Promotion and protection of health

Reproductive, family and community health and population issues
Healthy behaviour and mental health
Nutrition, food security and safety
Environmental health

4.1 Reproductive, family and community health and population issues

Promotion of reproductive health and research

Strategic issues

The WHO global strategy on reproductive health, adopted by the 57th World Health Assembly in May 2004 (WHA57.12), recognizes the crucial role of sexual and reproductive health in social and economic development in all communities. It aims to improve sexual and reproductive health and targets five priority aspects: improving antenatal, delivery, postpartum and neonatal care; providing high quality services for family planning, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities; and promoting sexual health.

Action taken in 2005 and results achieved

The WHO/UNFPA Strategic Partnership Programme (SPP) aims to promote the introduction, adaptation and adoption of practice guidelines developed by WHO to promote sexual and reproductive health at the national and district levels. The activities proposed within the programme bring together key work areas of WHO and UNFPA, namely those concerned with generation and synthesis of research data and compilation of best practices into normative guidance tools and assisting governments on the application of evidence-based interventions to improve sexual and reproductive health care, with specific focus on maternal and neonatal health, family planning and control and management of sexually transmitted infections, including HIV/AIDS. In its first phase of the implementation, SPP led to intensified efforts at all levels aimed at introducing up-to-date technical guidelines of making pregnancy safer, family planning, sexually transmitted diseases, including HIV/AIDS, and gender and rights in reproductive health to countries of the Region.

In January 2005, in collaboration with WHO headquarters and UNFPA, the Regional Office organized a joint workshop, in Cairo, Egypt, on using the WHO guidelines for making pregnancy safer and family planning. The workshop aimed at introducing appropriate technical guidelines; sharing experiences on existing national safe motherhood programmes and strategies; and determining the technical backstopping needs of the participating countries. The workshop concluded with the formulation of plans of action for introducing and applying the guidelines in local settings in nine countries. Five of these were subsequently finalized and approved, in Afghanistan, Iraq, Morocco, Pakistan and Sudan. In order to ensure adequate technical support and to follow up progress in implementation of the plans of action, a network of close communication was established among the concerned staff of the Regional Office, headquarters and UNFPA Country Technical Services Teams for Arab States, and South Asia, respectively. The plans of action aim to reduce maternal and neonatal mortality and morbidity by improving the quality of maternal and neonatal health care and family planning services. The results are expected to be achieved through advocacy campaigns and orientation workshops, adapting the required technical guidelines and training of the concerned health staff.

In order to facilitate the national efforts in this field, the Regional Office translated into Arabic and published two of the WHO guidelines in the Integrated Management of Pregnancy and Childbirth (IMPAC) package: Pregnancy, childbirth, postpartum and newborn care: a guide to essential practice and Managing complications of pregnancy and childbirth. Other IMPAC guidelines are being translated. Close technical backstopping was maintained throughout the year in order to support formulation of appropriate plans for adapting and using the guidelines in maternal and neonatal health services in countries with high maternal mortality levels. Also technical and financial support was provided to enable the implementation of these plans.

The WHO’s strategic approach to improving reproductive health policies and programmes is designed to assist country-level decision-making on improving reproductive health policies and programmes by focusing on user's needs, existing technologies and the service delivery system. The implementation of this approach was initiated by the Regional Office, in collaboration with headquarters, in Oman in 2003, followed by Afghanistan in 2005, with specific focus on birth spacing. WHO also provided technical and financial support to the University of Damascus, Syrian Arab Republic, for a national workshop on ethical issues in reproductive health research. The workshop concluded with the establishment of a national network of interested professionals––a step towards building a national ethical review committee in the country. Similar training activities were supported in Egypt, Oman and Pakistan. Technical support was provided to the United Arab Emirates to review and further develop its national registry of congenital abnormalities.

Future directions

The WHO's global strategy on reproductive health provides a framework for its implementation for health ministries and others in the health sector through five key action areas: strengthening health systems capacity; improving the information base for priority-setting; mobilizing political will; creating supportive legislative and regulatory frameworks; and strengthening monitoring, evaluation and accountability. For each of the determined action areas, action points for countries are suggested at policy and programme levels. A range of health care and health status indicators in five priority aspects of reproductive health are also provided to facilitate monitoring and evaluation of progress.

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Making pregnancy safer

Strategic issues

The central objective of the Making Pregnancy Safer (MPS) strategy is to ensure safe pregnancy and childbirth through the availability, access and use of quality skilled care for all women and their newborns. Resolution EM/RC51/R.4 urged Member States that have not already achieved the targets set by the Millennium Development Goals for improvement of maternal health to develop the required national policy and strategy documents and expand upon the achievements already made by Member States. The regional framework, Strategic directions for accelerating the reduction of maternal mortality in the Eastern Mediterranean Region, underlines six priority actions: achieving political commitment; promoting a favourable policy and legislative environment; ensuring adequate financing; strengthening the delivery of health care services; empowering women, families and communities; and strengthening monitoring and evaluation for better decision-making.

Action taken in 2005 and results achieved

World Health Day 2005 was marked with the theme “Make every mother and child count”, and The World Health Report 2005 was dedicated to mothers and children. In order to accelerate the reduction of maternal mortality in the countries with unacceptably high levels of maternal mortality, and to move closer to the achievement of the Millennium Development Goals in the Region, the Regional Office developed a regional framework entitled: Strategic directions for accelerating the reduction of maternal mortality in the Eastern Mediterranean Region, which was published in Arabic, English and French to ensure its wide dissemination and use in the Region.  The strategic directions serve as a regional model to guide planning, implementation, monitoring and evaluation of needs-based interventions and programmes at country level. Input to the document was provided by an intercountry consultation for making pregnancy safer in the Eastern Mediterranean Region, in Casablanca, Morocco. The consultation also discussed opportunities and challenges in addressing maternal health, among other things.

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Sensitizing the public to life-saving practices in maternal and neonatal health was given special attention in the workshop on media and health in satellite channels, which was held in collaboration with the Islamic Educational, Scientific and Cultural Organization (ISESCO), in Damascus, Syrian Arab Republic. Programme directors and producers from major satellite channels broadcasting in the Region participated. The workshop highlighted the need for evidence-based information that would direct and motivate the media to raise awareness among the public on issues related to making pregnancy safer.

In order to develop an appropriate strategy to improve neonatal health in Region, two technical consultations, on establishing national birth defect registries and on optimizing foetal growth and development, were organized by the Regional Office in collaboration with the Centers for Disease Control and Prevention (CDC), Atlanta, and headquarters. The next step will be to review and explore the feasibility of implementing the strategy with other maternal and child health strategies through the existing health care systems in the Region.

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Future directions

The current efforts in the so-called MDG priority countries of the Eastern Mediterranean Region are still insufficient to achieve the fifth Millennium Development Goal on improving maternal health. Resolution EM/RC51/R.4 underlined the main strategic directions required for improving maternal health in the Region. Strong commitment, intensive efforts and effective national policies and strategies are now urgently required in order to translate vision into action. Such efforts and plans should target the strengthening of health systems, expansion in the coverage of effective integrated interventions, and recognition of the essential role of individuals, families and communities in making pregnancy safer. Close technical support and follow-up will be maintained to support countries in adapting the regional framework and formulating their national plans aimed at accelerating the reduction of maternal deaths.

Protection and promotion of child health

Strategic issues

Every year in the Region 1.5 million children under 5 die from preventable causes. A substantial proportion of these deaths are increasingly occurring in the neonatal period. The 2005 report of the Secretariat to the 117th session of the Executive Board on the health-related Millennium Development Goals confirmed that inadequate effort to reduce malnutrition had slowed down progress in reducing child mortality. The Regional Office is supporting countries to achieve full coverage with cost-effective child health interventions, particularly for children that are hard to reach. However, the current pace of progress will not allow fulfilment of the various commitments made by the international community, particularly the Millennium Development Goals. Lack of sustained commitment, with intention often not translated into action, lack of adequate financial resources and qualified human resources, high turnover of trained staff, weak planning, monitoring, analytic and evaluation capacities, weak health information systems, poor availability of drugs and inadequate community involvement continue to be major constraints and challenges.

Action taken in 2005 and results achieved

The Child Health Policy Initiative (CHPI), launched in 2004, aims to: develop national child health policy documents, bringing together into one document all key policy elements related to child health; provide mid-term and long-term directions and commitments; and create a supportive environment for child care in countries. This regional initiative was identified in the Secretariat report to the 117th Executive Board as a major evidence-based strategy. Of the five countries that initially joined the initiative, four published the child health situation analysis reports signed by the Ministers of Health (first phase)––Egypt, Morocco, Sudan and Tunisia––and four more countries expressed interest in the initiative––Iraq, Jordan, Oman and Pakistan. As part of its support to the CHPI, the Regional Office conducted the second intercountry workshop on this initiative, to review the work undertaken by the initial five countries; discuss the steps and prepare a plan for the child health policy document (second phase); and share experience with the four interested countries.

The Regional Office continued to support scaling up of integrated management of child health (IMCI), recognized as the key strategy to achieve MDGs in the Region. Of the 17 countries at different phases of implementation, Egypt and the Islamic Republic of Iran exceeded 70% coverage of their health facilities by the end of 2005. Two countries moved to the expansion phase (Afghanistan and Djibouti) and three others progressed to the early implementation phase (Iraq, Jordan and Saudi Arabia). By end 2005 IMCI was implemented in 23 789 health facilities in 1115 districts in 12 countries. In 15 countries, 55 898 health providers have now been trained in IMCI case management skills. Results of evaluations and follow-up showed significant improvement in health providers and health facilities performance in providing quality health services. The Regional Office supported capacity-building in case management, facilitation, planning, supervisory, monitoring and evaluation skills of the IMCI teams in Djibouti, Egypt, Saudi Arabia, Iraq, Palestine, Sudan and Tunisia.

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Incorporating IMCI into the teaching curriculum of health personnel education institutions has been regarded by the Regional Office since the beginning (1998), as an approach to sustain and support child health interventions and broaden their coverage in the future. By end 2005, 21 medical schools in six countries (Egypt, Islamic Republic of Iran, Morocco, Pakistan, Sudan and Syrian Arab Republic) and two paramedical schools (Morocco and Sudan) had introduced IMCI into their teaching curricula (paediatrics and community medicine). To provide evidence for further expansion of the IMCI pre-service training initiative, the Regional Office established a technical committee on IMCI pre-service training evaluation, composed of WHO regional and country staff working in child health and senior professionals from teaching institutions and ministries of health from countries in which IMCI pre-service training had been fully supported. A draft document describing the objectives, evaluation questions and evaluation tool on both process and outcomes of teaching was developed and an electronic discussion group was also established.

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A third intercountry workshop on the IMCI community component was organized to provide further support to countries in involving the community in child health care. The status of implementation of the IMCI community component in the Region was reviewed and plans of actions were developed for 10 countries.

Training materials in Arabic on counselling for young child feeding were finalized and a regional training course to build the capacity of physicians from 10 Arab countries in this area was conducted.

Selected countries were briefed on the latest updates in diarrhoea management in under-5 children regarding low osmolarity oral rehydration salts and zinc supplementation. Egypt adopted the new oral rehydration salts and the zinc supplementation in its IMCI guidelines. In the area of research, a draft algorithm for acute exposure to hydrocarbons in children under 5 was developed, ready for validation in other settings. A visual library of burn case studies was developed to be used for the preparation of interactive training materials. In the area of advocacy for child health, the Regional Director visited IMCI health facilities and the paediatrics department in the Chatby Paediatric University Hospital in Alexandria, and a website on the theme of child and adolescent health was launched. Child health was one of the themes of World Health Day 2005 and was marked throughout the Region with events to highlight child health issues. The Regional Office participated in national child health events, such as the national child health forum in Pakistan and public health days in Tunisia.

Future directions

The Regional Office will support countries in finalizing their child health policy documents and in conducting child health situation analysis reports, as appropriate. In regard to scaling up of IMCI at least three countries are targeted to reach 100% coverage, and two more countries to move to the expansion phase. The pace of implementation will be accelerated in the other countries. The IMCI community component will continue to receive emphasis with special focus on practices affecting child feeding and breastfeeding promotion. Greater focus will be placed on increasing advocacy for child health, using all possible international, regional and national opportunities.

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Protection and promotion of adolescent health

Strategic issues

In the past few decades, adolescent people have emerged as the largest population group all over the world. In the Eastern Mediterranean Region, the size of the adolescent population (10–19 years) was 57.5 million in 1970 and grew to reach 120.3 million in 2000, constituting around 23.4% of the total population of the Region. In the same year, the youth population (15–24 years) constituted 34.4% of the total population. The dramatic socioeconomic and cultural changes occurring in the Region, coupled with the growing size of the adolescent population, create increasing challenges to the protection and promotion of adolescent health and development. This population group faces multiple risks and multiple opportunities, as they prepare to become the adults of tomorrow. A common set of factors has been identified that has a protective effect on the health risk behaviours of adolescents. Adolescents who have a positive relationship with their parents or other trusted adults, and feel connected to school, are less likely to initiate sexual activity early, use substances such as tobacco or alcohol, or experience depression. The 1989 UN Convention on the Rights of the Child expressed the right of adolescents to access information and services such as education, health, recreation and justice; have opportunities to actively participate in their communities; and acquire necessary skills to develop in a safe and supportive environment. The progress made in strategy development and implementation in most Member States continues to be slow in its response to adolescent health needs, while evidence-based planning for adolescent health also remains insufficient.

Action taken in 2005 and results achieved

In response to the need for technical guidelines to support national efforts to strengthen adolescent health and development strategies and programmes in the Region, the Regional Office embarked on developing a regional framework entitled Strategic directions for promoting adolescent health and development in the Eastern Mediterranean Region. The framework is intended to serve as a regional model to guide planning, implementation, monitoring and evaluation of needs-based interventions and programmes at the country level.

In order to discuss the existing opportunities and challenges in addressing adolescent health and development and identify appropriate mechanisms to operationalize existing and new strategies for improving adolescent health, including the regional framework, a roundtable discussion on promoting adolescent health and development in the Eastern Mediterranean Region was held in Manama, Bahrain. This was attended by experts from ministries of health and education, American University of Beirut, International Planned Parenthood Federation (IPPF), International Federation of Medical Students’ Associations (IFMSA), scouts’ and girl guides’ movements, and the Bahraini Parliament. The roundtable discussion identified effective programme practices and made action-oriented recommendations for adopting and applying the regional framework in countries of the Region.

The Regional Office maintained its technical support for strengthening national programmes of adolescent health and development in several countries. Jordan embarked on reviewing and updating the existing national guidelines on the health of adolescents. Morocco initiated necessary preparations for the conduct of a survey on adolescent health and development under the Pan Arab Project for Family Health (PAPFAM). International fellowship training for improving adolescent health services in secondary and tertiary health care facilities was provided to national staff in Tunisia.

A national workshop was held in the Islamic Republic of Iran involving close collaboration between the Ministry of Health and Medical Education and Ministry of Education on planning strategic actions for prevention of high risk behaviours among young people in formal and non-formal settings. The workshop significantly contributed to building appropriate technical capacity of 60 national staff. This activity also provided an excellent opportunity for introducing the grid methodology for determining priority strategies for adolescent health and development and elaborating WHO's concept of reproductive health of adolescents.

The United Arab Emirates formulated a national strategy for adolescent health and development as result of an intersectoral workshop on adolescent health and development using the grid methodology. The strategy is expected to be adopted and put into action through a national consensus meeting to be organized in 2006.

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Future directions

The Regional Office will continue to enable countries to pursue evidence-based strategies in order to reduce health risks, morbidity and mortality along the life course, promote the health and development of adolescents, and create mechanisms to measure the impact of those strategies. The development of adolescent health programmes still faces major challenges in some countries of the Region where adolescents are still perceived as a healthy population and a non-priority target group. While national adolescent health and development strategies, norms and standards are evolving 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. The regional framework delineates strategic directions aimed at promoting adolescent health and development and will be used for developing national policies and strategies.

Protection and promotion of women’s health

Strategic issues

It is increasingly well recognized that unequal power relations between women and men and the lower status accorded to women in many societies underlie much of the burden of ill health for women. Moreover, differences in the roles, responsibilities and behaviour of women and men, which are socially attributed, have different consequences for their health. These gender factors, in interaction with biological characteristics (sex) and with other sociocultural, political and economic variables, lead to different and sometimes inequitable patterns between women and men in terms of exposure to health risks, differential access to, and utilization of health information, care and services, response from services and providers, health outcomes and social consequences of disease.  However, in many instances the importance and implications of gender issues in public health are not yet fully understood or addressed. Consistent with this, the Platform for Action from the Fourth World Conference on Women (Beijing, 1995) recommended “gender mainstreaming” as the strategy to implement the tasks under all critical areas of women's health and identified women's health as an objective to increase women’s access to appropriate, affordable and good quality health care, information and services; to strengthen preventive programmes that promote women’s health; to advance research and disseminate information on women’s health; and to increase resources for, and monitor the impact of policies and programmes to improve women’s health. 

Action taken in 2005 and results achieved

The WHO/UNFPA Strategic Partnership Programme supported the conduct of the second workshop on transforming health systems: gender and rights in reproductive health in Khartoum, Sudan. National health staff from Afghanistan, Morocco, Sudan and Yemen, as well as from the WHO African region participated in this training activity.

In 2003 the Regional Office, in collaboration with the International Islamic Centre for Population Studies and Research (IICPSR) of Al-Azhar University, in Cairo, Egypt, published and disseminated to the affected countries 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. The manual supports advocacy activities aimed at increasing the commitment of decision-makers towards the elimination of female genital mutilation and supporting health and religious awareness and education activities in the community. UNFPA joined the Regional Office and IICPSR in reprinting and using this manual as a reference for initiating a female genital mutilation elimination project covering villages in 10 selected provinces in Egypt.

The Regional Office continued advocating the need to conduct nationwide, disaggregated situation analyses of the health of women. The Regional Office provided technical support to address priority issues in women's health in Oman which resulted in formulation of a national strategy to promote women’s health in the country. The strategy is expected to be adopted by the concerned national governmental, private and nongovernmental sectors at a consensus meeting in 2006.

Through the Ministry of Women’s Affairs in Afghanistan, WHO is supporting the training of female workers on health and hygiene education in Takhar and Samangan provinces in the country.  The trained female workers are expected to carry out house-to-house visits and impart health and hygiene messages to women and girls in the community. Around 10 000 women from these two provinces will be benefiting from this project. Local campaigns on the elimination of violence against women were also supported.

Future directions

WHO has made some progress towards the integration of gender considerations in health research, policies and programmes, however, more work is needed to ensure this approach is a core component of all public health work. Political will, commitment and accountability are key to achieving this objective. WHO will continue with its work on women's health problems of global importance like maternal mortality reduction and, through a gender mainstreaming strategy, will seek to ensure that all areas of work address the specific concerns of women, particularly where gender discrimination is a major underlying issue, such as in HIV/AIDS and gender-based violence. WHO will also continue to promote the full integration of gender considerations in health research, and in the development of gender-sensitive health systems, policies and programmes.

Protection and promotion of health of the elderly

Strategic issues

Important strategic issues include: updating the regional strategy on health care of older persons, reviewing national policies, strategies and plans of action to ensure the promotion of healthy lifestyles throughout the lifespan and the comprehensive care of older persons; promoting quality of life and well-being of older persons through approaches such as active ageing and community-based programmes or services for older people; integrating the health care of older persons into the primary health care systems and into the curriculum for training of primary health care and community care workers; and developing a computerized database on the status of the ageing population in the Region.

Action taken in 2005 and results achieved

The revised regional strategy on active, healthy ageing and old age care (2006–2015) was endorsed in a regional consultation on active ageing and promotion of health of older persons in the Eastern Mediterranean Region, organized by WHO and ISESCO in Manama, Bahrain. The consultation also resulted in a suggested set of minimum indicators for use in monitoring and evaluation of demographic trends and programmes caring for older persons.

The Regional Office continued its active role in sensitizing countries to the consequences of population ageing and the importance of developing national awareness, strategies and plans. Technical support was provided to Kuwait, Morocco and United Arab Emirates, to develop country profiles and national programmes. Serious efforts to formulate policies and to develop or strengthen programmes for the health of older persons are being increasingly realized. One example is the Doha International Conference on Ageing in View of Present day Changes which was held in Qatar.

The International Day of Older Persons (1st of October) is widely celebrated in several countries of the Region, especially in Jordan and Syrian Arab Republic, but further efforts are needed to enable communities and health systems to respond in time to the increasing needs of older persons.

Future directions

Action is needed at regional level to support countries in developing their national plans of action based on the revised regional strategy on active, healthy ageing and old age care (2006–2015). Promoting intersectoral action and networking among agencies, organizations, academic institutions and community-based organizations interested in the care of older persons is another direction to work on at regional and national levels. Research and training in the field of active, health ageing and community care should be enhanced.  

Protection and promotion of occupational heath

Strategic issues

Protection and promotion of the health of the working population is a strategic public health issue, as well as an important condition for sustainable development. Therefore, encouraging countries to include occupational health activities in their collaborative programmes with WHO is one of main directions of support to countries seeking to promote the health of workers and workplaces in general. Strengthening of regional and national policies for health at work; development of human resources for occupational health; and strengthening of occupational health services are also important aspects of the regional strategic directions for developing occupational health in the Region.

Action taken in 2005 and results achieved

The Regional Office continued to support the existing collaborative programmes on occupational health in 16 countries. One of most important lessons comes from the excellent results in developing occupational health that can be achieved when there is good understanding and cooperation between the two ministries responsible for occupational health and safety (Ministry of Health and  Ministry of Labour), in addition to an active role from nongovernmental organizations. Bahrain is now heading firmly towards establishing a national executive authority for occupational safety and health–– the first of its kind in the Region.

Other countries organized several major activities. A national workshop on health promotion at the workplace was conducted in Kuwait, a training course in occupational health for primary health care physicians was held in Dubai, United Arab Emirates, the National Institute for Occupational Safety and Health in Tunisia (a WHO collaborating centre) organized the sixth international conference of occupational health and safety on the prevention of chemical hazards at workplaces, and an ILO/WHO national training workshop on prevention of pneumoconiosis was held in Teheran, Islamic Republic of Iran. Egypt developed a unified country profile on occupational health and safety and, in cooperation with WHO, Jordan developed a national strategy for occupational health for 2006–2010.

There were extensive efforts to strengthen the capacity of primary health care systems in the Region to respond effectively to the needs of the working population in agriculture, the informal sector and small-scale industries. The intercountry workshop on primary health care and basic occupational health services, held in Sharm El Sheikh with support from WHO headquarters provided an opportunity to update participants on the regional situation. The Regional Office and Member States participated actively in the global effort to evaluate and update the WHO global strategy on occupational health for all.

Other aspects of WHO support were provided in the fields of capacity-building, establishment and strengthening of surveillance systems, and improvement in quality and coverage of promotive, preventive, curative and rehabilitative occupational health services in health systems.

Future directions

The Regional Office will continue its active participation in the process of updating the global strategy on occupational health for all. Regional and national policies for health at work will be strengthened. Promotion of healthy workplaces and coordination with other programmes, such as healthy cities, will be strengthened. Establishment and development of occupational health registration and data systems need to be encouraged. Networking and partnership with other international and regional organizations, such as ILO and the Arab Labour Organization, need to be enhanced. Interactive sharing of information will be encouraged. 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.

Protection and promotion of school health

Strategic issues

Building capacity to advocate for improved school health programmes; creating networks and alliances for development of health-promoting schools; and promotion of research to improve school health are important strategic issues for strengthening school health programmes and services the Region. The role of health-promoting schools as an effective approach in protection and promotion of the health of schoolchildren is gaining increased attention in the Region. The school setting is also being realized as a very important entry point for integrated public health interventions.

Action taken in 2005 and results achieved

The Regional Office continued its support to countries, where the recognition of schools as an important setting for health protection and promotion is gaining increased attention and better collaboration between the health and educational sectors in the field of school health is being clearly realized.

Technical support was provided to Bahrain, Iraq, Oman and Qatar to formulate national strategic directions for developing school health programmes and services; prepare national guidelines and action-oriented recommendations on health-promoting schools and school health information systems and conduct national training courses for capacity-building in school health. The second national conference on health and environment-promoting schools in Egypt was an excellent opportunity to shed more light on the experience to date and on the intention to expand the number of participating schools. School health day in Jordan was celebrated in April. The annual school health meetings in Saudi Arabia were successfully conducted.

The WHO initiative on health-promoting schools is attracting more attention in the Region and the Regional Office conducted a survey to evaluate this initiative. A regional consultation on health-promoting schools was held in Sana’a, Yemen, at which temporary advisers from around the Region convened, for the first time, to share experiences and develop a minimum set of indicators for the evaluation of health-promoting schools at country and regional levels.

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Future directions

The Regional Office will continue to promote efforts to establish regional and national networks of health-promoting schools, and to develop national standards for such schools. Cooperation between the health and education sectors is the cornerstone for successful implementation of school health programmes at national level. The Regional Office will promote development of regional and country databases in order to support evidence-based decision-making, and to promote schools as very important settings for public health interventions in the school community and the community at large.

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4.2 Healthy behaviour and mental health

Mental health promotion

Strategic issues

There is growing awareness of the mental health needs of the population in the countries. This is not limited to resource-rich countries. For example, Afghanistan has recently included mental health as part of the basic package of health services. In addition to the mental disorders seen in all communities, a number of countries in the Region are in conflict and post-conflict situations where the needs of the population are greater for mental health services. A special regional challenge is the high prevalence of various mental disorders in the community coupled with limited professional resources to address the needs. Even in high-income countries, development of mental health care is not in keeping with the development of general health care. There is high stigma, arising from a number of sociocultural factors, attached to people who are mentally ill and their families. There are still large, poorly managed mental hospitals in the Region which add to stigmatization of mental disorders. Most countries do not have updated mental health legislation.

Action taken in 2005 and results achieved

In Iraq, there is acute need for rebuilding of the mental health services. During 2005 the following initiatives were undertaken: needs assessment; rebuilding of the mental health infrastructure; and reorientation of mental health professionals along with updating of information and psychological first aid. Further initiatives were taken to build psychiatric services, including: training of psychiatrists in specialized fields like child psychiatry, treatment of substance abuse, psychotherapy, community psychiatry and geriatric psychiatry; training in research methodology and support for research work; training of the general medical doctors for 3 months and training of health personnel, school teachers and staff of voluntary organizations in essential mental health care, along with a campaign to fight stigma in the community through public awareness campaigns. These approaches have resulted in improving the mental health services.

Similar efforts at human resource development were undertaken in Djibouti, Somalia and Yemen. A number of countries were supported in their training programmes, for example for nurses in Yemen and primary health care personnel in Djibouti, with regard to integrating mental health care with general health services.

Support materials for mental health policy development and revision of mental health legislation were developed in Arabic. These documents address the topics of advocacy, financing, organization of services, human resources and training, planning and budgeting for service delivery, quality improvement, legislation and human rights, psychotropic drugs, and child mental health. The EM/ACHR identified mental health as an important area for funding. A regional monograph on epilepsy was developed which will contribute to understanding of mental health and neurological problems in the Region. At the XIII World Congress of Psychiatry held in Cairo, the Regional Office organized special regional sessions on epidemiology, school mental health, innovative approaches to mental health care and disaster mental health care. An educational CD containing more than 70 documents on ethics relevant to psychiatrists was compiled and distributed to over 5000 professionals.

Mental health promotion was another area of focus. Based on the international experiences and the regional initiatives, resource material on life skills education was developed to meet the regional needs. In the Islamic Republic of Iran, following national capacity-building for life skills education, parenting skills training was started and focal points from all provinces were trained to scale up the activities.

The massive earthquake in Pakistan in October left at least 3.5 million people in need of psychosocial support. The Regional Office worked jointly with national counterparts in the preparation of the National Mental Health Relief Plan for survivors, and has been active in the implementation and monitoring of the activities. The main strategies are: establishment of a national multidisciplinary, inter-agency, multisectoral coordinating and steering group; provision of mental health services including emergency mental health services, integrated with primary health care; mental health education; and intersectoral collaboration.

By end 2005, the Ministry of Health, in collaboration with WHO, had deployed 27 teams with more than 100 personnel to the major affected areas. Currently mental health/psychosocial support teams are working in Muzzafarabad, Bagh, Rawlakot, Battagram, Balakot and Mansehra. These teams are providing biopsychosocial interventions for survivors and families of survivors, and promoting resilience and recovery in individuals and the community, providing psychosocial support to the rescue workers, relief personnel and volunteers, and public mental health education. The teams are also coordinating with the district health authorities and local and international nongovernmental organizations. By end 2005 the teams had provided more than 10 000 consultations, conducted orientation and training sessions for 283 doctors including doctors from field hospitals,135 paramedical staff , 227 community health workers, 134 psychologists, 512 volunteers/social workers, 103 school teachers and 144 religious scholars and students of seminaries. Workshops and meetings for the media were held and a range of public education materials were developed.

Future directions

Taking into consideration the rapidly evolving conditions of the Region and the conflict situation in many countries, the demographic shift, the social changes following rapid urbanization and the large differences between countries in terms of economic growth, the following areas will need to be addressed: long-term results-based strategic orientation for mental health programmes; resource mobilization for mental health programmes for low-income countries; human resource development, especially for low-income countries; mental health needs assessment using sound methods and valid and reliable tools; reducing stigmatization and violations of human rights associated with mental and neurological disorders and substance abuse; regional capacity-building for psychosocial/mental health in disasters; shifting from a predominantly disease-oriented approach towards a mental health promotion model, and a more active role in relation to general health through promoting healthy behaviour; and capacity-building for research on mental health and information generation, particularly on disease prevention and promotion of mental health.

Disability prevention and rehabilitation

Strategic issues

The countries of the Region have special needs for the rehabilitation of persons with disabilities. Due to the number of countries in the Region in conflict and post-conflict situations, the numbers of persons requiring rehabilitation services is large. The Pakistan earthquake resulted in over 600 persons with spinal cord injuries and thousands with amputated limbs. Other types of injuries are also common in the Region, adding to the burden of disability. There is need both for community-based rehabilitation and specialized services.

Action taken in 2005 and results achieved

A comprehensive review of disability and rehabilitation services in the Region was planned to take place in 2006. This review will provide a situation analysis of the needs of the population, existing services, national policies, role of voluntary organizations, consumer participation and related matters.

Good beginnings have been made to integrate services for the disabled with overall disaster care. Following the Bam (Islamic Republic of Iran) earthquake in 2003, over 200 persons with paraplegia were provided with community-based rehabilitation. A similar approach to reach all of the more than 600 paraplegics is planned in Pakistan.

Future directions

People with disability suffer from a high level of stigma and discrimination in the Region. Development of a regional policy to reduce the stigma of disability will be a priority. The achievements in the Region with regard to mental health legislation should be completed and complemented by developing or improving legislation in support of people with disabilities. Finally, countries need to strengthen the application of the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities. As a first step a meeting is planned for May 2006 which will bring different stakeholders related to disability and rehabilitation services from countries to discuss the situation with regard to the application of four of the Standard rules (rule 2 on medical care; rule 3 on rehabilitation; rule 4 on support services; and rule 19 on personnel training) in the participating countries, to identify major constraints and problems.

Prevention and control of substance abuse (including tobacco)

Strategic issues

The public health importance of substance use and dependence is growing from year to year as it is more than a health problem; it is a formidable socioeconomic challenge with pandemic dimensions. Not a country or place in the world can be certified as “drug free”. As part of one of the most important transit areas of the world for illicit drugs, with many countries experiencing rapid social change and conflict situations, the countries of the Region are increasingly vulnerable to health, social and economic problems related to substance use and dependence. The trend in substance use among youth (15–24 years) and women is rising. The commonest substances of dependence are cannabis, sedatives, opiates and stimulants. Injecting drug use is a new development with significant public health implications, specifically related to spread of blood-borne infections. The most frequently injected drugs are opiates. The rate of HIV positive status among injecting drug users increased from 0.16% in 1999 to 3.26% in 2003. Similarly HIV transmission through injecting drug use increased from 2% in 1999 to 13% in 2003.

The first session of the Conference of the Parties to the WHO Framework Convention on Tobacco Control (FCTC) concluded with many challenges ahead for Member States, especially those that are Parties to the Convention. The two main challenges are implementation of the FCTC and international collaboration. Thirteen Member States from the Region are currently Parties to the FCTC and the remainder have all signed the Convention except one (which has neither signed nor acceded to it). Globally and regionally the challenges are the same, but ratification/accession to the FCTC by the non-Party Member States is an additional task that should be taken into consideration. National capacity remains an area that needs attention. The instability and lack of continuation of tobacco control-related activities has serious implications for the success of tobacco control in the Region. Limitation of both human and financial resources at national level is a problem that both the Regional Office as well as the countries continue to face.

Action taken in 2005 and results achieved

There is growing awareness of the need to address the problem of substance use and dependence in the countries. In May 2005, the World Health Assembly discussed the public health problems caused by harmful use of alcohol and adopted a resolution on the same subject. In June 2005, the first high level Arab Conference for Protecting the Youth from Substance Abuse was held in Cairo. The member states participating in the conference recognized the need to address the problem, in addition to legal measures. The Egyptian approach of working through schools was much appreciated.

Recognizing the urgent need to recognize the health impact of substance use and dependence during the past two years, the Regional Office, with advice from the members of the Regional Advisory Panel on the Impact of Drugs (RAPID) has made good progress in formulating a regional response to the problem. A regional strategy to address substance use and dependence was developed, focusing on development of national policy with focus on multisectoral actions and networking; increasing understanding of and knowledge about substance use and dependence; development of human resources; increasing accessibility to a wide range of services; and community-centred actions. The Regional Committee adopted a resolution (EM/RC52/R.5) calling on Member States to inter alia establish a national coordinating body to address the issues related to substance use and dependence.

In the area of prevention of drug abuse in school students, Egypt is conducting a major initiative. The National Project for Drug Abuse Demand Reduction among youth has been in operation since April 2001. The strength of the project is the active participation of the youth in school settings and out-of-school settings. The project is being implemented in 100 preparatory and secondary schools and 30 youth centres and clubs and includes a media campaign and capacity-building of 30 nongovernmental organizations to address the problem. In 2005, the programme was further extended to cover an additional 150 schools. As part of another initiative, a national trust fund provides support for delivery of services, including a hot-line for drug abuse with linkages to the different treatment and rehabilitation centres. In Morocco, there are active programmes with preventive interventions for street children.

A number of countries have set up national committees on drug abuse, such as the National Commission on Drugs in Morocco, National Project for Drug Abuse Demand Reduction in Egypt and National Harm Reduction Committee in the Islamic Republic of Iran. Several countries have recently opened new modern specialized treatment and rehabilitation centres (Bahrain, Kuwait and Saudi Arabia), and the Islamic Republic of Iran has been active in prison health including drug abuse.

Under the theme of “Health professionals against tobacco” the Regional Office and Member States celebrated World No Tobacco Day throughout the Region with the medical societies and their different disciplines. For the first time data from a health survey of professionals was released covering nine countries and highlighting important and alarming facts about health professionals and tobacco.

Improved surveillance and research in the areas of health, economics, legislation and behaviour in support of tobacco control is an important expected result for the Regional Office. In accordance with this objective a workshop on the Global Youth Tobacco Survey was held in the Regional Office in collaboration with the Centers for Disease Control and Prevention (CDC), Atlanta to train six countries on the implementation of the survey in its first repeat phase, and to analyse the data of those countries that have already completed it. The workshop was also used to give training on the implementation of the Global Health Professionals Survey. By holding this workshop, all Member States of the Region are now covered by the Global Tobacco Surveillance System. Five countries were also involved in training on the implementation of the Global Health Professionals Survey, held in Bangkok, Thailand.

The Regional Office hosted a meeting for WHO and CDC staff to plan for the finalization of the GTSS policy paper on data release, as well as the tobacco-free initiative annual retreat to discuss issues related to the Conference of the Parties and future directions.

The Regional Office published fact sheets on the health professionals survey in the Region (Arabic, English and French), The role of health professionals in tobacco control (Arabic) and The tobacco health toll (Arabic and English; the French edition is in preparation).

Ratification of the FCTC is a vital issue when it comes to the future of tobacco control in the Region. In collaboration with headquarters and the League of Arab States, a three-day workshop was held in Amman, Jordan to raise awareness and build capacity for the FCTC.  Participants from Ministries of Health, Justice, Foreign Affairs and Parliamentarians participated in this workshop. The Regional Director sent letters to all Member States of the Region following the completion of this workshop in an attempt to enhance the action taken at national level. A one day meeting was also held in Amman at the same time for countries that are Parties to the FCTC on the implementation phase and the Conference of the Parties.

In this regard, the Regional Office directly and indirectly supported a number of national activities to facilitate and move the ratification process forward including translation of the FCTC into the local language in Afghanistan and a national workshop in Tunisia. The nongovernmental organizations network is still active and the Regional Office supported tobacco control-related projects with nongovernmental organizations in Egypt, Libyan Arab Jamahiriya and Somalia.

Future directions

The focus will be on needs assessments regarding the pattern and size of the problem of drug abuse in different countries; mapping of the pattern of drug abuse and identification of the shifting trends in the Region; promoting transparent reporting on drug-related health problems; capacity building for advanced research on drug use in the Region involving the macro issues; development of regional policies on less investigated drugs, such as alcohol and khat; and focusing on health of special groups, especially prisoners, in respect to drug abuse.

In tobacco control, focus will be placed on efforts at national level to speed up the process of ratification and accession to the FCTC in the remaining eight Member States. Taking a multisectoral approach in this area is vital for the success of the efforts targeting ratification and accession. By end of 2006, each Member State must have the basic infrastructure, including budget allocation for tobacco control and at least a focal point who can dedicate 50% of his/her working time to tobacco control. An updated national plan of action in line with the FCTC should be adopted in the Member States that are Parties to the Convention, and in the other Member States a plan towards ratification should be developed and implemented so that by the end of 2006 more countries will have become Parties to the FCTC. However, lack of resources, both human and financial, and lack of basic infrastructure at both the national and regional levels is negatively affecting the progress of tobacco control and will have serious implications in the future if not addressed. The Regional Office will continue to support future studies in areas of health and economics and to ensure availability of tobacco control publications in different languages to technically support tobacco control efforts at national level.

Health education (including school health curriculum)

Strategic issues

The epidemiological transition in most countries of the Region, with the increasing burden of noncommunicable disease due to unhealthy lifestyles, calls for more emphasis on health prevention and promotion through appropriate audience-specific health information and education, including life skills, for behaviour change, within a comprehensive multisectoral health promotion strategy. The impact of globalization on consumer behaviour and health, especially of children and young adults, through modern advertising and marketing, needs to be addressed by appropriate media literacy education and regulation. There is still a need to further strengthen the organizational structure of health education to meet the growing needs, including appropriate staffing by qualified personnel and sufficient budgetary allocations. Close coordination and cooperation with the different departments and programmes across concerned sectors needs strengthening and consolidation on an institutional basis. Further capacity-building in strategic planning of health education and communication is needed. Consolidating the partnership between health education, school health and healthy settings will enhance health promotion initiatives involving local communities and civil society. The development of health-based life-skills among children and young people, including media literacy, continues to be a key strategy.

Action taken in 2005 and results achieved

Technical support was extended to the launching of the new programme cycle of Qatar’s television programme “Sahitak bi dinia” underscoring personal and collective responsibility for health. National capacity-building in health promotion was strengthened in Oman. A workshop for Ministry of Health programme managers was conducted on priority issues to be considered in developing the framework of a national health promotion strategy and its plan of action, drawing upon the draft regional health promotion framework developed by the Regional Office.

Technical support was extended to the Joint Committee for Health Education and the National Centre for Educational Planning in the Libyan Arab Jamahiriya through an orientation workshop for curriculum specialists and the members of the health education committee on the methodology of integrating health education concepts into school curricula.

The multi-media Arabic version of the action-oriented school health curriculum was presented at the Conference on Health Promotion in the Gulf Cooperation Council States, held in Kuwait, and at the Information Technology Institute Second International Digital Media Conference held in Cairo. Interagency cooperation was further consolidated with ISESCO, UNESCO and UNICEF through an intercountry workshop on the Arabic experimental multimedia version of the action-oriented school health curriculum for basic education, held in Damascus, Syrian Arab Republic in which 15 countries participated, in addition to Health Care International, Save the Children and FIRDOS.

National capacity-building in the field of school health and health education, in close collaboration with the school health programme, was strengthened in Iraq through a training workshop for 50 health officials to facilitate collaboration among key ministries involved in school health activities; review methodological approaches for integrating health concepts into school curricula; and introduce the concept and methodology of health-promoting schools and other initiatives such as FRESH (Focusing Resources on Effective School Health).  

The programme provided technical input on the role of health education in road traffic safety and accident prevention at the regional consultation on injury prevention and injury surveillance system held in Oman, and at the celebration of World No Tobacco Day in the Libyan Jamahirya, with presentations on youth and tobacco and on the code of conduct of health professionals to combat tobacco. Regional experiences, best practices and perspective in promoting healthy lifestyles and health promotion were shared with other WHO regions and institutions as well as specialists and health officials involved in health education and promotion, in the 6th Global Conference on Health Promotion held in Bangkok, Thailand and the parallel WHO global meeting on school health.

Collaboration with UNESCO Regional Office, Beirut, was further strengthened through participating in a coordination meeting for the FRESH initiative in the Arab States, held in Amman, Jordan. School health officials were briefed on WHO’s contribution to FRESH, particularly school health and health education in school curricula.

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National capacity-building of school health staff in strategic planning for the prevention of high-risk behaviour among adolescents and young people was strengthened in the Islamic Republic of Iran and United Arab Emirates through a training workshop on use of the WHO grid method of prioritizing actions for adolescent health and development. A draft strategic framework was developed. Capacity-building of school health officials was also strengthened through sharing national experiences, best practices and perspectives in health-promoting schools at the regional consultation on health-promoting schools held in Sana’a, Yemen. A basis for networking among health-promoting schools was established.

Technical support was provided, in close collaboration with headquarters and CDC, Atlanta, on the planning and implementation of the Global Student-based School Health Survey to Egypt, Lebanon, Morocco, Oman, Sudan and United Arab Emirates.

Future directions

Strategic planning and evaluation of health promotion programmes as well as advocacy for health promotion, particularly the creation of a regional parliamentarian forum on health promotion, will be a priority. Materials on media literacy education and health will be developed to counterbalance the increasing impact of modern advertising on behaviour of children and young adults. National capacity-building will continue to receive attention through the elaboration of reference materials and training on health education and communication strategic planning, inter-personal communication and development of counselling skills, as well as health education and communication-related qualitative research. Cooperation and coordination with other United Nations agencies, ISESCO, World Scout Organization Regional Office of Arab Countries/Arab Scout Organization and other institutional partners will be further strengthened through joint ventures and activities at the regional and country levels. The experimental multimedia Arabic version of the action-oriented school health curriculum for basic education will be revised in light of comments received from countries of the Region and will be produced and disseminated. Moreover, a web-based version allowing periodic updates will be made available.

Health information for the public

Strategic issues

Every day the media world is changing: no incident can occur, anywhere in the world without becoming public news, almost instantly. Tsunami, SARS and avian flu on the global level, and the Pakistan earthquake on the regional level, brought WHO’s role to the forefront.  Outbreak communications featured high on the WHO agenda, with three global meetings taking place and a regional meeting, in the Syrian Arab Republic, with all the Arab Satellite Channels. Resource mobilization is a major strategic issue. Regional Office participation in regional satellite telethons, with MBC and Al-Arabiya channels, to raise regional funds for Tsunami and Pakistan opened the venue for possible resource mobilization to be channelled, next time, through WHO. Creative and non-traditional ways of simplifying, producing and disseminating health messages and of promoting and enhancing the image of WHO as a whole and the Regional Office in particular continue to be pursued.

Action taken in 2005 and results achieved

Considerable effort was put into working closely with headquarters and with other UN agencies to promote the image of one WHO and one UN with common goals. As a cross-cutting unit the Media and Communication programme carried out many activities in cooperation with other programmes and organizations.

Following the Pakistan earthquake the Regional Director paid two visits to the disaster area, one jointly with the WHO Director-General. The Arab media were kept updated on all events and the Strategic Health Operations Centres (SHOC) of both headquarters and the Regional Office proved their worth for communicating directly and instantly. MBC satellite channel was spurred to conduct an excellent telethon donation campaign for earthquake victims in which both WHO and UNICEF participated.

In response to the need for media training at WHO headquarters on coping with disaster, the regional media and communications programme was invited to participate in training of the senior management of WHO, who learned many lessons about addressing the public in front of a media camera. The role of and need for spokespersons was expressed widely during the year, especially in relation to the avian flu outbreak and a special meeting was held at headquarters for all those dealing with the media. Questions and answers on avian flu were translated, printed and distributed to the media, and a multitude of television and public appearances were made to inform people about the subject.

The Arab satellite channels were all invited to a meeting to discuss promotion of health issues and to brief programme directors and producers on key areas of work, including AIDS and maternal health, as well as emergencies and other current priorities. The meeting was held in collaboration with ISESCO.

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On the occasion of World AIDS Day, the Regional Office in cooperation with the Egyptian AIDS Society and celebrity Samir Sabry, took part in a 2-hour television programme on AIDS. In cooperation with the Egyptian Ministry of Health and the Communication for Health Project Johns Hopkins University, the day was observed in a non-traditional way. A train was rented and youth gathered from all the governorates of Egypt, ending in Aswan with a parade featuring anti-AIDS banners. The parade culminated in a meeting with the governor and star singer Simone, Ministry of Health officials and over a 1000 youth participating. A question and answer session lasted for 3 hours in a lively meeting with WHO moderating, and coverage by Egyptian and other television channels.

World Health Day 2005 was another example of working closely with headquarters. Egypt was selected to represent the Region in a web photo feature, entitled “Great Expectations”. The selection of the candidate and photographer and follow-up with the Ministry of Health were all part of the preparations. The story of Samah, the young mother whose pregnancy was documented, was a delight to behold. A regional advocacy kit was produced around the “Make Every Mother and Child Count” theme.

The 20th anniversary of the WHO Regional Centre for Environmental Health Activities (CEHA ) was marked by the production of a documentary film about CEHA ’s work over the past 20 years. Health projects and programmes were filmed as they were being implemented, including projects on water conservation and recycling, and the film was shown to the Regional Committee for the Eastern Mediterranean.

The Regional Office collaborated with the country office for Iraq in the design and production of posters for fund-raising for Iraq, which were displayed at an exhibition for donors.

The second media evening organized by the Regional Office emphasized partnership with media stations, other UN agencies, donors and nongovernmental organizations, under the title “Partnership in Health”. The WHO Director-General and the Regional Director inaugurated the event. A 10-minute film was produced on the theme and stars from all over the Arab world, including Egypt, Iraq, Jordan, Sudan, Tunisia and Yemen, were presented with awards in recognition of their contribution to health promotion.

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In collaboration with Roll Back Malaria , the Media and Communications unit assisted in the launching of the joint WHO/UNICEF World Malaria Report 2005, a prime example of mutual cooperation between United Nations agencies. The Governor of Khartoum, Sudan, addressed the gathering on the success of the Malaria-Free Khartoum initiative and a malaria patient from Yemen talked about his first-hand experience with the disease.

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The theme of World No Tobacco Day 2005 was “Health Professionals Against Tobacco” for which a film was prepared. The Egyptian Medical Syndicate, the Egyptian Pharmaceutical Syndicate, Cairo University Faculty of Medicine, the Egyptian Association for Cessation and Treatment of Smoking and the Alexandria Library were all represented on the occasion and each gave an overview of the success of their anti-tobacco campaigns and projects. Among the guests of honour at the event was Dr Nasr Farid Wasel, the former mufti of Egypt, who was the first to issue the Islamic ruling on smoking, declaring it prohibited, and actress Raghda who, having been a close friend of the late actor Ahmed Zaki, who died of lung cancer caused by smoking earlier in the year, spoke about the dangers of tobacco.

Exploring the issue of health as a human right has been a major concern for WHO and other United Nations agencies, and the Regional Office organized a meeting to raise media awareness of the importance of this issue. The meeting was attended by journalists, television presenters and representatives of nongovernmental organizations. Training of the participants was through a number of different approaches, including role play which proved to be very effective, informative and enjoyable.

The Regional Office continued its collaboration with the Arab Scouts Organization, with exchange visits to the Regional Office to learn more about the health of mothers and children, HIV/AIDS, tobacco, avian flu and other health-related issues. In cooperation with the Egyptian Red Crescent, staff of the Regional Office met with representatives from every governorate in Egypt and talked about the important role of media in the creation of health awareness among the public. The “Partnership in Health” film was shown, which helped to visually illustrate this concept in greater detail.

The Regional Office played an active role in the Congress of the International Pharmaceuticals Federation held in Cairo, with the Media and Communications programme tackling the issue of pharmacists and tobacco. Many presentations were given around the subject of nicotine replacement therapy and the ethical role that pharmacists and chemists need to play to discourage the use of tobacco among customers and patients. A presentation was also given on the role of media in the campaign against tobacco and its dangers.

Future directions

The Regional Office will continue to make use of satellite channels as key players in resource mobilization and as advocates for the work of WHO and for health, as well as other media, United Nations agencies, nongovernmental organizations, universities and other partners. A workshop will be held to train WHO Representatives on how to deal with the media and to develop suitable campaigns for the advancement of health in the Region, and training will be conducted for media professionals in the production and dissemination of health messages. An in-house media production unit will be inaugurated. A regional media plan of action will be prepared and existing country plans updated. Country offices and satellite channels will be encouraged to send in health films, documentaries, etc. produced in their countries, which can then be adapted/translated for wider distribution. The Regional Office will continue to collaborate with celebrities, whose artistic skills and charisma can contribute to advocacy for WHO’s work.

Promotion of healthy lifestyles (including oral health)

Strategic issues

Although data is scarce on the prevailing risk factors in the Region, the available evidence suggests that a variety of risk factors are equally dispersed in almost all the countries. Currently, over 40% of the regional disease burden is due to noncommunicable diseases , and this is expected to rise to 60% by 2020. As shown from data collated by WHO, there is an increasing trend in diseases which are related to unhealthy behaviour. Lack of physical activity is taking a heavy toll, with sedentary lifestyles among the population as high as 75%–85% in some countries of the Region (higher even than countries in Europe where 60%–70% are reported to be inactive). Overweight and obesity account for an increasing burden of noncommunicable diseases and the Region faces an epidemic of obesity due to lifestyle changes and unhealthy dietary habits, particularly in the younger population and among females. Additionally, many countries are experiencing a double burden of disease, with communicable diseases still not fully controlled, and noncommunicable diseases and injuries showing an upward surge. This requires all countries to be more proactive about addressing the emerging health risk factors and health conditions while remaining vigilant about the persistent health problems of development.

A key challenge needs to be urgently addressed. Health education and health promotion are used interchangeably when health education is but one vehicle for health promotion. This confusion in the understanding of health promotion may hinder its evolution as a credible professional entity or distinctive discipline that stands on its own. It has also resulted in limiting the effectiveness of health promotion to the prevention of noncommunicable diseases thus inviting less attention from those Member States where the burden of communicable disease is relatively high. At the same time in low and middle income countries that are still overwhelmed by communicable diseases, more resources are allocated to their control. Therefore, both financial and human resources for health promotion are considerably affected.

The index of decayed missing and filled teeth (DMFT), an indicator of the oral health of the population is still high in most Member States compared to the global DMFT standard of 1.74. Mainstreaming of oral health in primary health care and within overall health promotion continues to be delayed. Another major challenge for oral health promotion in the Region is the scarcity of resources. Since it is not in itself an area of work, oral health promotion efforts still do not receive sufficient resources from headquarters and the Regional Office.

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Action taken in 2005 and results achieved

The growing interest in, and evidence linked to, the relation between people’s health and their lifestyles, and in the issue of health promotion in general, in addition to the development of the global strategy on diet, physical activity and health culminated in a myriad of achievements at the global and regional levels. The Regional Office adopted a forward-looking vision which was reflected in numerous important activities.

The regional strategy on health promotion was endorsed by the Regional Committee (resolution EM/RC52/R.8). The strategy was the result of extensive discussion within the Regional Office and with experts through two regional consultations and takes into account important issues for health promotion, such as making health systems responsive, devising a financing mechanism for health promotion initiatives and the impact of globalization on people’s health. It identifies a number of strategic elements with regard to raising health promotion on the political agenda, financing of health promotion programmes, building capacity for health promotion, placing the community at the centre of health promotion and an intersectoral approach to influence the policies made outside the health sector that have impact on the health of the population. The Eastern Mediterranean Region is the first to have a regional strategy on health promotion endorsed by the Regional Committee and should help Member States in devising their own multisectoral national plans of action.

The Regional Office made active inputs to the 6th Global Conference on Health Promotion in Bangkok, Thailand, ensuring that regional specificities were taken into account in the resultant Bangkok Charter. Another important strategic achievement was the formation of a regional expert panel on health promotion and the agreement by the Regional Director to establish a regional parliamentarian forum on health promotion. The Regional Office conducted an exercise in 16 countries to map the capacity in health promotion, not only within the ministries of health but also among other partners, including nongovernmental organizations. This exercise seeks to unveil health promotion initiatives and programmes (not necessarily in the health sector) with regard to human resources, health promotion training, financing, available infrastructure and available opportunities in terms of partnerships at the national and regional level. The results of the mapping exercise were analysed at the regional level and presented at the global conference (Figure 4.1).

Figure 4.1 Capacity mapping for health promotion: results for the core areas used for assessing the situation in countries with capacity for health promotion

In close collaboration with the WHO Kobe Centre for Health Development, the Regional Office continued to build capacity in health promotion leadership by including six experts from two countries in the second PRO-LEAD leadership course. PRO-LEAD is aimed at producing leaders in health promotion from various fields and sectors. This will enhance the capacity of policy-makers and academics to think strategically in planning health promotion initiatives. After completion of the final part of the course in May 2006, these six experts will be an immense local resource for the Region in capacity-building for health promotion. The Regional Office is also collaborating with headquarters and the Kobe Centre on a health promotion effectiveness programme through documentation of successful experiences in the Region.

Following concerted efforts to place health promotion high on the political and development agendas, many countries identified health promotion as a priority area in their country cooperation strategy (CCS) and a number of countries, particularly the GCC countries, included implementation of the global strategy on diet, physical activity and health in their coming workplans. Promotion of health was introduced into the medical curriculum in a number of countries while others have included health promotion in their health sector reform agendas.

The Regional Office supported national level community surveys to identify lifestyle-related risk factors for noncommunicable diseases in five countries. These surveys complemented the WHO STEPwise surveillance approach (implemented in 12 countries) and helped in establishing a baseline for those risk factors. Moreover, seven countries have been monitoring behavioural risk factors among students through health-promoting school initiatives.

The level of collaborative interventions was increased within the existing community-based initiatives to make use of existing national community-based programmes for healthy lifestyles promotion. Community-based initiatives intervention areas (particularly basic development needs areas) offer a ready playing field for addressing the social and environmental determinants of health. Moreover, health promotion programmes can be delivered easily through existing community-based initiatives which include all the elements (e.g. community leadership, intersectoral collaboration) required for health promotion programmes to be effective.

Oral health promotion is an integral part of broader health promotion initiatives of WHO collaborative programmes in most countries. Despite resource constraints, great strides have been made in oral health promotion in most countries. A few embarked on national level surveys enabling them to update and validate their DMFT index, others conducted fluoride mapping, and activities aimed at oral health promotion in schools and community were conducted by most countries. Eleven countries conducted extensive review of existing and required training skills for oral health professionals.

The WHO collaborating centre for research, training and demonstration for oral health in the Syrian Arab Republic played a pivotal role in building capacity of dental health care providers in research, service delivery and programme management. Efforts are under way to collaborate with the Tobacco Free Initiative to minimize the harmful effects of different forms of tobacco on oral health and to address preventive and promotive aspects as well.

Future directions

The way is now clear for the translation of the regional health promotion strategy and the Bangkok Charter, into action, mainly through the development of national action plans for health promotion. Along this line two key activities will be to prepare these plans of action and to advocate for more political and financial support for health promotion. A regional consultation will take place with the participation of parliamentarians from all countries, a Regional Parliamentarian Forum on Health Promotion being the aim. Close collaboration with health systems and communicable diseases programmes is a prerequisite for mainstreaming health promotion into the existing national programmes. A framework will be developed to guide this process and find the right place for health promotion in the wider health sector reform agenda. A regional implementation strategy and plan of action is being drafted for the implementation of the global strategy on diet, physical activity and health, for which resources are pledged by headquarters. An effort is being made to expand the training capacity of the collaborating centre for oral health in the Syrian Arab Republic by revising the curriculum and methodology. The implementation of healthy lifestyle promotion programmes through community-based initiatives will be expanded, as will the PRO-LEAD programme. A training package will be prepared to strengthen the capacity of mid-level managers and policy makers in this regard.

Safety promotion

Strategic issues

With increasing urbanization, mechanization, industrialization and globalization, injuries are a major cause of death in developing countries. According to the World Health Report 2003, globally, the burden of disease due to injuries has increased from about 12% in 1990 to 15% in 2000, and is expected to increase to about 20% by 2020. Globally the rate of death from road traffic injuries in 2002 was 19.0 per 100 000 people. Low- and middle-income countries of the Eastern Mediterranean Region, accounted for the second highest rate (after the African Region) averaging 26.3 deaths per 100 000 people. In 2000, interpersonal violence caused 21 203 deaths and around 433 484 disabilities in the Eastern Mediterranean Region accounting for 1.8% of the total death burden and 1.4% of DALYs respectively. Injuries on the roads, at home and in the workplace have increased due to lack of safety-related policies and programmes. The health sector bears the maximum brunt in terms of provision of acute care and rehabilitation services. Indeed, the burden of injuries imposed on health care systems in the Region is enormous.

Injury and violence prevention is currently receiving unprecedented support in the Regional Office and from headquarters. The increasing proactive interest of ministries of health and other sectors and their active involvement in regional policy-making and research initiatives has contributed greatly to the Regional Office’s efforts. There is also growing interest from the United Nations, donors and other international organizations in the issue, which has proved very beneficial to the collaborative efforts of WHO and Member States.

However, prevention still needs to be placed higher up on the public health agenda of most countries. This is largely attributable to the lack of reliable health information. Existing surveillance systems do not provide sufficient information to assisting policy-makers to make informed decisions. More research activities on the causality and magnitude of injuries in the vulnerable groups are needed.

Furthermore, injury prevention is still largely considered to be the domain of other sectors––police, transport and judiciary––and of individuals, when it has become universally recognized as a major public health issue. There is also a need for more integrated action and work in unison at the regional and country levels. The health systems in the Region need to be better geared to handle this emerging problem in terms of prevention. There is, especially, a lack of professional and technical capacity and expertise, limited intersectoral collaboration, lack of effective policies and programmes and inadequate financial resources at the country and regional level.

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Action taken in 2005 and results achieved

Injury and violence prevention has received immense high level political support from heads of the states and first ladies in the Region. The acceptance by Her Majesty Queen Rania Al-Abdullah of Jordan to become WHO Patron for Violence Prevention generated tremendous interest from donors, United Nations agencies and other governments in the issue of violence prevention. Subsequently, many projects were launched in Jordan supported by WHO as well as other UN agencies, and the Arabic version of the World report on road traffic injury prevention was launched under Her Majesty’s patronage. The political leadership provided by His Majesty Sultan Qaboos of Oman played a vital role in keeping the issue of road traffic injuries on the global landscape. The United Nations General Assembly adopted a third resolution on road safety, efforts being spearheaded by His Excellency Ambassador Fuad Mubarak Al-Hinai, Permanent Representative of Oman.

The Regional Conference on Family Protection, which was organized in Jordan by the National Council for Family Affairs Jordan in collaboration with WHO, UNICEF, USAID, Embassy of United Kingdom and Embassy of Holland under the Patronage of Her Majesty Queen Rania Al-Abdullah, chalked out a comprehensive way forward for violence prevention in families, particularly violence against women and child abuse and neglect. A regional consultation on the United Nations study on child violence took place under the patronage of Her Excellency Mrs Suzanne Mubarak, First Lady of Egypt. The consultation was arranged by the National Council for Childhood and Motherhood Egypt in collaboration with UNICEF, WHO, OHCHR and international and national nongovernmental organizations.

A regional expert consultation was held to enable the Regional Office to assist the nine priority countries in the Region in the preparation of a multisectoral national strategy, a multisectoral injury surveillance system and identification of research priorities in injury prevention and control. These priority countries were identified based on their high burden of deaths and injuries, relying on the data provided by the national authorities or assimilated from national/regional studies. The process resulted in five countries (Islamic Republic of Iran, Jordan, Oman, Pakistan and Yemen) developing strategic multisectoral plans. The other four (Egypt, Lebanon, Saudi Arabia, Syrian Arab Republic) are in the process of devising similar strategic plans with technical support from the Regional and country offices. Regional guidelines on injury prevention and control were developed from the consultation and will help policy-makers to design policies and multisectoral plans for injury prevention and control.

An initiative on good practices was launched by the United Nations Economic and Social Commission for Western Asia in collaboration with WHO and UNICEF, involving 13 countries in the Region.

The Regional Office was the first to take forward the WHO TEACH-VIP curriculum, conducting a regional training course in Jordan on injury and violence prevention using the WHO TEACH-VIP curriculum, in collaboration with headquarters. The aim was to train policy-makers from Jordan, Iraq, Egypt, Syrian Arab Republic, Palestine, Saudi Arabia and Yemen in injury prevention policy-making. Participants represented multiple sectors, such as interior, traffic, human rights, labour, social affairs, academia and nongovernmental organizations, as well as health.

The Regional Office continued to pursue its close collaboration with the African Region and headquarters with the launch of a joint project in Africa to align activities and actions with the African Union declaration of 2005 as the year of violence prevention in Africa. The Regional Office also contributed to the 4th African Regional Conference on Safe Communities held in Port Said, Egypt.

The Regional Office continued to translate WHO publications on injury and violence into Arabic, the latest publications being Guidelines for conducting community surveys on injuries and violence, Guidelines for medico-legal care for victims of sexual violence and Guidelines for essential trauma care. Jordan is among six countries in the world to have pilot-tested the WHO medico-legal guidelines on sexual violence.

The response of health systems to unintentional injuries and violence was strengthened with support provided to nine countries (Egypt, Islamic Republic of Iran, Jordan, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, United Arab Emirates) to establish an effective emergency trauma response mechanism. 

Finally, a major milestone was the launching of a regional web page for injury and violence prevention (http://www.emro.who.int/vip/) as a resource for information, advocacy and knowledge sharing among the Member States and other organizations. 

Future directions

The momentum created by WHO in the Region and the growing political support for the issue of injury and violence prevention will be further translated into more meaningful partnerships and actions towards injury prevention. The political support emanating from the Region for the issue of injury and violence prevention has already contributed greatly, culminating in three UN General Assembly resolutions. Having Her Majesty Queen Rania Al Abdullah of Jordan as WHO Patron for Violence Prevention is an opportunity to muster more political support for the issue at various levels. The National Report on Violence and Health will be launched in Jordan in the footsteps of the World report on violence and health, the first report of its kind in the Region.

Efforts will continue to be made to mobilize resources from the Region and to strengthen partnerships with other United Nations organizations and international and national nongovernmental organizations. Collaboration within the Regional Office and at the country level will be further strengthened to identify synergy in strategic directions and avoid overlapping of scarce resources. Collaboration with headquarters will provide an opportunity to work more proactively for resource mobilization, technical backstopping and advocacy. In 2006 the Islamic Republic of Iran will host the International Conference for Safe Communities which will be organized in collaboration with WHO and the Karolinska Institute of Sweden. WHO and its regional offices will actively participate in the 8th World Conference on Injury Prevention and Safety Promotion in South Africa which will be preceded by a meeting of the Eastern Mediterranean injury prevention focal points to discuss future needs and activities. The Regional Office will continue to support capacity-building in injury prevention policy-making through the WHO TEACH-VIP curriculum, which is being translated into Arabic.

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4.3 Nutrition, food security and safety

Nutrition

Strategic issues

The nutrition situation in the Region remains varied and diverse. High levels of overweight and obesity along with pockets of under-nutrition and micronutrient deficiencies, high consumption of energy-dense foods and aggressive marketing of ‘processed’ and ‘fast’ foods and carbonated drinks prevail in some countries. In others, moderate to low levels of overweight/obesity co-exist with moderate levels of under-nutrition and widespread micronutrient deficiencies. Existing nutrition programmes were often uncoordinated and accompanied by unclear nutrition policies, strategies and targets. Long-lasting complex emergencies and humanitarian crises affect a number of countries, where overall poor health and environmental conditions co-exist with inadequate institutional capacity and insufficient trained human resources. The strategic approaches adopted to address these issues consist of: strengthening capacities of countries to formulate and implement adequate national food and nutrition strategies and activities; responding to the nutrition needs of the population living under complex emergency situations; developing standard guidelines and protocols to detect, prevent and manage all forms of malnutrition; regularly updating the regional nutrition information-base; and assisting in monitoring and evaluation of national nutrition programmes.

Action taken in 2005 and results achieved

A regional technical consultation on developing national food-based dietary guidelines was organized in collaboration with FAO. The consultation addressed what and how countries should advise their population on improving their dietary selection and consumption practices. Financial and technical support was provided to three countries, Islamic Republic of Iran, Oman and Pakistan, to develop national food-based dietary guidelines.

Technical and financial support was provided to countries to develop national food and nutrition strategies. The food and nutrition strategy document developed in Jordan was under finalization while in Egypt, a multi-sectoral committee was created by the national authorities to proceed with consolidating the activities of the different government sectors involved in food and nutrition. Two supportive training modules entitled ‘Management of nutrition programmes for senior programme managers’ and ‘Effective communication strategies for improving nutrition programmes’ were developed. To improve the counselling skills of health workers, an Arabic-version of a training module on counselling in complementary feeding for infants and young children was prepared.

A technical consultation reviewed the draft integrated global strategy for optimal fetal development and recommended that additional work was required to bring about a greater integration of the different vertical strategies identified in the draft strategy. It also emphasized the need to look beyond the current focus on low birth weight and neonatal rates as indicators of outcome of fetal development.

The Multi-centre Growth Reference Study (MGRS) will soon replace the current international growth references which are based on children from a single country, with a set based on an international group of children in relation to several health behaviours, consistent with WHO recommendations on infant and young child nutrition and maternal nutrition. The new growth reference curves will be available by mid-2006. Updated information on the new growth reference curves and the need to improve the current growth monitoring practices in the Region, were the themes of a workshop organized by the Regional Office.

Emphasis on the importance of micronutrient deficiencies was maintained. A team of regional experts and representatives of international organizations reviewed two field guides on iron deficiency anaemia (IDA) and iodine deficiency disorders (IDD). The field guide on IDD will be a joint regional publication between WHO, the International Council for the Control of Iodine Deficiency Disorders (ICCIDD), WFP and UNICEF.

Technical support was provided to the Ministry of Health, Oman for the completion of its national micronutrient survey and to the Ministry of Health and Medical Education, Islamic Republic of Iran, to develop the national food/flour fortification plan.

The cooperative agreement between WHO and CDC, originally initiated by the Regional Office, was renewed for the fourth year, with the Regional Office for the Americas and headquarters joining as additional partners. The cooperative agreement will continue to provide financial and technical support towards the monitoring and evaluation of national micronutrient deficiencies programmes.

Future directions

As part of improving integrated food and nutrition policies for meeting the nutrition needs of the populations of the Member States, a training workshop on developing national nutrition plans and policies and two technical consultations to finalize the training modules on management of nutrition programmes for senior programme managers and effective communication strategies for improving nutrition programmes will be conducted. In order to implement the new WHO growth standards and strengthen the regional and national nutrition surveillance systems, a regional training workshop on the use of the new WHO reference curves is also envisaged.

As part of the overall technical and policy support provided to improve nutrition in crises and in special circumstances, including people living with HIV, the Regional Office, in collaboration with the Centre for Research in the Epidemiology of Disaster (CRED), Belgium, has developed a training module on nutrition response in emergencies. It is intended to pilot the training module in countries faced with complex emergencies. Other technical support to these countries will comprise the services of national nutrition officers and additional training workshops on the management of children with severe malnutrition.

Food safety

Strategic issues

The availability of wholesome and safe food is a basic human right and is essential for adequate human health. Food safety is increasingly viewed as essential and a major public health issue in the Region. Most countries in the Region have undertaken extensive reviews of their food safety systems. Some have harmonized their food safety systems; others have changed organization of food control systems and updated food safety legislation.

The strategic intent of the programme is to reach high level quality for consumer protection and ensure that all foods during production, handling, storage, processing, and distribution are safe, wholesome and fit for human consumption. Collaboration with countries in food safety is based on risk analysis strategy. Risk analysis must be the foundation on which food safety policy and consumer protection measures are based. It comprises risk assessment, risk management and risk communication. Risk assessment in food safety provides a scientifically based process consisting of four steps: hazard identification in food; hazard characterization in food; exposure assessment in food; and risk characterization. Risk management and risk communication provide a management and communication option that takes into account the health and economic consequences and feasibility of risk management while recognizing the need for consistent consumer protection requirements.

The problem of the consumption of contaminated food and its detrimental effects on human health has not been fully studied in the Region. However, countries are taking necessary measures to ensure the availability of safe food for all in order to sustain the health and economic development of their people. The health sector has responsibility for food safety but the multisectoral nature of food control requires effective collaboration and coordination by all governmental institutions involved in order to allow for the most efficient use of resources and avoidance of duplication of efforts and budgets.

Action taken in 2005 and results achieved

WHO collaborated with several countries to improve and update their food standards and regulations. The Islamic Republic of Iran, Sudan and the Syrian Arab Republic have reviewed and updated their food standards. Many countries have changed the organization of their food safety control systems. Morocco created a Central Regulatory Authority, responsible for all food control activity in the country; Saudi Arabia and Jordan have established a Food and Drug Administration which is responsible for the enforcement of the food and drug legislation. Kuwait, Oman and Syrian Arab Republic have made special efforts to revive existing coordination mechanisms, such as an interministerial committee known as the food control council. Tunisia established a national agency for the control of food and environmental safety.

Bahrain, Egypt, Iraq, Jordan, Qatar and Saudi Arabia continued to strengthen their national risk assessment and modernized existing laboratories in ensuring food safety. Bahrain’s food safety inspectors continued to receive training on food quality management, including radiation detection techniques and risk analysis. Egypt continued to emphasize prevention and control of food-borne disease and control of food delivered by street vendors, implementing a project for physical improvement of healthy marketplaces in Cairo and Alexandria and establishing a supervision and monitoring system for the healthy markets. Iraq continued to develop its national food safety programme. Pakistan conducted a national food safety profile and collected food legislation for updating. The Islamic Republic of Iran included consumer protection within the scope of the consumer information centre and continued to conduct national training activities for workshops on HACCP and Good Manufacturing Practices (GMP). 

National food safety focal points continued to participate fully in the Global Food Safety Network (INFOSAN). Saudi Arabia continued to strengthen its food surveillance system particularly of food poisoning outbreaks and improved epidemiological investigation of food poisoning outbreaks. Tunisia continued to update food inspection techniques and the food legislation framework, evaluate laboratories involved in food safety, and define measures for their upgrading. Several countries developed and implemented awareness campaigns and reproduced the WHO Five Keys to Safer Food in Arabic as posters and pamphlets. The WHO Five Keys to Safer Food project was implemented in collaboration with the community-based initiatives and women in health and development programmes in disadvantaged communities in Cairo.

The regional guidelines for developing food legislation were finalized. The Regional Office and FAO jointly conducted a regional meeting on food safety and the Regional Codex Coordinating committee in Jordan in 2005. This provided capacity-building for all food safety personnel in the areas of microbiological and chemical analytical techniques, laboratory quality assurance, risk analysis, food-borne disease surveillance and food monitoring, and the provision of relevant tools and methodologies.

Future directions

The Regional Office will continue to assist Member States to address the fundamental problems in food safety and reduce the health, social and economic burden from food borne illnesses and food contamination. The challenges related to food safety in the Region are: poor epidemiological characterization of food hazards, foodborne diseases and their direct and indirect impact on public health; inadequate public health infrastructure including laboratories and personnel; and the weak leadership of the health sector in the development of food safety policy, plans and programmes as an essential public health function. The Regional Office will continue to support strengthening of the place of food safety on the national public health agenda; enhancing countries’ capacities to plan and carry out national foodborne disease surveillance programmes; enhancing countries’ ability to collect data on the incidence of contaminants in food, including exposure assessment; supporting countries to undertake risk assessments on food safety hazards, or develop the capacity to do so if needed; facilitating communication for inspection services, food control laboratories, food contaminant monitoring systems; foodborne disease surveillance systems and consumers;  strengthening national food control systems by strengthening food control management, modernizing food legislation, and improving inspection services and foodborne disease surveillance systems.

4.4 Environmental health

Environmental health policy, including core functions of CEHA

Strategic issues

It has been estimated that environmental degradation causes between 19% and 25% of the total avoidable disease burden in the world, and that this proportion is much higher in developing countries and among children. The populations in the Region continue to be exposed to traditional environmental health risks, such as diarrhoeal diseases in infants due to lack of water and unsanitary conditions, and acute respiratory infections in children and women due to indoor air pollution. At the same time, these populations are increasingly exposed to modern environmental risks. Air pollution, principally due to traffic emissions, is a source of concern in large cities. The World Bank estimated the cost of damage to health and quality of life due to environmental degradation at 1.8% to 3.4% of GDP in five countries of the Region. These ratios are to be compared to total expenditure on health that is not much higher in these countries. Yet, in many countries delivery of the environmental health function of the Ministry of Health is inadequate, intersectoral collaboration is quite weak, legislation enforcement is very weak and accurate data are scarce both on exposure to environmental health risks and health outcomes, and there are insufficient financial resources for environmental health at country level. In addition, many countries of the Region do not have procedures for assessing the impact of development projects on human health and environment. In other countries, environmental impact assessment procedures exist but do not address human health in a proper manner.

The Regional Committee, at its 50th Session in 2003, called on Member States to develop and implement strategies that will result in increased support from donors and involvement of communities and nongovernmental organizations to ensure safer environments for children.

 As for the healthy environment programme, its financial and human resources continue to shrink, with insufficient clarity on sharing the extrabudgetary resources at different levels of the Organization. Lack of regular budget resources to cover the cost of CEHA core functions continues to be a major problem.

Action taken in 2005 and results achieved

The first meeting took place of the Regional Advisory Committee for Health and Environment, establishment of which was requested by Regional Committee resolution EM/ RC49/R.8. The terms of reference of the Committee include guidance on development of a renewed regional strategy on healthy environments for all. The aim of the meeting was to orient the Committee to health and environment in the Region and to discuss and amend a draft regional plan of action and charter for healthy environments for children in the Region. Among other things, the Committee recommended that it should meet annually and that a regional conference should be convened to discuss, amend and endorse the draft regional plan of action and charter.

The Regional Office is leading the process of preparing a WHO desalination guidance monograph, in collaboration with WHO headquarters and other regional offices. The first technical committee meeting was held in Irvine, California, USA in 2004; the five work groups of the technical committee began to develop their assessment documents in their respective subject areas, prepared initial drafts and assigned responsibilities for continued analyses after the meeting. Revised and expanded assessments were prepared for the second meeting of the technical committee which was hosted by the Kuwait Foundation for the Advancement of Sciences in Kuwait in 2005. Consolidation of the technical guidance document is now in process and the final document is due early in 2007.

The 3rd edition of the WHO guidelines for drinking-water quality, published in September 2004, was presented in a regional workshop hosted by the WHO collaborating centre for training and research in matters of water supply at ONEP, Rabat, Morocco. Presentation of the new guidelines was also the subject of national workshops in the Libyan Arab Jamahiriya and Tunisia, and a contract agreement was made to prepare a draft update of the national standards on drinking-water quality in Pakistan. CEHA extended technical support to Iraq, Jordan, Kuwait, Lebanon, Sudan and Pakistan to refine existing drinking-water quality surveillance systems or establish new ones where they did not exist.

The Regional Committee acknowledged CEHA ’s role in responding to the environmental health challenges during the past 20 years (EM/RC52/R.1) and its cost-effectiveness in addressing the burden of environmental health risks in the Region, and called on Member States and donors to support CEHA in responding to the ever increasing environmental health challenges.

A multi-faceted approach to creating healthy environments for children was pursued: gathering and disseminating scientific knowledge; assessing and characterizing risk factors affecting children and developing response mechanisms, awareness and education efforts; and developing and establishing healthy settings for children in homes, schools, and communities. Several national activities were supported in Jordan, Oman, Pakistan, Tunisia and Yemen. CEHA organized a regional workshop on children’s environmental health indictors, a clearing house for information on children’s environmental health was developed, and a catalogue of education and public awareness material available in the Region is now under development for easy web access. The first phase of the Health and Environment Linkages Initiative (HELI) in the Region was completed. HELI supported a demonstration project in Jordan which analysed the health, environmental and economic benefits and costs of government policies on increased efficiency in water use.

The achievements made by CEHA NET included linking CEHA 's computer and telecommunication networks to the WHO Global Private Network, production of a digital library of all CEHA documents and technical meeting reports, and providing traditional and electronic information services to more than 4400 users in the Region. Electronic access to environmental health information was strengthened in Islamic Republic of Iran and Yemen through supporting development of national environmental health web sites, and in Syrian Arab Republic through strengthening information exchange capacity.

Production of training and learning materials and awareness-raising materials continued. CEHA produced and disseminated 13 training and learning materials, 10 video films and more than 25 brochures and other instructional aids, in different formats and languages.

Support was provided for capacity-building of Iraqi environmental health professionals in different areas of environmental health and rehabilitation of environmental health, action in the areas of drinking-water quality, and continuation of strengthening of the health component in existing environmental impact assessment guidelines in five countries (Jordan, Oman, Morocco, Tunisia and Syrian Arab Republic).

CEHA ’s major efforts focused on and succeeded in raising additional resources to make up for the substantial decrease in its regular budget. During this biennium CEHA developed 30 funding proposals, of which 21 received funding totalling around US$ 1.12 million. Collaboration with regional and international partners resulted in a number of successful joint activities.

Future directions

Harmonized and improved planning and implementation of environmental health programmes in countries of the Region will be targeted. Focus will be placed on ensuring CEHA continues to respond to the needs of Member States; increasing awareness and knowledge of agencies and professionals about environmental health problems in the Region; stronger information management capacity in at least eight countries; and establishing environmental health information centres in Iraq and other needy countries in the Region. Support will be provided to minimize the adverse impacts of development projects on health and environment through building capacity of nationals to conduct environmental health impact assessment of development projects, and address the adaptation strategy at country level on climate change and health. Demonstration projects on healthier environments for children in Yemen and Pakistan will be supported, for replication in other countries of the Region later. The WHO guidance document on desalination for safe water supply will be finalized and updating of national drinking-water quality standards in line with the 3rd edition of the WHO guidelines will continue.

Water supply and sanitation

Strategic issues

Around 17% of the population in the Region, the majority of whom reside in rural areas, do not have access to an improved water source. The renewable water resources in the world amount to 7000 m³ per capita per year. In the Region, the per capita availability was 1430 m³ per year in 2000 (almost one-fifth of the world average).  In spite of the water scarcity, wastage of water is widespread and the water resources available are threatened by salt water intrusion and pollution. The cost of extending and sustaining water supply services is rising dramatically. The countries of the Region with large populations, with the possible exception of Egypt, will probably fail to achieve the water supply and sanitation targets of the Millennium Development Goals, unless a major shift takes place in resource allocation to enable substantial achievements in improving water supply and sanitation in these countries. National programmes on health education, with emphasis on personal hygiene, need to be developed and strengthened. Reuse of raw sewage or inadequately treated sewage is still practised in a number of countries, putting the public at serious health risk. There is a 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. Capacity-building and awareness-raising are also needed. The lessons learned from major disasters in the Region have emphasized that environmental health conditions during emergencies need sustained attention, particularly water supply and sanitation aspects.

Action taken in 2005 and results achieved

In response to the pubic health concerns related to water shortages in the Region a four-year initiative was launched to produce an evidence-based guidance document on household domestic water requirements for health. The initiative began with generation of evidence through studies in Jordan, Lebanon, Morocco, Oman and Tunisia.

Promotion of the health aspects of wastewater treatment and reuse, and of the need to perform proper sanitary inspection measures on water supply systems were other approaches that were followed by CEHA to help countries of the Region to respond efficiently to water shortages. The capacity of water agencies was strengthened through training, provision of relevant training and learning materials, and supply of equipment.

Cooperation in the area of health care waste management received sustained attention in many countries, including through streamlining health care waste management in seven countries (Jordan, Morocco, Sudan, Syrian Arab Republic, Oman, Saudi Arabia and Yemen). CEHA ’s action included three technical support missions, 11 national training activities, a demonstration project, production of a manual in three languages, arabization of a global WHO manual; production of a training video and 17 posters on safe practices. The support of the World Bank was essential in undertaking many of these activities. Solid waste management was addressed also through a pilot project on community-based solid waste management in Yemen, and arabization of a guidance document on dumping sites.

Manmade and natural disasters affected environmental health in Afghanistan, Djibouti, Iraq, Islamic Republic of Iran, Somalia, Sudan, Palestine and Pakistan. In the case of the earthquake in Pakistan, WHO environmental health staff and consultants were assigned to Muzaffarabad, Rawalakot, Bagh, Balakot and Manshera. During the acute phase, WHO assisted in activation of water supply and sanitation facilities, particularly in hospitals and health facilities, advising local rescue and relief workers on disinfection of water, installation of field latrines and solid waste management and hygiene awareness-raising. WHO as an active member of the WATSAN cluster worked very closely with UNICEF and other United Nations and relief agencies. Among the lessons learned as a result of the environmental health response to the earthquake is the critical need for clearly defined roles and institutional arrangements at all levels.

CEHA upgraded the water and hygiene kit, which was used in Islamic Republic of Iran, Iraq, Sudan and Somalia. Timely information was offered to the teams handling emergencies in the affected countries. A regional training course was convened for water planning and disinfection during disasters. Manuals and other supporting materials were developed and disseminated. Project proposals were prepared to support Sudan Somalia and Pakistan.

Future directions

The Regional Office will continue to provide technical support for improving access to water supply and sanitation facilities. This support will include capacity-building of Iraqi agencies to supply water and provide sanitation services, including health care waste management; gathering evidence to relate water security with health and development; promoting sanitation and basic environmental health; promoting health aspects of wastewater treatment and reuse; and capacity-building of national agencies for action in rural areas in needy countries. The water supply and sanitation components of the Millennium Development Goals and water supply and sanitation aspects of community-based initiatives projects are other areas for support. Promotion of cleaner and healthier environments through better health care waste management practices will continue. This will include control of infection in health care establishments through better management of health care waste as well as promoting community-based approaches in solid waste management.

The Regional Office will support the development and implementation of plans to strengthen the health departments’ capacities for environmental health in emergency response. In partnership with UNICEF, UNDP, Habitat and donors, the Regional Office will actively support the development and implementation of masterplans to strengthen capacity at all levels, defining the responsibilities and needs of key national and local agencies and clearly establishing linkages. The Regional Office will seek to clearly identify its role in environmental health in emergencies.

Chemical safety

Strategic issues

Chemical industries are rapidly increasing in the Region, with all countries producing chemical products, from plastics to pesticides. Chemicals are essential materials for national development and agricultural, industrial, public health and household use of chemicals continues to grow. The problem of human exposure to chemicals is therefore increasing in the Region. There is concern with regard to acute poisonings or chemical accidents and the effects caused by long-term exposure to chemicals. There are no data available on diseases of chemical etiology in the Region and inadequate information globally on the adverse health effects of chemicals. Chemical safety is an intersectoral issue in which the health sector has important responsibilities. There are close links between chemical safety and other issues of concern, e.g. chemical air pollution, food contamination with chemicals, and hazardous wastes. Weak coordination between different sectors responsible for different aspects of chemical safety is a major constraint. Member States’ concerns about use of chemical and biological weapons have increased since 2002. The tsunami disaster in December 2004 and the crisis in Iraq provided additional impetus for the development of chemical safety programmes in the Region.

Action taken in 2005 and results achieved

WHO collaborated with several countries to improve and review their chemical safety profiles. Priority was given to continuing the work on national chemical safety profiles, particularly in Islamic Republic of Iran, Jordan, Libyan Arab Jamahiriya, Morocco, Pakistan and Yemen. Egypt, Islamic Republic of Iran,  Jordan, Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Saudi Arabia and Syria Arab Republic are strengthening their poison control centres.

Other collaborative work consisted in supporting activities relating to: national policy and strategy in chemical safety in Egypt, Jordan and Pakistan; inventory of toxic chemicals in Iraq, Sudan and Yemen; safe and judicious use of chemicals in Egypt, Islamic Republic of Iran and Sudan; chemical safety assessment and chemical inventory establishment in Yemen; establishment of a poison control centre in Yemen; and chemical emergency preparedness and response in Jordan, Djibouti and Somalia. Missions were conducted by the Regional Office to assess the adverse health effects of chemical and nuclear exposure in the north-east of Somalia following the tsunami. Information was provided to a great number of institutions, industries and some individuals regarding the health effects of various chemicals.

Future directions

The Regional Office will continue to collaborate with countries in operationalizing their national chemical safety profile, as well as in working with national chemical safety managers to identify gaps and prioritize actions. Human health protection and risk reduction will be the core of the programme by providing countries with information on the hazards, risks and safe use of chemicals. Other priorities for Regional Office collaboration will be children and chemical safety, occupational health and safety, and implementation of the Globally Harmonized System of Classification and Labeling of Chemicals (GHS) in close collaboration with other relevant international organizations. There are several challenges that countries will need to address in the long term, including the rising quantities of chemicals consumed; the poor level of public knowledge about the benefits and risks of chemicals; inadequate registration of hazardous chemicals; and the rising number of chemical plants, the future repercussions of which have not been fully studied. 

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