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1. Health development and health security
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Strategic objective 4:
To reduce
morbidity and mortality and improve health during key
stages of life, including pregnancy, childbirth, the
neonatal period, childhood and adolescence, and improve
sexual and reproductive health and promote active and
healthy ageing for all individuals
Issues
and challenges
Improving maternal, neonatal and
child health has been endorsed as a key development
target by Member States,
through resolutions EM/RC51/R.4 on maternal and child
health, and EM/RC54/R.2 on neonatal mortality. An
estimated 57 000 mothers and 1.1 million children
under 5 years of age, 510 000 in the first 4 weeks of
life, die every year as a result of pregnancy and
childbirth complications and common childhood illnesses.
Only an 18% reduction in maternal and child mortality
has been achieved in the Region since 1990. Maternal and
child deaths occur in countries that suffer from
political instability, inadequate financial and human
resources, lack of supportive regulations, poor
socioeconomic conditions and gender-based
discrimination, and poor access to and utilization of
health services. Of these deaths, 95% take place in
seven countries in the Region. Unless extensive efforts
are made in these countries, they are unlikely to
achieve Millennium Development Goals 4 and 5.
Despite this situation, financial and
human resources have shifted dramatically away from
health protection and promotion programmes, especially
maternal and child health. Lack of necessary resources
in some countries is now coupled with the global
financial crisis to further aggravate the quality and
coverage of maternal, child and reproductive health
services. This is especially the case where the services
are most needed, in both remote and
peri-urban areas which are characterized by high
turnover of health workers, inadequate supplies and
equipment and poor health services. Competing health
priorities, vertical programme approaches and lack of
coordination between the concerned national health
authorities and international and local development
partners have resulted in working with different plans
of action rather than one concrete national workplan,
programme fragmentation, missed opportunities and
inefficient use of the limited resources that are
currently available.
Information on major determinants of
health throughout the life span is still insufficient to
enable evidence-based programme development and
implementation in countries of the Region. Health
information systems and research capacity need
strengthening in several countries to improve monitoring
and evaluation of programmes aimed at reducing morbidity
and mortality during key stages of life, including
pregnancy, childhood and adolescence, and at improving
sexual and reproductive health and active and healthy
ageing. Moreover, lack of accurate information on health
throughout the life cycle has led to insufficient
political recognition of the need to prioritize these
programmes on the national public health agenda.
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Achievements
towards performance indicator targets in each expected
result
The Regional Office maintained
technical support to build national capacities in
implementation of WHO cost-effective interventions and
guidelines that ensure integrated approaches in
maternal and neonatal health care delivery,
including the Integrated Management of Pregnancy and
Childbirth (IMPAC). The IMPAC guidelines were adopted
and are being implemented in 10 countries in the Region:
Afghanistan, Djibouti, Iraq, Islamic Republic of Iran,
Lebanon, Morocco, Pakistan, Sudan, Syrian Arab Republic
and Yemen. These countries are implementing strategies
for ensuring skilled care throughout pregnancy,
childbirth, and the postpartum and neonatal periods,
particularly for poor and disadvantaged populations.
In order to review progress achieved
in strengthening national maternal and newborn health
programmes and to update the participating countries on
emerging priority issues in this context, the Regional
Office held a follow-up meeting with national programme
managers of Making Pregnancy Safer. The outcome of the
meeting was an implementation framework for
operationalizing the recommendations and technical
support was provided to enhance their implementation.
Capacity-building in making pregnancy
safer was supported for Afghanistan, Iraq, Morocco,
Pakistan, Sudan, and Yemen through the global
orientation workshops which familiarized participants
with WHO guidance on interventions and related health
system issues for maternal and newborn health. They also
enhanced their skills to improve related programmes and
to plan, implement and evaluate services in countries
with high maternal and neonatal mortality.
Capacity-building was supported for seven countries
(Afghanistan, Egypt, Jordan, Iraq, Pakistan, Palestine
and Yemen) in order to improve the introduction,
adaptation, utilization and scaling up of proven
effective technical and managerial practices. Jordan
formulated and implemented a workplan to introduce
post-abortion services to essential obstetric care.
In order to support strengthening of
national health care services, the Regional Office
collaborated with the International Federation of
Gynaecology and Obstetrics in its initiative for
prevention of unsafe abortion through the conduct of
unsafe abortion situation analysis in
the Region. National plans of action responding
to deficiencies identified were formulated in three
countries (Egypt, Sudan and Syrian Arab Republic). In
collaboration with the Ministry of Public Health and
Population, Yemen, necessary preparations were initiated
to conduct a national survey on maternal, neonatal and
child health. This survey is expected to update the
available data on progress made towards achieving
Millennium Development Goals 4 and 5 and help in
accelerating the reduction of maternal and child
morbidity and mortality in the country. Preparations
were also initiated to conduct a demographic and health
survey in Afghanistan. This will be a unique national
activity that is expected to outline the health needs of
mothers and children in the country. The GCC member
countries began implementation of the World Health
Survey. The findings are expected to update existing
data on reproductive and family health in these
countries.
The Region witnessed 19.5% reduction
in under-5 child mortality compared with the year 2000.
More than three quarters of those 1.1 million deaths
occur in just four countries, Afghanistan, Pakistan,
Sudan and Yemen. There is slow progress in reducing
child mortality in countries with high under-5 mortality
rates and large populations. This is mainly due to lack
of financial resources and of qualified human resources
to lead the child health programmes. Even in
countries where national and external resources are
allocated to child health, progress has remained very
slow in some.
To promote child health, support was
provided to two countries to develop child health policy
documents as part of the child health policy initiative
promoted by the Regional Office. Oman outlined some
broad child health policies in a written document and
Afghanistan started a similar process. The Regional
Office also supported four priority countries, Egypt,
Pakistan, Sudan and Yemen, to develop national plans
towards the attainment of universal coverage of primary
health care facilities with the integrated management of
child health (IMCI) approach. Almost two thirds out of
47 892 primary health care facilities in 13 countries
are equipped with staff trained in IMCI. Of those, three
countries are moving closer to reaching 100% coverage of
facilities, namely Djibouti (87%), Egypt (84%) and the
Islamic Republic of Iran (99%).
The decrease in resources available
for IMCI implementation was accompanied by a decreasing
trend in the total number of health providers trained in
the past two years compared with earlier years.
Nevertheless, regional support was provided to build
capacity in IMCI clinical training in the Libyan Arab
Jamahiriya, where the approach has not yet been
implemented. Support was provided to Yemen for expansion
of the mobile team approach to provide child health
services to remote areas. To build planning capacity,
the Regional Office published a Guide to planning for
implementation of IMCI at district level, which was
introduced to national coordinators from six countries
(Egypt, Jordan, Morocco, Sudan, Tunisia and Yemen).
The number of countries that
incorporated IMCI intervention for care in the first
week of life increased from four to a total of 13. Given
the importance played by adequate feeding practices in
child health, technical support was provided to two
additional countries, Iraq and Tunisia, to introduce the
regional training package on counselling on infant and
young child feeding.
Introduction of IMCI into teaching
programmes was promoted and supported. The regional work
to guide and standardize teaching methodology and
evaluation for medical schools led to the drafting of
modules for an IMCI pre-service education package. This
was reviewed by a group of senior academic staff of
paediatrics departments of medical schools from
countries in the Region together with national IMCI
coordinators from ministries of health and WHO staff.
Support was also provided for the conduct of national
orientation and planning workshops to introduce IMCI
into six more medical schools in Egypt—bringing the
total number of schools involved to 14 in Egypt, six in
Pakistan and two in Yemen.
A quick review of adolescent
health programmes was conducted in Egypt, Sudan and
Yemen, and collection of data on adolescent health
activities in countries of the Region was undertaken to
complete the related situation analysis. The school
health programme is gaining increasing support in the
Region. Several countries made extensive efforts to
strengthen school health, including Oman and Jordan
which developed national strategies for school health.
Thirteen countries have now adopted the health-promoting
schools initiative and plans are being considered by the
Regional Office to expand the implementation of this
initiative to cover all schools in these countries. In
this context, Libyan Arab Jamahiriya launched a website
advocating the concept and providing necessary
information to facilitate its application in the
country. In recognition of this initiative as an
approach for health protection and promotion in the
community, several countries organized national
conferences, forums and symposia for school health and
health-promoting schools, including the second national
forum of health-promoting schools in Oman. The Regional
Office prepared an electronic distance access to the
national profiles as effective tools for data collection
and sharing experiences for the Eastern Mediterranean
Network of Health-Promoting Schools (EMNHPS).
The Regional Office maintained its
technical support to countries to build national
capacity for developing responsive policies and
strategies and implementing and monitoring programmes
for improving sexual and reproductive health and
achieving health-related MDGs. The WHO global strategy
on reproductive health was introduced to all Member
States and necessary follow-up was maintained to
strengthen and scale up the existing national
reproductive health policies and strategies. Country
profiles on reproductive health were formulated and
completed by all countries of the Region to serve as a
baseline for monitoring progress in implementing
national programmes.
In-depth review of the national
reproductive health strategy and plans was undertaken in
collaboration with the Ministry of Public Health and
Population and major concerned stakeholders in Yemen
resulting in a supportive workplan aimed at accelerating
the achievement of the Millennium Development Goals,
implementation of which started and is being monitored.
A 5 year project with the American University of Beirut
was initiated in support of national capacity-building
in reproductive health operations research.
Emphasizing an evidence-based
approach for strategic planning for promoting
reproductive health, the Regional Office completed a
reproductive health research directory, through linking
with the Index Medicus for the Eastern Mediterranean.
This tool is available through the Regional Office
website to ensure wide dissemination of information. It
currently provides information on 3713 reproductive
health research studies conducted in the Region and
published in the period 1990–2007. Other activities in
reproductive health research supported by the Regional
Office included: a long-term institutional development
grant to the Afghanistan Public Health Institute, Kabul,
Afghanistan; a haemoglobin colour scale multi-centre
study in Afghanistan; WHO multicountry study on maternal
and perinatal health in Afghanistan and Pakistan;
research on female genital mutilation and sexuality in
Egypt; research on the impact of environmental
pollutants on reproductive health in Egypt; and
institutional development of the Lebanese National
Collaborative Perinatal Neonatal Network (NCPNN)
in Lebanon.
Despite the lack of trained human
resources and insufficient financial resources, it is
increasingly noticed that the active ageing approach and
old age care is attracting special attention at
national, sub-regional and regional levels. The regional
strategy on active, healthy ageing and old age care:
2006-2017 continued to guide national efforts towards
responding to the health needs of the elderly. The
Regional Office extended its technical support to
Bahrain, Jordan, Libyan Arab Jamahiryia and Syrian Arab
Republic in developing national strategies and plans on
healthy ageing. Similar activities were initiated in
Egypt and Saudi Arabia and are expected to be completed
in the coming year.
Community-based activities were
supported in countries to improve the public awareness
of health and ageing issues. The city of Hama in Syrian
Arab Republic joined the age-friendly cities initiative,
joining Amman, Jordan, Islamabad, Pakistan and Tripoli,
Lebanon. In order to further support the implementation
of this successful initiative in countries of the
Region, the Regional Office translated into Arabic the
WHO guide on global age-friendly cities. Bahrain and
Oman are heading firmly towards age-friendly primary
health care practice. Oman developed packages for
improving the primary health care services for ageing
population.
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Future
directions
By the end of 2008, only 15% of the
planned budget for this strategic objective had been
received. The extreme financial constraints under this
strategic objective are having a negative impact on
support for countries to implement WHO resolutions and
achieve international goals, including the Millennium
Development Goals. WHO will maintain close monitoring of
national efforts to ensure achieving the national
targets in line with resolutions and goals. It will
support countries to develop synergies and strengthen
integrated interventions among relevant programme areas
(such as health promotion, nutrition, HIV, emergency and
humanitarian action), and address the specific health
needs of people while ensuring continuum of care through
the life stages, from home to the health facility.
Geographical areas with high morbidity and mortality
levels, especially among mothers and children, need to
be the focus of sustained attention. Capacity-building
in operational research and managerial skills and use of
the generated information in advocacy, fund-raising and
evidence-based programme development and implementation
will continue to be supported. Generation of information
and evidence to enhance the translation of the political
commitment expressed to maternal and child health into
actual investment of resources in priority areas and
universal coverage with the package of cost-effective
interventions will be strengthened. Strengthening
national health database, reporting and information
systems will facilitate monitoring of progress towards
achieving the Millennium Development Goals and help
evaluate the cost-effectiveness of the interventions
implemented in promoting health in key stages of life.
At national and sub-national levels,
the Regional Office will support the building of
partnerships that encourage effective and coordinated
involvement of civil society, private sector, donors,
international organizations and United Nations agencies
in promotion of maternal,
child and adolescent
health and healthy ageing. It will also support
community-based activities that promote the role of the
community in life-saving practices. The Regional Office
will continue to provide guidance and coordination of
donor inputs in maternal and child health in accordance
with national plans and strategies, to avoid duplication
of efforts and to ensure optimal utilization of
available resources.
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