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1. Health development and health security
Back to chapter 1
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
This strategic objective aims at strengthening the core
service components of primary health care and reducing
an enormous burden of disease, while intensifying action
towards reaching key health-related Millennium
Development Goals (especially goals 4 and 5) and meeting
relevant international commitments. The situation in the
Region is worsening for some markers, such as the
incidence of HIV and other sexually transmitted
infections among young people, and progress is slow for
others, such as maternal, neonatal and child mortality.
The unmet need for contraception is large and growing in
several countries, resulting in a high total fertility
rate.
Some Member States are still not on track to achieve the
internationally agreed goals and targets concerned with
health protection and promotion in key stages of life.
Political will is flagging and resources are
insufficient to achieve these goals. Those who are most
affected, such as poor children, women and the elderly,
have limited influence on decision-makers and often
cannot access health care. Competing health priorities,
vertical and disease-oriented approaches and lack of
coordination between governments and development
partners result in programme fragmentation, missed
opportunities and inefficient use of human and financial
resources.
Creating networks and alliances for expanding
health-promoting schools in the community and research
are important strategies for promoting the health of
school students as a critical approach for family and
community health protection and promotion. Age-friendly
cities and communities and age-friendly primary health
care are also crucial to meeting the health needs in
relation to the visible growth in the ageing population.
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Achievements
towards performance indicator targets in each expected
result
In maternal and neonatal health, The Regional
Office addressed special attention to building national
capacities in promoting maternal and newborn health
through ensuring skilled care for every birth; improving
information and reporting systems; strengthening the
implementation of best practices in reproductive health
programmes, especially maternal health and family
planning; and improving knowledge and skills on
life-saving practices through community-based programmes.
The number of countries adapting and using the
guidelines on integrating management for pregnancy and
childbirth increased from 5 to 10 (Afghanistan, Egypt,
Iraq, Islamic Republic of Iran, Morocco, Pakistan, Oman,
Sudan, Syrian Arab Republic and Yemen). Specific
attention was focused on the eight priority countries
with regard to the Millennium Development Goals. The
Regional Office continued to support capacity-building
in making pregnancy safer, specifically, development of
technical competence in WHO evidence-based health system
interventions for scaling up maternal and newborn health
care in six countries (Afghanistan, Qatar, Somalia,
Sudan, United Arab Emirates and Yemen). Responding to
the need for investment in building national human
resources capacity in maternal and newborn health, the
Regional Office extended its support to recruit local
and international staff to support programme development
and implementation activities in Afghanistan, Iraq,
Palestine (Gaza Strip), Morocco, Pakistan Sudan, Somalia
and Yemen. The challenge of providing life-saving
obstetric surgery for the most deprived segments of
populations is extreme due to the shortage of physicians
in poor communities. Recognizing this, the Regional
Office supported capacity-building for Afghanistan,
Somalia and Sudan in enhancing access to human resources
for maternal and neonatal survival through
task-shifting, by training of front-line health workers
for emergency obstetric care, in a course run by the
Karolinska Institute, Sweden.
In order to support monitoring of maternal morbidity and
mortality and strengthen national capacity in addressing
related public health issues, the Regional Office
expanded its technical support to build national
maternal mortality surveillance systems in Islamic
Republic of Iran, Morocco, Lebanon, Syrian Arab Republic
and Tunisia. Making emergency obstetric care available
and accessible to all women when and where they require
is critically important for reducing maternal and
neonatal mortality. Recognizing the need for transfer of
technical know-how in this area, WHO published a
handbook on monitoring emergency obstetric care. To
facilitate its adoption and use in countries, the
handbook was translated into Arabic.
With regard to protection and promotion of child
health, the Region has witnessed around a 26%
decline in under-5 child deaths since 1990. Progress
towards achieving Millennium Development Goal 4 has
remained slow in six countries (Afghanistan, Djibouti,
Iraq, Pakistan, Somalia and Sudan), where 80% of child
deaths in the Region take place and the decrease in
under-5 mortality rate is less than a third of its level
in 1990. The challenge of accelerating the achievement
of goal 4 in these countries is substantial. Lack of
financial and human resources required for promoting
child health, coupled with shifting priorities, remained
a major obstacle to progress in this area.
Further progress was made in the implementation of
integrated management of child health (IMCI) strategy to
improve the quality of primary child health care
services. This has now reached 65% of all primary health
care facilities in the 13 reporting countries, where the
strategy has been introduced in more than half of all
districts. Continued investment was made in the area of
IMCI pre-service education, addressing the issue of
sustainability and responding to the increased demand of
the teaching institutions. An IMCI pre-service education
package was completed including guides on orientation,
planning and evaluation, teaching sessions, e-lectures
and a question bank for student assessments. Support was
provided to build national capacity in introducing and
evaluating the IMCI pre-service education. Forty-five
medical schools have now introduced IMCI into their
teaching programmes.
The Regional Office launched the “teleconsultation and
continued medical education via video conferencing”
initiative. This will establish linkages between
teaching institutions and remote deprived areas in order
to improve the knowledge and skills of child health care
providers working in these locations. A joint project
was established in Egypt in collaboration with UNDP,
Alexandria University, and the ministries of
telecommunication and health, linking the Department of
Paediatrics of Al Shatby University Hospital with Siwa
Oasis.
The Regional Office worked closely with countries in
building the capacity of child health staff in Saudi
Arabia and Tunisia in planning for IMCI implementation
at district level, using the planning guide developed by
the Regional Office. Six countries are using the
regional package on infant and young child feeding and
capacity-building of physicians in Morocco and Yemen in
line with this package took place.
Recognizing the need to improve the accessibility of
newborn and child care, an intercountry orientation was
conducted on use of the new WHO/UNICEF training
materials on care for newborn and child at home by
community health workers, and national plans of action
to implement this package were developed. The
orientation highlighted the need to adapt the special
training for health providers with low or no literacy,
and to plan and monitor health system supportive
elements that are essential for relevant community
interventions. Supportive national policies on which
services and medicines community health workers would be
allowed to deliver, availability of medicines and
supplies, feedback and motivation schemes by the health
system and community, were highlighted as priority
issues.
While the issue of adolescent health and
development has received the attention of the
international community, it has not yet been recognized
as a priority public health issue in many countries of
the Region. In order to determine priority issues for
promoting adolescent health and development in
countries, the Regional Office conducted a regional
situation analysis which highlighted the scarcity of
age- and gender-specific data. Inadequate information on
priority adolescent health and development issues, the
absence of a relevant management structure within
ministries of health in many countries and
implementation of fragmented activities by multiple
players, are all major challenges revealed by this
activity. With these facts in mind, the Regional Office
developed its vision for adolescent health and a
regional road map that: indicates the need for, and
suggests the mandate of, an adolescent health management
structure within the Ministry of Health; indicates the
role of the Ministry of Health in promoting adolescent
health and development; demonstrates a comprehensive
stepwise and phased approach that respects the
multisectorality of adolescent health interventions; and
describes the principles of adolescent health services.
Mapping of adolescent health programmes within the
Region was also conducted to guide efforts aimed at
advocating for establishing an adolescent health
management structure within ministries of health. As a
result, two countries officially established an
adolescent health programme (Sudan, Yemen).
Recognizing the need to provide evidence as a first step
to guide adolescent health programme establishment and
planning, the Regional Office developed a situation and
response analysis tool (SARA) to guide countries in this
process. The SARA report will serve as a baseline for
adolescent health in the Region. It includes sections on
relevant demographic, socio-cultural, economic and
health indicators, as well as analysis of the response
to adolescent health needs in terms of policies,
legislation, strategies and interventions. The vision
and progress were shared with countries and consensus
obtained on the regional directions for adolescent
health.
The Regional Office continued to provide technical
support to school health. Countries are actively
engaged in expanding national networks of
health-promoting schools and implementing the Global
School Health Survey – an important tool to identify
behavioural risk factors among adolescents. Technical
support was provided to the 2nd Gulf Conference on
School Health, held in Bahrain. The electronic tools for
the regional network of health-promoting schools were
reviewed and revised in collaboration with the countries
and a set of methods to facilitate evaluation of
health-promoting schools was also developed. A technical
review of medical screening activities for
schoolchildren in Oman was conducted. The Regional
Office continued to advocate for the integration in
schools of the school policy framework on implementation
of the WHO global strategy on diet, physical activity
and health. This policy has received increased attention
and has been adopted in most countries.
With regard to reproductive health and research,
the Regional Office maintained its technical support of
national efforts to accelerate progress towards the
attainment of international development goals and
targets related to sexual and reproductive health, in
line with the global reproductive health strategy. Five
countries (Afghanistan, Djibouti, Jordan, Somalia and
Yemen) developed their national strategies and
programmes to achieve universal access to reproductive
health care and started implementation. In-depth review
of the national reproductive health strategy and
programme implementation took place in Afghanistan,
Pakistan, Sudan and Yemen and necessary actions were
outlined. In order to ensure synergy among partner
agencies while supporting national efforts to scale up
national reproductive health programmes, a joint
WHO/Partners conceptual plan of action and country
workplans on implementing best practices in reproductive
health were formulated.
Information, reporting and surveillance systems of
national reproductive health programmes are still
inadequate and inefficient in identifying the major
determinants of reproductive health in most countries.
In response to this situation, a framework for
monitoring and evaluation of reproductive health
programmes in the Eastern Mediterranean Region was
developed. This guide document aims to strengthen
technical capacity and to facilitate the obtaining of
relevant and reliable data and information to monitor
progress and evaluate performance of national
reproductive health programmes. To put theory into
practice, 18 country workplans aimed at strengthening
reproductive health monitoring and evaluation were
subsequently developed.
National capacity-building in reproductive health
operational research was conducted for the first time,
benefitting four countries (Jordan, Lebanon, Palestine
and Syrian Arab Republic). Capacity-building in gender
and rights in reproductive health continued to be
supported in collaboration with the Institute for Women,
Gender and Development Studies, Ahfad University for
Women, Khartoum, Sudan. Five countries (Afghanistan,
Egypt, Morocco, Sudan and Yemen) as well as three
countries from the African Region have so far benefitted
from this.
Recognizing the critical role of research in generating
the evidence required for programme development and
implementation, the Regional Office continued its
support for relevant priority research activities. The
Centre of Human Reproduction Research and Studies,
National Family and Population Office, in Ariana,
Tunisia, was designated a WHO collaborating centre for
reproductive health research and training.
In support of active and healthy ageing, the
regional survey on active, healthy ageing and old age
care revealed increasing awareness among decision-makers
and programme managers of the major challenges in
promoting healthy ageing and the required response of
the health sector at the national level. Eight countries
have now developed policies on provision of
comprehensive services for the elderly through primary
health care. Four countries (Egypt, Islamic Republic of
Iran, Jordan and Libyan Arab Jamahiriya) have
successfully established multisectoral partnerships and
shared vision through development of national
strategies. Meanwhile, extensive efforts are being
exerted to scale up the development of national
strategies in another six countries (Bahrain, Oman,
Morocco, Pakistan, Syrian Arab Republic and Tunisia).
Five cities (Amman, Jordan; Tripoli, Lebanon; Islamabad,
Pakistan; and Hamah and Deir Atiyeh, Syrian Arab
Republic) showed interest in adopting the WHO
age-friendly cities initiative. Extensive advocacy
efforts were made to support other cities to adopt this
initiative in Bahrain, Egypt and Libyan Arab Jamahiriya,
and technical support was provided to evaluate national
programmes and activities in Syrian Arab Republic and
United Arab Emirates.
Efforts for closer cooperation and coordination for
improving age-friendly primary health care were made
with the South-East Asia Regional Office. The WHO tool
kit on age-friendly primary health care is being adapted
and translated in several countries. Egypt, with WHO’s
technical support, prepared a curriculum for training of
primary health care workers on age-friendly principles
and practices. The Regional Office developed a draft
regional guideline on age-friendly legislation which was
one of the main references used in preparing Al Riyadh
Charter on Elderly Care, adopted in Riyadh, Saudi
Arabia, in March 2009.
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Future
directions
Approaches to achieving this strategic objective require
a country-led planning and implementation process for
scaling up towards universal access to, and coverage by,
maternal, newborn, child, adolescent, reproductive and
ageing health care. Programmes and interventions must be
integrated and harmonized, especially at the primary
health care level. A continuum of care must be ensured
throughout the life course, at home and in the
community, by the health care system, with priority
given to marginalized and underserved groups.
Community-based interventions have to be promoted in
order to increase the demand for services. The different
roles and needs of women and men should be given due
attention in order to optimize health outcomes. Member
States and partners must commit resources and prioritize
national action, with intensified advocacy and the
mobilization of all partners around one concrete plan at
the country level.
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