A regional strategy outline and a plan of action for developing occupational health in the next decade, 2004-2013, will be prepared. The integration of occupational health into the primary health care system in order to provide appropriate care to workers in the community will continue to be a focus of attention. Success stories will be shared and a website will be created. Country profiles on occupational health and safety will be published. Interactive sharing of information will be encouraged. Protection and promotion of school health Strategic issues Development of regional and country profiles, strategies and plans of action is one of the most important aspects of the strategic directions for enhancing school health programmes and services in the countries of the Region. Promotion and expansion of healthy schools, health-promoting schools, environment-friendly and health-friendly schools and community schools is also an important strategic area. Capacity-building, developing of standards and performance indicators and closer partnership and networking are of great importance for strengthening school health at regional and national levels. Action taken in 2003 and results achieved The Regional Office provided support for strengthening and expanding school health services and promoting collaboration between the health and educational sectors in many countries. Bahrain established a Supreme Committee for School Health. Other member countries of the Gulf Cooperation Council adopted initiatives to establish health-promoting schools networks. Eight countries (Bahrain, Egypt, Islamic Republic of Iran, Jordan, Lebanon, Oman, Saudi Arabia and Syrian Arab Republic) completed their country profiles and identified priority areas for national school health programmes. Several countries have included in their joint collaborative programmes with WHO targets aimed at establishing health-promoting schools networks. The second conference on school health, organized in Beirut, Lebanon, by the Arab Organization for School Health and Environment and supported by the Regional Office, was a good opportunity for experience sharing regarding the best approaches for developing health-promoting schools in the Region. Future directions Cooperation between the health and education sectors is crucial and must be encouraged and ensured. Despite the fact that the potential of the school health programme is very promising, community schools and other health-promoting schools must be evaluated. National standards for such schools should also be developed. Development of regional and country databases in order to support evidence-based decision-making will be promoted. 4.2 Healthy behaviour and mental health Mental health promotion Strategic issues The regional challenge in the field of mental health is the wide gap between the availability of mental health interventions and their application for the benefit of the population. The available human resources for mental health care are uniformly low in all countries of the Region, including the countries with well developed general health services. This means the governments are not giving adequate importance to mental health in relation to other health issues. Care is still largely institution-based with little movement towards care in the community. For example, the majority of psychiatric beds are in mental hospitals rather than in general hospitals and community care facilities. The public understanding of mental health is very limited, resulting in low priority being given to mental health by people, both in their values as well as in their demand for services. This means that pressure is not placed on the governments to invest adequately in mental health programmes. The populations of the Region are experiencing massive social changes, such as urbanization, migration, conflict and loss of traditional family and community structures. All of these changes have the potential to de-stabilize mental health and to manifest in mental disorders, substance abuse, increased rates of suicide, and violence and injuries. The strategic issues are: to enhance the importance of mental health among populations and planners; to create appropriate community-based mental health interventions; and to minimize the negative effects of rapid social change on the population. Table 4.1 Prevalence of mental health disorders in countries of the Eastern Mediterranean Region, 2003
Action taken in 2003 and
results achieved Five countries in the
Region, (Afghanistan, Egypt, Islamic Republic of Iran, Lebanon and
Morocco) conducted epidemiological studies of mental disorders among the
general population. These have, for the first time, provided information
about the magnitude of mental disorders and their relationship to the
social and economic variables. The finding that over 10% of the adult
population have an identifiable mental disorder is an important one,
supporting the call for greater public health action to address the
problem. Women were found to have up to twice as much depression as men
(Table 4.1). The regional consultation on psychiatric services in the countries in conflict (Afghanistan, Iraq, Palestine, Somalia and Sudan) in July 2003 was a major effort to understand the needs and to develop interventions. Following the consultation, interventions in the respective countries have been initiated along with development of appropriate materials. The intercountry meeting on epilepsy as a public health concern, held in March 2003, identified a wide gap in the availability of care for persons with epilepsy in all countries of the Region. Two countries, Pakistan and Saudi Arabia, have developed a community approach to care of persons suffering from epilepsy. There is need for similar national initiatives in other countries. The programme of integrating mental health with primary health care is progressing well. Pakistan selected five districts for extension of the model pilot programmes, while the programme in the Islamic Republic of Iran continued to extend its coverage. A number of countries of the Region have developed training materials and trained primary health care personnel. Other initiatives undertaken in countries to address mental health needs included suicide prevention, school mental health programmes with special emphasis on life skills, revision of the mental health legislation in some countries, and celebration of mental health week with focus on child mental health. A regional consultation on health and behaviour provided an opportunity to understand the linkages between health and behaviour and to bring the best of the knowledge of mental health to other areas of health. Future directions The growing recognition of the importance of the mental health needs of the community requires more focused efforts in a number of areas. Important among these is human resources development. There is an urgent need to create both specialist mental health professionals as well as to develop alternative and appropriate types of non-specialist mental health care personnel. The need to develop mental health programmes in countries with very weak infrastructure for general health services is a continuing challenge. Similarly, efforts will have to be made in economically rich countries to develop comprehensive mental health programmes, commensurate with the general health care goals in these countries. Greater efforts will need to be directed to understanding the linkages between social, economic and political changes with mental health impact. Development of social and community interventions will be a long-term need. Disability prevention and rehabilitation Strategic issues The care of people with disabilities is undergoing major changes in the world. The World Health Assembly’s adoption of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) in 1980 have influenced the way impairments and disabilities are perceived and the way medical rehabilitation services have been planned and implemented during the past two decades. In May 2001, the World Health Assembly approved a new system of classification to replace ICIDH, the International Classification of Functioning, Disability and Health (ICF) which reflects the changes taking place in rehabilitation. Important among the developments of the past 20 years are: a move away from a biomedical emphasis to a model based on social determinants of disability; and the implementation of the United Nations Standard Rules on the Equalization of Opportunities for People with Disabilities as guidelines in health, education, work and social participation; increased participation of people with disabilities in service organization, programme development and policy initiatives. There is increased social awareness of the rights of people with disabilities and of the need to reduce stigma and discrimination and promote greater inclusion in social life. There has been a shift in organization of services from a charity-based model to rights-based model. In addition, there has been a clear statement from the United Nations agencies that disability is a human rights issue in the establishment of a United Nations Special Report on Disability. In January 2004, a new convention on disability was discussed at the United Nations. One of the most striking changes in the care of people with disabilities has been the shift in the paradigm of care, from institutional settings to care in the community. This shift is not simply about location of care but a recognition of the importance of the total needs of persons with disabilities. In the Region, lack of legislation to empower the rights of the disabled is an important barrier. In most countries, relevant legislation, programmes and policies are absent, and when they are present they do not cover all the relevant aspects. Action taken in 2003 and results achieved The number of people with disabilities continues to be estimated at about 10% of the population, although individual countries have given numbers that vary from approximately 4% to 20%. The variation can be partially explained by the low life expectancy and by the categorization of people with disabilities in some countries. It is notable that those countries that have census questions that enable them to identify the population of people with disabilities generally find a percentage greater than 10%. These figures provide a rough idea of the unmet needs in terms of rehabilitation and full participation. The first Pan Arab African Conference for Care and Rehabilitation of Handicapped was organized in Cairo, Egypt, in October 2003, followed by the first Festival for the Care of the Handicapped, in Saudi Arabia in December 2003. Other activities in the Region included a collective wedding for couples with special needs in the Syrian Arab Republic and launch of a hot line for children with special needs in Egypt. The Regional Office started to collect comprehensive data on the rehabilitation activities of countries. Future directions The first task is the prevention of disabilities. A number of avenues are open for prevention of disabilities in the Region. These include adequate antenatal, natal and postnatal services, universal immunization coverage, iodization of salt, vitamin A supplementation and prevention of injuries in childhood. Public health personnel working at the primary health care should be fully trained to implement these preventive measures. The second task is early recognition and intervention of corrective measures. The third task is support to families. The majority of persons with disabilities are living with their families. Too often families are not provided with the skills for caring for the disabled. Family support in the form of skills for caring, periodic home visits by support staff and, where needed, financial support will decrease the burden of families as well as provide a better quality of life to those with disabilities and to other family members. The fourth task is to develop community-based rehabilitation. It is important that all the countries develop community-based rehabilitation programmes in phases to cover the total population. The fifth task is human resources development. Each of the countries should develop programmes to address this need. In many situations, it may be more appropriate to think of regional training programmes for human resources development. The sixth task is to develop a wide range of care services, including self-care, family care and community-based rehabilitation, which form the foundation, and referral support from specialized centres which is important for care of persons who need specialist interventions. The seventh task is to ensure availability of assistive devices to decrease the disability, in forms that are affordable and acceptable to the population. The last of the measures is at the level of the community. It is too often the experience that stigma and discrimination within the community is the biggest barrier to a full life for persons with disabilities. Prevention and control of substance abuse (including tobacco) Strategic issues Substance abuse is more than a health problem; it is a formidable moral, social and economic challenge with pandemic dimensions. Not a single country in the world can be called “drug free”. The Eastern Mediterranean Region is an important centre for both the production and transit of illicit drugs with more than 75% of the world’s opium grown in Afghanistan. The people of the Region are increasingly vulnerable to drug-related health, social and economic problems. Drug abuse in general is not decreasing, but rather shows an increasing trend. The mode of use of such drugs is shifting from oral use and inhalation to the injection route, which is more harmful. Younger and younger age groups are falling victim to drug dependence. The increasing numbers of women who abuse drugs is likely to cause even greater harm to the families and community. There is a need for a strategic plan to address the issues of drug abuse from a multi-sectoral and multi-pronged manner. Although tobacco control is one of the main challenges of public health in the Region, there are some positive signs that the efforts of tobacco control advocates in the Region are effective. Still, more efforts are needed to lower the prevalence of tobacco use among all population groups. The national plans of action that were developed and adopted during the past two years need to be followed up and implemented in order to reach the expected targets and achievements. Such steps should consider taking evidence-based approaches based on results of the studies and the surveys that were conducted during the past two years at the national level. The adoption of the Framework Convention on tobacco Control presents the Regional Office with a great challenge. Although the Regional Office has an important role in mobilizing governments in this area, the greatest role has to be taken by the ministries of health, they being involved in implementation of the Framework Convention at the national level.
Figure 4.4 Substance abuse problems in the Eastern Mediterranean Region, 2003 Action taken in 2003 and results achieved Through a survey questionnaire distributed to all countries of the Region, information on the drug abuse situation, current policies and interventions, and treatment and rehabilitation was collected for 18 countries (Figure 4.4). The positive aspect of the current situation is the high recognition given by most countries to the problem, evident in the creation of professional units, passing of legislation, and development of different interventions. However, there is very little factual information available about the nature, magnitude, consequences and cost of the problem, or of outcome of interventions in the countries. The general approach to problems of substance abuse is more legal and penal than medical. The preventive programmes in the countries are few and limited to pilot programmes. Only the Islamic Republic of Iran has conducted pilot studies to develop harm reduction methods, especially for the prevention of the spread of HIV/AIDS. The second meeting of the Regional Advisory Panel on the Impact of Drug Abuse (RAPID) was held in December to review the developments in the countries. The regional strategic planning document on substance abuse was finalized by the Panel and specific research initiatives were identified for the coming years. Recognizing the importance of the mass media in promoting tobacco use and their potential in supporting tobacco control, World No tobacco Day 2003 concentrated on freeing the entertainment industry, in particular cinema, from tobacco. Under the theme of “tobacco-free films, tobacco-free entertainment”, the Regional Office and the countries celebrated World No tobacco Day throughout the Region in collaboration with popular stars, actors and actresses. A study was released on the use of tobacco in Egyptian films over a 10 year period, its effects on youth and magnitude in films and the images projected by and associated with smoking in films (Figure 4.5). Enhancing regional understanding of the tobacco epidemic and raising social awareness is a main target of the Regional Office. In line with this, the Regional Office provided technical as well as financial support to 11 projects in seven Member States under the first phase of its advocacy-based project “Channelling the Outrage”, which was successfully completed in 2003. The first phase concluded with a workshop in September 2003 in which all the nongovernmental organizations that were involved in this phase participated as well as other potential nongovernmental organizations that were likely to be part of the second phase. The workshop was aimed at enhancing understanding of the Framework Convention on tobacco Control and at the same time evaluating the final outcomes of the first phase. WHO is now implementing the second phase of the project in which the involvement of civil society in tobacco control will be further supported.
Figure 4.5 Images associated with tobacco use in 100 Egyptian films, 1950s-present day Improved surveillance and research in the areas of health economics, legislation and behaviour in support of tobacco control is another important objective. In accordance with this, a workshop on the Global Youth tobacco Survey was held in collaboration with the Centers for Disease Control and Prevention, Atlanta, to analyse the data of those countries that had completed the survey and to enable seven more countries to conduct the survey. By the end of 2003, all countries were involved in the survey, including Afghanistan and Iraq and despite the very difficult circumstances in both those countries; this shows the level of commitment of national governments to tobacco control. Five publications were issued: tobacco control country profiles for the Eastern Mediterranean Region, The cigarette “transit” road to the Islamic Republic of Iran and Iraq: Illicit tobacco trade in the Middle East; The tobacco industry’s tactics and plans to undermine tobacco control efforts in Egypt and North Africa; Analysis of the economics of tobacco in Morocco; and The economics of tobacco in Egypt: A new analysis of demand (the latter two in collaboration with the World Bank). The Regional Office supported national workshops to develop national plans of action for tobacco control in Djibouti, Pakistan and Yemen, as well as national capacity-building projects in Djibouti, Morocco, Pakistan, Somalia and Yemen. The challenge facing the Region with regard to the ratification, accession and acceptance of the Framework Convention on tobacco Control was addressed in detail in a sub-regional workshop held jointly with the League of Arab States and the Health Minister’s Council for the Gulf Cooperation Council States with participants from ministries of health, justice and foreign affairs. Briefing letters were then sent from the Regional Director to all Member States on the Framework Convention and the regional situation with a view to enhancing action at national level in this area. Having proved very effective in the past, and in collaboration with the Ministry of Health and Population in Egypt, the poster of the Islamic Ruling on Smoking was redistributed to more than 53 000 mosques in Egypt for the second time in two years in line with the Regional Office’s efforts to promote the role of religion in supporting public health. Future directions The Regional Office will continue to work on substance abuse in a realistic way and in active coordination with other concerned programmes, such as HIV/AIDS and healthy lifestyles. Specific areas for action are to: improve knowledge about the regional drug abuse situation and related services; identify measures to support Member States in comprehensive country planning of substance abuse activities which in the health and social sectors would be capable of addressing primary prevention, demand reduction and harm reduction; create and/or support centres for longitudinal study of drug abuse in the countries; and collect evidence-based, region-specific models of effective drug abuse prevention, treatment and rehabilitation and encourage collaboration and inter-sectoral coordination of activities The Regional Office, with
the support of WHO Representatives’ Offices will continue to lobby and
work with the media and civil society groups to activate the process of
ratification, accession and acceptance of the Framework Convention at
the national level, through regional events and meetings, such as the
annual meeting of the Arab Ministers of Health. Ministries of Health are
the main supporters of the Convention, having been involved in the
negotiations from the start of the process in 1999, and their ability to
move the process of implementing the Convention forward will be crucial Health education (including school health curriculum) Strategic issues Many countries of the Region have not yet developed comprehensive multisectoral health promotion frameworks. Health education is still given low priority in many countries of the Region. Moreover, close coordination and cooperation with the different departments and programmes need further strengthening and consolidation on an institutional basis. Many health education interventions still lack theory-based grounding and do not draw systematically on research findings. Pre-testing of health education materials is not carried out systematically and target groups are not adequately involved in the different phases of programme development. Health education research capabilities are still weak in a number of countries and there is a need for national capacity-building in this area. Regular follow-up and evaluation of health information, education and communications interventions are not ensured systematically. Health education has progressed in health-promoting schools, nonetheless school-based health education needs to further consolidate its partnership with school health programs. Greater attention should be given to developing health-based life skills and to adopting participatory learning approaches, including developing interpersonal communication and counselling skills of both school and health staff. Action taken in 2003 and results achieved Technical guidance was provided to the League of Arab States through contribution to the capacity-building of representatives from 11 Arab countries at an intercountry meeting on integrating reproductive health into school curricula, held in Sharm El Sheikh, Egypt. A joint regional workshop on enabling the school to plan and implement health education programmes in its environment was conducted in collaboration with ISESCO in Beirut, Lebanon. School health officials from 10 Arab countries benefited from this training. Experiences and best practices in health promotion in the Eastern Mediterranean Region were exchanged with other WHO regions at an intercountry workshop on capacity-building for health promotion and an intercountry workshop on integrating health promotion into health systems held in Bangkok, Thailand in February and November 2003, respectively. The Regional Office organized and hosted an intercountry meeting of health education and information directors in Cairo, Egypt which provided health education officials from 15 countries with an excellent forum to exchange successful experiences, specify country programme needs and expectations from the Regional Office, and learn about recent developments and emerging issues. Technical support was provided to the Arab Organization for School Health and Environment through active participation in the second Arab Conference on School Health held in Lebanon in 2003. Actions were initiated, in close collaboration with the Health and Biomedical Information unit and the WHO Arabic Programme, to produce an electronic version on CD-ROM of the action-oriented school health curriculum, which is currently under revision. Action was also initiated to collect, and compile on CD-ROM, health education and communication materials produced by the national programmes, with a view to strengthening the sharing of experiences among countries of the Region. Technical comments, guidance and inputs on health education materials and documents were provided to countries on request. Technical support was provided to Oman in the elaboration of a multisectoral adolescent health and development communication strategy using the WHO grid approach. WHO contributed, jointly with UNICEF, to the capacity-building of Omani media professionals on health issues. National capacity-building in health communication strategic planning, using a computer software package developed by CDC, Atlanta, was strengthened in Pakistan. Technical support was provided to Kuwait in the training of medical officers on health education as a medical skill, as part of their continuing medical education. Technical support was also provided to the Adolescent Health Committee in Bahrain, at a national training workshop on counselling skills in adolescent sexual and reproductive health for health providers and school social counsellors. A participatory workshop on the elaboration of the narrative research questionnaire was conducted in close collaboration with the Women’s and Reproductive Health unit and a questionnaire was prepared, pre-tested and revised by the participants at the end of the workshop. Future directions Priority will be given to the elaboration of a regional framework for health promotion in the Eastern Mediterranean Region, drawing on best practices in the Region and the conclusions and recommendations of the different technical consultations. National capacity-building will continue to receive priority through the elaboration of reference materials and training on health education and communication strategic planning, interpersonal communication and counselling skills development, as well as health education and communication-related qualitative research. Capacity-building in health communication strategic planning using the CDC package will be strengthened in member countries of the Gulf Cooperation Council as well as other countries of the Region. The dissemination of experiences and lessons learnt among countries of the Region will be strengthened through the production and dissemination of a CD-ROM on information, education and communication and audiovisual health education and communication materials produced in the countries of the Region, as well as the establishment of a health education and communication web page on the Regional Office web site which will provide a forum for discussion, exchange of ideas and feedback as appropriate. Cooperation
with United Nations agencies, ISESCO and institutional partners will be
strengthened, including strengthening health education in
health-promoting schools in collaboration with the Arab Organization for
School Health and Environment, as well as the elaboration of health
education training packages in collaboration with the UNESCO Chair for
Health Education and Al-Sibai Institute. The action-oriented school health curriculum will be broadened to cover basic education and will incorporate recent developments as well as appropriate sample materials from countries (up to grade 10), including the new elements introduced in the FRESH initiative and the Health Information Series elaborated by headquarters. The draft experimental electronic Arabic version will be ready in 2004. The electronic version on CD-ROM will provide the possibility of periodic on-line updates. Health information for the public Strategic issues The main strategies in 2003 were to: reinforce relations with the media and with governmental and public institutions; ensure coverage of Regional Office events at country, regional and global levels; ensure monitoring of press and media; raise the health awareness of people through media products; and raise the profile of WHO as the leading United Nations organization in the health field. In addition to this the Regional Office took steps to improve communication with headquarters and other regional communication units. The boom in the number of satellite channels and internet users poses challenges with regard to how to make use of these media and the production of high quality and attractive material that will reach the target audience. The diversity of political, economic, demographic, epidemiological and environmental situations are some of the most challenging for developing and communicating health messages in the Region. Some have very advanced systems and media networks with up-to-date computer technology, whereas others rely on basic means of communication, such as radio programmes. Another challenge is the issue of language diversity, especially in densely populated countries such as the Islamic Republic of Iran and Pakistan. Meanwhile, the unprecedented growth in the activities and influence of civil society actors in the area of public health within the Region has created a complex environment but has also contributed positively to improving human health and development. There is a vital need to expand collaboration with nongovernmental organizations and to work more closely with other United Nations agencies in the field. Action taken in 2003 and results achieved Although all the preparations were made for World Health Day 7th April under the theme “Healthy Environments for Children”, the celebration itself was suspended due to the war in Iraq. The Regional Director’s message on World Health Day was produced in the form of a documentary film, which was shown on many occasions and almost all the major local, national and regional television stations showed all or part of it. The regional annual art competition for schools attracted over 2000 paintings from the Region and 48 were selected as winners. Among those who sponsored national events were the regional Centre for Environmental Health Activities in Jordan and various nongovernmental organizations in Egypt, Islamic Republic of Iran and Pakistan. Government-sponsored events were held in many countries, reflecting the high profile of the topic. Daily briefings were issued by the Regional Office on the situation in Iraq before, during and after the war. This helped in responding to the queries of the media and helped create better understanding of the role of WHO in providing relief and rehabilitating the health system in Iraq. To mark the 50th anniversary of the Regional Committee for the Eastern Mediterranean a pictorial book In pursuit of health was published highlighting WHO’s work in the Region The pictorial was also issued on CD, Betacam and digital Betacam format. The 160 pictures were selected from around 4000 photos specially taken for the occasion throughout the Region and which now form a valuable archive for the Region as well as for WHO. Publication of the book was accompanied by an exhibition entitled “50 years of devotion to health”. The year saw an increase in activity in terms of the number of press releases issued (37 compared to 22 in 2002) in Arabic and English, and in the number of regional and national television interviews. Considerable efforts were also made to widen the scope of activities outside the Office, with the primary aim of strengthening collaboration with private and governmental institutions to enable further dissemination of health information, including the Rotary Club, the Institute of Higher Technology, in 10th of Ramadan City, Egypt, newspapers such as Al-Ahram, the Scouts Federation and various schools. An “on air contest” during the month of Ramadan, was aired on El Shabab wa El Riyada radio station and raised public awareness of tobacco, nutrition and environmental issues. Joint activities with Member States also became more frequent. Workshops on the Iraq health crisis, AIDS, sexual education and reproductive health were held in Jordan, Saudi Arabia and Lebanon, respectively. The Regional Office also worked to maintain close connections with local media and press agencies. An internet-based system was acquired to help monitor news coverage of WHO and the Regional Office in particular in the local and international press. The media was briefed on The World Health Report 2003: Shaping the future and an Arabic version of the press kit was issued to reach as many media people as possible. Cooperation was strengthened with the press centre in WHO headquarters to ensure more orchestrated efforts in the field of media and information. World No tobacco Day 2003, with the theme of tobacco-free media, brought a unique opportunity to use the popularity of the Region’s media personalities to promote the health message. Television spots and posters in Arabic and English featuring television presenter George Kordahi were produced and the opening of the campaign saw the arrival of actors and journalists at the Regional Office, including actors Hisham Selim, Mohamed Nagaty and Karima Mokhtar and singer Simone, as well as footballer Captain Mahmoud Al-Khatib. The response in the local press was very positive and, in general the local media did a lot to publicize the campaign, including many television interviews. Another illustrated message and printed package were produced for World AIDS Day 2003 promoting the “3 by 5 Initiative” and stressing that AIDS is treatable. A media day on mental health was held during November 2003. Excerpts from different films on health were shown and wide media coverage was provided. The Regional Office celebrated a United Nations day of solidarity with the Palestinian people on 1st of December 2003. Palestinian officials and intellectuals attended the event along with a wide range of regional figures, and local and regional media covered the event. December 2003 witnessed important visits from HRH Princess Muna Al-Hussein of Jordan, WHO Patron for Nursing and Midwifery in the Eastern Mediterranean Region, HRH Prince Talal Bin Abdul Aziz Al Saud, who attended the launch of the report The Reality of the Arab Child issued by the Arab Council for Children and Development, and HRH Prince Abdulaziz Bin Ahmed Al-Saud, President of IMPACT-EMR, who attended the international meeting on Vision 2020. Future directions The Regional Office will collaborate with countries in developing and implementing a regional plan of action for health information of the public, as well as in working to increase mutual understanding of the importance of cooperation between the media and the health sector, based on transparency, objectivity and credibility, and capacity-building in this regard. The Regional Office will continue to make the best use of regular health events to promote health issues and to raise awareness of such through the media and media personalities. It will work with official media centres in countries to contribute to the provision of good quality, low price regionalized advocacy products, while maximizing the in-house production of advocacy material. Planning meetings and workshops will be held to train regional human resources through exchange of experiences of experts, with a view to developing suitable campaigns for the advancement of health in the Region. Work will continue to establish the regional photographic archive. The Regional Office will continue to strengthen relations with the media, and other public relations offices in health-oriented organizations, and to produce media packages to raise awareness of the work of WHO in the Region. An in-house media production unit will be established. Promotion of healthy lifestyles (including oral health) Strategic issues The Region shares with the rest of the world in many of the global changes taking place with regard to the burden of risk factors and determinants contributing to the burden of Noncommunicable diseases and injuries. Sedentary lifestyles, rapid urbanization, escalation in the social and environmental determinants, globalization and poverty together contribute to making the populations of the Region susceptible to the same challenges as those faced by industrialized countries. Although data are scarce on the prevailing risk factors in the Region, the available data suggest that a variety of risk factors are equally dispersed in almost all the countries of the Region. The prevalence of smoking ranges from 15% to 75% in males and from 2% to 29% in females. Lack of physical activity is taking a heavy toll, with the prevalence of sedentary lifestyles as high as 75% in some countries of the Region. Obesity ranges from 10% to 63% among adult females in some countries. Dental caries and periodontal diseases are also caused by unhealthy lifestyle, especially high intake of sugar, lack of fluoride in the environment and negligence of oral hygiene. The latest surveys in countries show the index for decayed, missing and filled teeth (DMFT) among 12 year-olds has improved in very few and deteriorated in many other countries. This explains why most of the efforts made in the countries have been focused on clinical rather than preventive oral health. The technical expertise and infrastructure for promoting healthy lifestyles in the Region is weak and there is a need to reorient health services from the clinical and curative to the preventive and community-based. The Region, however, has now gained considerable experience in putting in place effective interventions, such as healthy settings and community-based initiatives, aimed at addressing the social and environmental determinants of health. The World Health Report 2002 identified critical risk factors and determinants of health, and emphasized the relevance and importance of adopting a multisectoral approach if major risks to health are to be curtailed before they make individuals sick. Action taken in 2003 and results achieved New experiences and interventions were tried for healthy lifestyle promotion in different countries. A notable intervention was the link-up with community-based initiatives in Afghanistan and Oman. The healthy settings approach (e.g. health-promoting schools) was used effectively to build up skills and knowledge in communities on addressing the determinants of, and reducing risks to, health. Health education and risk communication were used as an effective tool for enhancing these skills. School health interventions were a particular focus with a major thrust on health-promoting schools. Evaluation of school health programmes in Jordan, Oman, Pakistan and United Arab Emirates, led to the formulation of a comprehensive strategy aimed at strengthening the existing school health programmes. Capacity-building at the national and sub-national level through training courses, consultancies and designing protocols and guidelines were among the major achievements. Sudan and United Arab Emirates conducted surveys to assess the types of risk behaviour inducing ill health, which led to the formulation of plans of action for the population to adopt healthy lifestyles to control smoking and obesity and to increase the level of physical activity with a view to reducing the burden of cardiovascular diseases. The Regional Committee adopted a resolution on promoting healthy lifestyles (EM/RC50/R.6) which urged Member States inter alia: to formulate policies, strategies and plans of action aimed at risk prevention and management and develop systems for surveillance of risks to health; to strengthen their coordination with different governmental sectors and nongovernmental organizations for the adoption of health-sensitive policies; and to encourage investment of additional resources in promotion of healthy lifestyle activities through collaboration with multilateral and bilateral donors. Many countries consolidated their existing oral health programmes. Four countries (Cyprus, Islamic Republic of Iran, Jordan, Syrian Arab Republic) established training centres to train dental health care providers both from within and outside the country. The Islamic Republic of Iran, in particular, established a centre of excellence in collaboration with the Government of Finland to offer doctoral degrees in oral health disciplines. Fluoridation of salt and water was carried out in a number of countries (Bahrain, Islamic Republic of Iran, Jordan, Lebanon, Syrian Arab Republic, United Arab Emirates) in order to decrease levels of tooth decay. The oral health departments of hospitals in several countries were strengthened by providing state-of-the art equipment and technology. The Regional Office supported capacity-building among the national programme managers in different countries through the fellowships programme. Various regional consultations and intercountry expert meetings provided impetus to such activities. Of particular importance were the meeting to discuss regional input to the global strategy on diet, physical activity and health, a regional consultation on health and behaviour, and an intercountry meeting on oral health. There is growing interest and awareness in the countries of the Region with regard to investing in comprehensive policies and interventions for healthy lifestyle promotion. WHO is initiating action to highlight the importance of this change and the need for reorientation of health systems towards risk reduction approaches and comprehensive prevention strategies. A regional framework for integrated action between healthy lifestyle promotion and community-based initiatives was drafted. The added value of both the areas in relation to each other will serve to couple resources and initiatives to address the social and environmental determinants of ill-health and disease. Future directions The Regional Office will continue its efforts to promote healthy lifestyles through expanding and strengthening community-based initiatives as well as healthy settings, such as healthy schools and healthy workplaces. The ongoing healthy lifestyles projects in countries will provide useful and practical examples and models and may be visited by other countries of the Region. The regional framework for integrated action will be finalized in 2004 and will provide a tool to the countries for building their capacities in promoting healthy lifestyles. A major emphasis in the near future will be placed on the implementation of the global strategy on diet, physical activity and health. Health systems need to respond to the healthy population in addition to taking care of disease and illnesses. Capacity-building in
health promotion will be essential at the country level in order to
respond to the growing needs and demands. A major focus, therefore, will
be placed on risk surveillance and risk reduction. Safety promotion Strategic issues Every year over half a million reported deaths in the Region are due to injuries and this number is increasing. Injuries are becoming a major burden on health and they occur at any age. However, except for a few countries, they account for more deaths in people below 45 years of age than all other causes of death combined. One in nine premature deaths are injury-related and for every person that dies, many more are left with permanent disabilities. The leading injury-related causes of death in the Region are war, road traffic accidents and interpersonal violence. The magnitude of injuries is more serious when disaggregated by age. Violence in all its forms is increasingly affecting countries of the Region and political unrest, rapid urbanization and poverty contribute to this negative trend. In addition to death and disability, violence contributes to a variety of other health consequences. These include depression, alcohol and substance abuse, smoking, eating and sleeping disorders, and HIV and other sexually transmitted diseases. Action taken in 2003 and results achieved There is growing attention among nongovernmental organizations, women’s organizations and health providers towards different forms of injuries and violence. For some countries awareness of the problem is still emerging. A few are beginning to take action. With the increasing incidence of unintentional injuries (including road traffic accidents) some of the countries have responded well and have put in place programmes to address the issue. Egypt and Islamic Republic of Iran are two such examples in the Region. Capacity-building among health personnel, advocacy through the media and training of health care providers in the ‘safe community’ concept are the main features of the injury prevention programme in the Islamic Republic of Iran. Egypt established an injury prevention surveillance database at the national and governorate level aimed at integrating the information available with the health information system. Several countries initiated intersectoral approaches. Elsewhere, major focus has been placed on the prevention of injuries in industrial settings (Lebanon, Syrian Arab Republic) where development of educational materials and advocacy through the mass media was initiated for industrial workers. There is increasing recognition among countries that injuries and violence are a public health issue and require public health approaches to prevention. This has contributed to a more multisectoral approach to addressing the problem of injuries and violence. Countries in the Region are at different stages of devising mechanisms for involving other sectors/ministries in combating the burden of death and disabilities caused by injuries and violence. At the regional level, the World Report on Violence and Health was launched in Jordan, an important event in the efforts for primary prevention of violence in the Region. The report was translated into Arabic and widely distributed among the countries. An inter-regional consultative meeting provided input to the World Report on Road Traffic Injury Prevention. Future directions The issue of injury prevention, and to a greater extent violence, has not been studied sufficiently in the Region. Countries are at different stages of addressing the problem, however very few have a systematic and strategic approach for formulating and implementing their plans. There is a need to assist countries to implement surveillance programmes and to conduct research to understand the root causes, in order to evaluate preventive measures and develop effective interventions. The theme of World Health Day 2004 will be ‘Safe Roads’. Political commitment from the highest level is important to devise strategies and create multisectoral approaches. The Regional Office will endeavour, together with partners and country offices, to muster that commitment. 4.3 Nutrition, food security and safety Nutrition Strategic issues Under-nutrition in the form of wasting (2%–21%) and stunting (2.4%–over 50%) affected children below the age of 5 years in several countries, while iron deficiency and its anaemia continued to affect an estimated 323 million people, mostly women, children and adolescent females. At the same time, several countries reported high prevalence of overweight and obesity, in many instances as high as over 50%. Action taken in 2003 and results achieved The Regional Office supported the development and implementation of national nutrition policies and promotive and protective nutrition programmes. The regional consultation for preparing the regional contribution to the preparation of the global strategy on diet, physical activity and health recommended that countries develop comprehensive national strategies for the control and prevention of overweight/obesity through a combination of diet, physical activity and lifestyle. The Regional Office supported the participation of national nutrition focal points from several countries (Bahrain, Egypt, Islamic Republic of Iran, Iraq, Jordan, Morocco, Pakistan, Palestine and Syrian Arab Republic) at the ninth Asian Congress of Nutrition. A bi-regional technical consultation for sustaining the control and prevention of iodine deficiency disorders (IDD) was organized in collaboration with WHO’s Regional Office for South-East Asia. The national IDD programme managers from four countries of the Region with successful national IDD programmes attended the consultation. A regional workshop on infant and young child feeding was organized with the objective of reviewing national activities in relation to the global strategy on infant and young child feeding. Participants recommended that national strategies on feeding children should be developed immediately and be comprehensive and multi-sectoral in nature. The Regional Office is coordinating with collaborating international organizations in assessing the national IDD control and prevention programmes of seven countries where IDD has been eliminated as a public health problem. The Regional Office continued to support the development of nutrition standards, guidelines, training manuals, methodologies, and criteria for the detection, prevention and management of all forms of under and over-nutrition in the Region. Two national training workshops on improving communication strategies for the prevention and control of micronutrient deficiencies and utilizing a computer-based training module were conducted in Egypt and Pakistan. Formulation of national communication strategies for the control and prevention of micronutrient deficiencies are expected as an outcome of this workshop. The Regional Office commissioned external experts to develop regional field guides on the monitoring and assessment of iron deficiency anaemia and IDD. The preliminary draft of the IDD field guide has been forwarded to a select group of experts for critical review. Preparations for the national micronutrient survey in Oman with technical and financial support from the Regional Office were finalized. The survey will be completed by early 2004. All three activities received technical and financial support from the Centers for Disease Control and Prevention, Atlanta, through a cooperative agreement. A training module for improving the managerial skills and technical knowledge of national nutrition programme managers is under preparation. The module includes key nutrition issues to be considered in every national situation as principles of nutrition programme management, monitoring and evaluation. The Regional Office
continued to provide support to ensure that food consumed by vulnerable
population groups is adequate and effective in both complex emergencies
and stable environments, through food fortification and equitable food
distribution. As part of a multi-disciplinary team, a mission was
undertaken to Somalia to assess the status of the national nutrition
programmes. Missions were also undertaken to Sudan and Palestine to
assess the status of the nutrition programme and to identify areas for
technical support. In Sudan, the mission focused on reviving the
national IDD control/prevention programme and the need to address the
persistence of high rates of chronic malnutrition in children. In
Palestine, the rapid rise of acute malnutrition among children was
reviewed with the national authority and international organizations.
Two staff members from the nutrition department were granted fellowships
for training in the management of common nutritional problems. Future directions A regional and a national training workshop will be held to further promote improved communication strategies for the control and prevention of micronutrient deficiencies, and a regional training workshop will be held on a standardized nutrition surveillance system with focus on micronutrient deficiencies. Technical and financial support will continue for the completion of the proposed Oman national micronutrient survey. The Regional Office will continue to support the development of national strategies for diet, physical activity and health, and to support assessments of national IDD control and prevention programmes. Food safety Strategic issues Responsibilities for food safety are complex and usually shared across several different ministries and departments with weak coordination and little clarity on roles. There is a growing demand in the Region for safe and nutritious food. Harmonization of food policies, regulations and standards has received attention in member countries of the Gulf Cooperation Council, which have drafted a common food export procedure that allows for shared inspection policy and standards, and for food produced in or imported into any of the member countries to enjoy circulation throughout the GCC countries. In general, food policies, standards, regulation and food inspection activities vary greatly throughout the Region. There is a growing trend for eating outside the home and for eating ready-to-eat food, particularly among young people. Regional activities are targeted at addressing the need for improvement of food control systems, appropriate food inspection, food laboratory analysis, food legislation, consumer awareness and protection, and developing a regional food safety network. Action taken in 2003 and results achieved Throughout the Region, efforts to improve food safety have been carried out in continuous communication with the Regional Office. Morocco and Tunisia developed a national strategy for food control. Several countries drafted new food legislation in line with international requirements (Egypt, Jordan, Lebanon, Morocco, Oman, Pakistan, Sudan and United Arab Emirates). The Islamic Republic of Iran, Sudan, and Syrian Arab Republic reviewed and updated their food standards and regulations. Yemen finalized its food safety country profile and Egypt, Jordan, Morocco and Tunisia harmonized their food safety standards with the Codex Alimentarius and are moving towards an approach based on risk management. Jordan established a food and drug administration unit where all stakeholders in food safety coordinate their efforts. The United Arab Emirates adopted the use of customized soft-ware for food inspection to monitor and control the safety of food, whether domestically produced or imported. A manual on the development of food legislation was developed and finalized in collaboration with the Pan American Institute for Food Protection and Zoonoses. The manual will assist authorities in development of legislation that incorporates the health aspect of food safety and in accordance with accepted international regulations. The Regional Office continued working towards putting food safety firmly on the national public health agenda by addressing the issues with different authorities. The Ministry of Health of Jordan, in collaboration with CDC, Atlanta, and Health Canada, is conducting a special study on the burden of foodborne disease to enable it to identify and address gaps in disease surveillance and, in particular, foodborne disease surveillance, based on laboratory surveillance. Regional training courses were conducted on salmonella surveillance (levels 1 and 2) microbial risk analysis management, and the Codex Alimentarius Commission. Regional Codex Alimentarius meetings were held. Future directions Implementation of resolution EM/RC46/R.6 will continue to guide food safety strategy in the Region. Foodborne disease surveillance and risk assessment will be strengthened and countries will be encouraged to initiate and implement risk assessment. National food safety control systems will be strengthened in countries that have completed their national food safety profiles and developed food safety strategy and other countries will receive support to initiate and implement these activities. The guideline for developing food legislation for food control systems will be distributed to all countries. Countries will be encouraged to participate in the Codex Alimentarius Commission, and the Codex Committee for the Near East to ensure a supply of safe food, whether imported or domestically produced, that follows international food safety requirements. Capacity-building of national food safety staff will continue in the areas of radiation detection in food, food risk analysis and foodborne disease surveillance. The Regional Office will conduct regional training workshops on food risk assessment and prevention and control of food-borne disease. The global salmonella survey will continue. The food inspection techniques initiated and implemented by the United Arab Emirates will be studied, validated and customized for other countries of the Region. Environmental health policy, including core functions of CEHA Strategic issues One-third of the global disease burden can be attributed to environmental risk factors; this figure may be higher in the Region due to the double burden of disease resulting from the transitional stages of development of several countries. Therefore, there is an ever-growing need to identify and analyse health problems related to environmental conditions, and to devise appropriate solutions for environmental health problems. The lessons learned from major disasters in the Region have emphasized that environmental health conditions during emergencies need sustained attention. Availability of and accessibility to environmental health information continues to represent a major problem and the large gap in access to information through the internet and e-mail is worth emphasizing. Lack of regular budget resources to cover the cost of core functions, which are usually not covered by donors, continues to be a major problem for the Regional Centre for Environmental Health Activities (CEHA). Action taken in 2003 and results achieved The Regional Office continues its direct support to environmental health activities in some countries through the presence of international environmental health staff (Afghanistan and Iraq) or national staff (Afghanistan, Iraq, Lebanon, Pakistan and Somalia). It also continued its support to the school of health inspectors in Lebanon. The environmental health situation was assessed in two countries (Afghanistan and Pakistan) and a course of action proposed in consultation with environmental health stakeholders at central, provincial and district levels. In Pakistan, a national meeting on development of a national environmental health profile was sponsored. Promotion of environmental health activities in refugee camps and during emergencies involved technical support to the concerned agencies in Afghanistan, Djibouti, Iraq, Islamic Republic of Iran, Jordan, Somalia, Sudan and Syrian Arab Republic. Activities included development of 2000 water and hygiene kits for field testing in emergencies; arabization and dissemination of resource materials on environmental preparedness during disasters; and fund-raising to strengthen the emergency preparedness capacity and improve environmental health conditions in refugee camps in Iraq, Jordan, Somalia and Sudan. CEHA conducted four training courses for the Public Water and Sanitation Authority and Mayoralty of Baghdad. The UNOPS-supported project for Northern Iraq on drinking water quality control and source protection was completed. One of the milestones in the development of the initiative on Healthy Environments for Children was that of the ministerial roundtables at the World Health Assembly. The Minister of Health of Jordan chaired one of the four roundtables. The delegates of eight Member States from the Region addressed the ministerial roundtables (Cyprus, Egypt, Jordan, Morocco, Qatar, Pakistan, Saudi Arabia, United Arab Emirates) and expressed, inter alia, their commitment to the initiative. The initiative was further promoted before different bodies, including the WHO Regional Consultative Committee and the Executive Council of the Council of the Arab Ministers in Charge of Environment, which adopted a resolution welcoming the initiative and expressing willingness to contribute to its implementation in the Arab region. Pilot applications of the Global Initiative on Children’s Environmental Health Indicators have started in Islamic Republic of Iran, Oman and Tunisia. An assessment of Environmental Health risk factors affecting children’s health will be conducted in Pakistan and Yemen with AGFUND support. Assessment and survey tools have been developed for finalization and application in 2004. Funding was also granted by AGFUND to CEHA for demonstration projects designed to establish healthy settings for children in Pakistan and Yemen. Technical support was extended to Lebanon and Yemen for the development of healthy and safe school physical environments. Remarkable celebrations marked the occasion of World Health Day 2003, which was dedicated to healthy environments for children, throughout the Region including in Afghanistan, Bahrain, Djibouti, Egypt, Islamic Republic of Iran, Lebanon, Morocco, Pakistan, Tunisia and Yemen. The President of Afghanistan lent his personal support in celebrating the event. In Jordan, a national conference on healthy environments for children was convened in July 2003 under the patronage of the Her Majesty Queen Rania. The Regional Director addressed the conference, and support was granted to the Queen Alia competition on the subject. The Regional Committee adopted a resolution on the subject calling on Member States to, inter alia, develop and implement strategies that will result in increased support from donors, involvement of communities and nongovernmental organizations, and mobilization of traditional social security nets such as awqaf and zakat. It is also worth mentioning that the Regional Office added children’s environmental health to its research priorities. With the financial support of AGFUND, electronic access to environmental health information was assessed in Egypt, Lebanon, Islamic Republic of Iran, Pakistan, Syrian Arab Republic and Yemen. Provision of electronic information services by CEHA via the internet and e-mail continued, with such services now being offered to more than 1800 users; CEHA’s website was enriched with several on-line databases including directories of professionals and institutions and bibliographies on children’s environmental health. Traditional information services continued to be provided to users where access to electronic information is not reliable. More than 6500 documents were disseminated, and some 200 information requests were handled to support several environmental health projects in countries. CEHA continued its efforts to raise extrabudgetary resources for intercountry as well as country projects, with project proposals submitted to AGFUND, European Union, Japan International Cooperation Agency, the Government of Norway and UNICEF. Staff costs excluded, more than 90% of CEHA activities continued to be funded by resources from international and regional donors. Future directions The Regional Office will continue to promote national policies and actions that protect health against environmental risks and to advocate for well staffed and operational environmental health units in the ministries of health. It is planned that the Regional Advisory Committee on Health and Environment in the Eastern Mediterranean Region will have its first meeting in September 2004. Demonstration projects for creating healthy settings for children will be implemented in Lebanon, Pakistan and Yemen. The Healthy Environments for Children web pages will be developed and maintained at CEHA. Efforts will continue to build an electronic environmental health information network in the Region. This will include human resources development; development of national websites; and provision of equipment. Production of training and learning materials in Arabic and other local languages will continue. Water supply and sanitation Strategic issues In 2002 the World Summit for Sustainable Development called on countries to halve the proportion of people without access to safe drinking water and sanitation by 2015. These targets represent monumental challenges to many countries in the Region because of severe water scarcity, rapid population growth, accelerating urbanization, paucity of funds and economic downturn, and the disruptive effect of international instability. Based on year 2000 figures, 85 million people in the Region do not have access to improved water supply and 154 million are without access to adequate sanitation. Experience in several countries indicates that while access to water services may be granted, optimum water availability to the households for effective health gains may not always be secured. The main challenges include inadequate and intermittent supply, and poor drinking water quality. The efficiency of wastewater treatment plants remains questionable and pollution of freshwater by urban wastewater is a persistent problem. The reuse of the effluents of such treatment plants and raw sewage is still being practised in some countries of the Region, placing the public at serious health risk. In many countries, particularly in the lower income cities, there are serious shortcomings in collection, transportation and disposal of solid waste. There is a fast growing need in most countries to develop health care waste management plans at national and health care facility levels, and to establish legal and institutional frameworks for implementation. Action taken in 2003 and results achieved Support to Afghanistan continued, including technical support to the Ministry of Health on health aspects of rehabilitation of the water supply and sanitation system; training on water and health; rehabilitation of Kunduz and Faizabad water supply systems; and reinforcement of environmental health aspects of the sustainable development projects. In Somalia, a national sanitary engineer in the WHO sub-office in Hargeisa continued the work on supervision and monitoring activities and support to water quality testing in critical areas. In the Islamic Republic of Iran support was provided to carry out a situation and management assessment in regard to water supply and sanitation and to address water quality aspects of water harvesting. In cooperation with UNRWA,
technical support was provided to Palestine to assess the water supply,
sanitation and drainage situation in Jenin camp and to design facilities
to correct the situation. Technical support was also provided to promote
job creation in all refugee camps of the West Bank. A regional consultation on
minimum household water security requirements and health was held in
Amman, Jordan, in December 2003. The consultation reviewed available
evidence and called for data collection and research to document the
evidence linking household water security and health, in order to
support the development of WHO guidance on minimum water requirements
for health. A preliminary survey tool for measuring household water
security and health was developed and a small-scale pilot survey was
conducted in Irbid, Jordan. A regional training course on sanitation and wastewater management in small communities was convened with participation from Lebanon, Jordan, Palestine and Syrian Arab Republic. A training course handbook on design of sanitation and wastewater management in small communities was developed and used in three training courses in Jordan and the Syrian Arab Republic. In collaboration with the Arab Fund for Social and Economic Development, health aspects of wastewater treatment and reuse continued to receive CEHA’s attention. Applied research was carried out on infestation by intestinal nematode among populations of the Syrian Arab Republic, Saudi Arabia and Tunisia. Research was also conducted on the efficiency of wastewater treatment in removing nematode eggs in Egypt, Iraq, Syrian Arab Republic and Tunisia. Fourteen training courses for more than 350 technicians were organized in nine countries and 11 national profiles on wastewater treatment and reuse were reviewed by a regional consultation that was held in Amman in October 2003. A guide on sanitary parasitology was published in Arabic and will be published in English in 2004. A desk study on health aspects of grey water reuse was prepared, and a regional guide for health aspects of grey water reuse was proposed. Training materials for design and operation of rainwater harvesting systems were compiled, and systems were tested in Islamic Republic of Iran and Somalia, and two training courses on safe recreational water environments were organized, and training materials to help in the development of national standards were developed. Health care waste management needs and priorities were identified in many countries in the Region. Support was provided for training of personnel in Egypt and Libyan Arab Jamahiriya, and for printing of technical guidelines in Egypt. In Tunisia, support was provided for preparation of a national strategy on the prevention of legionellosis, for organization of a national public health day on hospital hygiene and for fellowship for training of four technical staff in nosocomial infection. Some support was also provided for training activities on solid waste management in Sudan and promotion of solid waste recycling activities in Lebanon. In collaboration with AGFUND, a training package on community-based solid waste management, comprising a training manual and 13 posters, was published and disseminated in the Region. A pilot project on community-based solid waste management was also started in Sana’a, Yemen. Future directions Ensuring the follow-up of the declaration issued by the Regional Conference on Water Supply and Sanitation in the 21st Century in the Eastern Mediterranean Region will be a major endeavour in the coming years. Methodology and tools for generating evidence on linkages between household water security and health will be developed and funding will be sought to carry out several population-based surveys to generate the evidence required to support the development of guidance on minimum water requirements for health. Information exchange services on wastewater projects in small communities, sanitary inspection of water projects and formulation and adaptation of regional guidelines on the use of recycled water and grey water will be given high priority. Strengthening of health care waste management at country level will require continued advocacy to policy-makers and decision-makers and collaboration and coordination of all stakeholders. Environmental health risk assessment and management Strategic issues Ensuring dissemination of the WHO guidelines related to the protection of the human environment (water, air, noise, recreational environments) and promoting the development of national standards based on these continue to be the main focus of this programme. Many countries do not have procedures for assessing the impact of development projects on human health and environment. In the past three biennia, the Regional Office has assisted several countries in development of environmental health impact assessment of development projects. There is a need to cover more countries. Action taken in 2003 and results achieved Training seminars on drinking-water quality and management of intermittent water supplies were held in Lebanon, Tunisia, Jordan, and Syrian Arab Republic. In Jordan annual plans for surveillance of drinking-water quality were developed, and pilot application of the procedures for rapid assessment of drinking-water quality was started in collaboration with headquarters. In Lebanon, the drinking-water quality surveillance system was designed. Technical assistance was also extended to Qatar for refining Doha’s drinking-water quality sampling programme. A proposal was developed by CEHA and submitted to AGFUND seeking support for establishment of a drinking-water quality surveillance system in Khartoum. WHO supported studies on health effects of environmental conditions in the Syrian Arab Republic and on noise and indoor air quality in Tunisia. Environmental monitoring was supported in a number of ways in Egypt, Lebanon and Pakistan. Following a request from Jordan, a process for initiating dialogue on phasing out leaded fuel has been developed. A project for strengthening national capabilities in the area of environmental health impact assessment was co-sponsored by AGFUND and CEHA. Within the framework of this project, Jordan, Tunisia and Morocco drafted their environmental health impact assessment guidelines for development projects. Future directions Methods for the effective control of quality of intermittent water supplies will be developed and disseminated and technical assistance and training will be extended to countries to introduce the third edition of the WHO guidelines for drinking-water quality, which were finalized in 2003. CEHA will facilitate the pilot application of the rapid assessment of drinking-water quality in Jordan by steering the process and providing technical assistance, capacity-building and training to the participating national authorities. There is an urgent need for environmental health auditing of existing development projects in order to mitigate existing environmental health hazards to the extent possible. Chemical safety Strategic issues The rapid globalization of chemical production and use has increased the potential likelihood of chemical exposure that could cause both acute and chronic poisoning. The use of chemicals in the household, public health, agriculture and industry has dramatically increased in the Region. Exposure to toxic chemicals is an important public health problem, especially where there are no systematic poisoning prevention programmes, toxicovigilance, or health sector contingency plans for chemical emergencies. Chemical safety is an intersectoral issue in which the health sector has important responsibilities. The concern of Member States with regard to use of chemical and biological weapons in 2002 contributed to raising the awareness of decision-makers. Following the crisis in Iraq many countries requested the assistance of the Regional Office to establish a poison control centre and countries accelerated in developing their national chemical safety profiles. Action taken in 2003 and results achieved National chemical safety profiles have been completed so far in Cyprus, Egypt, Islamic Republic of Iran, Jordan, Libyan Arab Jamahiriya, Pakistan and Syrian Arab Republic. The Regional Office supported activities relating to national policy and strategy development in chemical safety in Egypt, Jordan and Pakistan; inventory of toxic chemicals in Sudan; safe and judicious use of chemicals in Egypt, Islamic Republic of Iran, Jordan and Sudan; and chemical incident/exposure assessment in Djibouti, Jordan and Somalia. Egypt established functioning poison control and information centres at Ain Shams University in Cairo and in Alexandria. There are plans to establish further centres in Minya, Dekahlia, Beheira, Ismailia and Sohag. Jordan is in the process of establishing a poison centre at the University Teaching Hospital in Amman, following recently revised national chemical management profile. Morocco and Tunisia have well established centres providing a full range of poison control facilities. Centres in Oman, Pakistan and Syrian Arab Republic provide information and laboratory toxicological services. Saudi Arabia has a network of 20 poison centres, seven of which are well equipped regional centres, which include analytical toxicological laboratory services. Lebanon, Sudan and Yemen are in the process of establishing poison control centres. Future directions Harmonization
of classification and labelling of chemicals; establishment of risk
reduction programmes; information exchange on chemicals and chemical
risks; and prevention of illegal international traffic in toxic and
dangerous products all require cooperation with other international
organizations to provide greater support to countries for the
preparation of their national chemical safety profiles and programmes.
The preparation of inventories of chemicals, whether domestically
produced or imported, and establishment of a register of toxic
chemicals; establishing/strengthening of poison control centres and
dissemination of technical documents and provision of teaching and
learning materials and manuals will continue. |
