Promoting health across the life course

The life course approach

Health is the outcome of all policies, including those related to social determinants of health. In 2014, WHO continued its efforts to support countries in protecting and promoting the health, safety and well-being of the population in the Region, across the life course with special focus on maternal and child health as a strategic priority.

Maternal, reproductive and child health

Between 1990 and 2013, maternal mortality ratio decreased by 50%, and under-5 mortality rate decreased by 46% in the Region (see Figs 1 and 2). The level of maternal mortality shifted from second highest to third highest among WHO regions, after the Africa and South-East Asia regions. Despite these achievements, the levels of reduction fall short of meeting the targets of Millennium Development Goals (MDGs) 4 (67% reduction in under-5 mortality rate) and 5 (75% reduction in maternal mortality ratio) by 2015. Moreover 26 000 mothers and 845 000 children under 5 years of age still die every year in the Region. Around 95% of these deaths occur in nine Member States with high burdens of maternal and child mortality.

Fig. 1. Maternal mortality trend 1990-2013 and extrapolation to 2015

Source: Trends in maternal mortality: 1990 to 2013.Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2014.

Fig. 2. Under-5 mortality trends: 1990–2013 and extrapolation to 2015

Source: Levels and trends in child mortality. Report 2014. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation. Geneva: UNICEF, WHO, World Bank, United Nations Population Division; 2014.

Several factors contribute to the high maternal and child mortality. Weak health systems with lack of adequate numbers of well trained human resources and unsustained availability of necessary commodities, and non-functioning referral systems represent a major challenge in the high-burden countries. The situation is compounded by political instability, social unrest, and the protracted acute and chronic crises that affect these countries.

In 2014, the Regional Office maintained its support to reproductive, maternal, neonatal, child and adolescent health, with specific focus on maternal and child health in the nine priority countries, in close collaboration with UNFPA and UNICEF. The funds WHO allocated in 2013 to kick-start implementation of the national acceleration plans were absorbed by the end of September 2014. They were used to support the implementation of priority activities, including: capacity-building of health providers, procurement of life-saving commodities and strengthening of community-based interventions. All nine countries identified maternal and child health as priority programmes for the biennium 2014–2015 and so a further US$ 7 million were made available for implementation through the WHO collaborative programme. In addition, US$ 7 million and US$ 10 million were made available from trust fund resources to support relevant priority activities in Afghanistan and Pakistan, respectively.

The current status and challenges facing countries in the maternal, neonatal and child health area, including the main causes of maternal, neonatal and child mortality in the Region, were reviewed at an intercountry meeting for national programme managers, held jointly with UNFPA and UNICEF in June 2015. Based on this meeting, priority actions were identified for facilitating the implementation of acceleration plans in 2015, as well as strategic directions for reproductive, maternal, neonatal, child and adolescent health programmes post-2015. WHO maintained close follow-up and support for the implementation of the plans and provided technical support to cover gaps identified through country missions. Special attention is being given to strengthening the health system-related elements. These include analysing the availability of human resources for maternal and child health services, assessing services for quality and infection control, and promoting operational research activities to address gaps in the health care delivery system.

Supporting countries in establishing and strengthening preconception care is another priority for WHO’s work in the Region. The aim is to further improve maternal, neonatal and child health outcomes in Member States. A meeting held with Member States and international and regional experts resulted in consensus on a set of core interventions and service delivery channels for preconception care services. Further work is planned in 2015 to examine in more depth the evidence base relating to the interventions and to develop a regional operational framework.

WHO, in collaboration with partners, embarked on analysis of achievements in countries with regard to MDGs 4 and 5. The analysis indicates that seven countries have achieved low maternal and child mortality levels, of which six have achieved MDG 4 and two have achieved MDG 5. Taking this into account, five countries in addition to the nine priority countries should receive further focus on maternal and child health up to the end of 2015. The crisis in several countries has seriously affected achievements previously accomplished. Innovative approaches are required to address the health needs of mothers and children in this situation. Even in countries with low maternal and child mortality levels, strategic plans are required to sustain existing achievements and implement targeted interventions to further reduce maternal and child mortality, especially neonatal mortality.

Only a few months remain to report on MDG achievements. Of the nine priority countries, several will still have high mortality levels but will have demonstrated significant progress, thanks to joint and intensified efforts. It will be critical to continue these efforts, and to prepare appropriate plans based on the post-2015 development agenda. The commitment and involvement of Member States will be essential in driving the post-2015 agenda debate and in addressing priorities related to saving the lives of mothers and children. The updated global strategy for women’s, children’s and adolescents’ health, which will be launched at the UN General Assembly in September 2015, builds on the 2010–2015 strategy, with lessons learned from the Millennium Development Goals, and focus on the evidence for effective investment and action. It will target equity, human rights and social determinants of health. Member States will need to align their strategic directions to this strategy and to the five-year implementation plan which will be proposed for formal endorsement at the World Health Assembly in May 2016.

Nutrition

Nutrition indicators in the Region continue to be alarming. Countries are struggling with high rates of malnutrition, poor feeding practices, micronutrient deficiencies and obesity. Malnutrition contributes significantly to child mortality. It is the main underlying cause of death in children under 5 years of age, causing 45% of all child deaths in the world, as well as the Region, in 2013. Anaemia, which impairs health and well-being in women and increases the risk of adverse maternal and neonatal outcomes, affects about 40% of women of reproductive age in the Region. WHO is working with Member States to implement the comprehensive implementation plan on maternal, infant and young child nutrition and its global targets, which were endorsed by the World Health Assembly in 2012.

With regard to undernutrition among children under 5 years of age, the weighted regional average is 28% for stunting, 8.71% for wasting and 18% for underweight. The countries of the Region with the highest burden of stunting and underweight are Afghanistan, Djibouti, Pakistan, Sudan and Yemen, where the prevalence of stunting ranges between 33.5% and 46.5% and the prevalence of underweight ranges between 25% and 39%. The annual rate of change in the prevalence of stunting indicates that several countries (Egypt, Lebanon, Morocco and Palestine) are on track towards meeting the 2025 target related to stunting

Despite global commitments to promotion of exclusive breastfeeding, its practice in the Region is still as low as 34%. The level of implementation of the International Code of Marketing of Breast Milk Substitutes remains below the global target (50%). A regional assessment conducted in 2014 showed that only five countries are fully implementing the code, 10 countries are partially implementing it and six are not implementing it. A regional consultation was held to discuss ways of accelerating implementation of the Code. This resulted in a regional policy statement and action plan on the urgent need to fully implement the Code and relevant World Health Assembly resolutions, which were disseminated to all ministries of health for implementation. WHO is working with countries to monitor implementation of the plan.

Regionally, overweight and obesity in children under 5 years of age increased from 5.8% to 8.1% between 1990 and 2012, which is above the global average of 6.7%. Overweight and obesity in adolescents (13–15 years) are highly prevalent, particularly in group 1 and some group 2 countries. Most countries in these groups have rates of overweight and obesity above the global median value of 21.7%. Data are currently only available for two age-groups in the Region: under 5 years and 13–15 years.

The challenges facing the nutrition programmes in the Region, especially in group 3 countries, are enormous. There is a pressing need to raise the commitment and priority given to nutrition in all countries. An intercountry meeting on nutrition was held in June 2015 to guide Member States on how to implement the recommendations of the Second International Conference on Nutrition (ICN-2). A set of seven priority initiatives was identified during the meeting. A regional framework will be developed in 2015 to translate the priorities into concrete action for implementation over the next biennium and beyond.

Ageing and health of special groups

Despite competing priorities several countries took steps to strengthen efforts in the field of active and healthy ageing and health of special groups. Countries are directing specific attention to strengthening programmes on active and healthy ageing and implementing the global plan of action on workers’ health. The age-friendly primary health care initiative has been implemented in some countries and the outcomes are being made use of to improve the performance of the programme.

Technical support was provided to the Gulf Cooperation Council (GCC) countries to develop mechanisms for applying the occupational and environmental health standards for accrediting hospitals and other health care facilities, with clear roles identified for concerned stakeholders. A detailed action plan with process indicators and timeline was developed for scaling up workers’ health services in these countries. Collaboration with the mental health programme continued with the aim of strengthening psychosocial services in the school health environment and institutionalizing school mental health promotion and services. The prevailing complex emergency situation in 16 countries of the Region underlines the need for school health programmes to incorporate a mental health component. A training package for teachers was finalized and peer-reviewed by external reviewers and during a regional consultation held in Cairo and will be tested in five countries. In light of the importance of schools as an entry point for several public health interventions, the need for developing integrated criteria for healthy schools is increasing. Work towards this direction is being continued and a new initiative will be launched during the second half of 2015.

Violence, injuries and disabilities

The Region ranks second among WHO regions in terms of road traffic fatality rate (21.3 per 100 000 population compared to a global rate of 18.03 per 100 000 population). While the majority of deaths occur in middle-income countries, the high-income countries have the highest fatality rate among similar countries across the world. Road traffic injury is clearly a grave concern for all countries of the Region regardless of their income level. Serious gaps persist in the comprehensive implementation of proven cost-effective interventions. While some aspects of these interventions have been applied by the majority of countries, they have not been implemented as a package that covers all essential elements. This has a serious impact on their effectiveness.

Challenges include inadequate political commitment, insufficient coordination and multisectoral action, weak enforcement, implementation and evaluation of policy and legislative frameworks, widespread under-reporting and fragmented data systems, as well as significant gaps in post-injury trauma care and and limited rehabilitation services. The health sector has yet to fully assimilate its role in injury prevention and control.

A regional planning meeting for injury prevention focal persons of ministries of health was held at which countries identified priority activities for incorporation in their national plans. A regional framework for road safety action was developed in consultation with countries. Countries completed the reporting exercise for the 2015 global status report on road safety which will monitor progress across the Decade of Action for Road Safety 2011–2020. A standardized methodology for estimation of the cost of road traffic injuries was developed and will be tested in 2015. A regional instrument to profile trauma care systems was tested in three countries, paving the way for expansion to others.

A high-level meeting on road safety is planned for early 2016 to increase political commitment and agree on concrete actions for accelerated progress in the second half of the Decade of Action. In preparation for this meeting, an expert consultation will be held to finalize the specific framework for action and to review the resource document for the meeting, which is being developed by WHO with Johns Hopkins Bloomberg School of Public Health. This document will present the most information on the burden of road traffic injuries in the Region as well as action-oriented recommendations for the three groups of countries, building on WHO related work, including the global status report 2015, and taking into consideration recent global developments such as the new sustainable development goals.

In the area of violence prevention, the Global status report on violence prevention 2014 provided, for the first time, information on different aspects of violence prevention and control from 16 countries of the Region, representing 63% of the population. The report shows that the Region’s low- and middle-income countries rank third (7 per 100 000 population) in terms of homicide rate, among similar countries in all WHO regions. Many of the prevention strategies surveyed were shown to be available. However, their implementation needs to be evaluated. In 2015 national policy dialogues will be conducted in three countries around the findings of the global report, in order to develop clear action plans to address the gaps identified.

The draft global plan of action to strengthen the role of health systems in addressing interpersonal violence, in particular against women and girls, and against children was reviewed in a regional consultation. In preparation for implementation, a stakeholder analysis, as well as mapping of the current situation and efforts to address violence against women and girls and against children, will be pursued.

Since the launch of WHO’s global initiative Vision 2020: the right to sight, there has been progress in a number of countries in developing and strengthening eye care services, including raising public awareness and uptake, integration into primary health care and inclusion of relevant indicators into health information systems. However, there is a lack of systematic evidence of the impact of the actions taken by countries on prevalence of avoidable blindness. More than half of countries (Afghanistan, Bahrain, Egypt, Islamic Republic of Iran, Iraq, Jordan, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia and Sudan) have developed or are in process of developing national eye health plans in line with the WHO global action plan towards universal eye health, following regional capacity-building conducted in collaboration with the International Agency for the Prevention of Blindness – Eastern Mediterranean Region. Generally, the public sector in Member States is still not investing enough in the prevention and control of blindness and visual impairment.

Achieving the goal of eliminating avoidable blindness by 2020 will depend on the ability of health systems to scale up efforts. This will require development and integration of eye health care into the general health system in line with the global action plan 2014–2019 for universal eye health.

Health education and promotion

The Region has the highest prevalence of physical inactivity among adults globally. Following recommendations of the World Health Assembly and Regional Committee, a high-level multisectoral regional forum on a life-course approach to promoting physical activity was held in Dubai, United Arab Emirates. The outcome was a regional call to action on physical activity, with a set of interventions for specific sectors. A regional advisory committee was established to support implementation of the call to action.

A survey on assessing national capacity to develop and implement physical activity policies and programmes was expanded from 12 to 16 countries. In 2015, WHO focused on building national capacities in the development of national multisectoral plans of action on physical activity and in development of plans for social marketing and mass media campaigns. In addition, in partnership with the WHO Collaborating Centre on Physical Activity, Nutrition and Obesity, Sydney, Australia, a training package was developed on mass media and social marketing on physical activity and healthy diet, to support countries in implementing the related “best buys”.

Social determinants of health and gender

In the current biennium (2014–2015), 14 countries have social determinants of health in their work plans, focusing mainly on implementation of the Rio Political Declaration on Social Determinants of Health; effective integration of social determinants of health within health programmes; and strengthening country capacity to implement health-in-all policies, intersectoral action and social participation to address social determinants of health.

A preliminary analysis was prepared by WHO and the Institute of Health Equity linking the social and environmental determinants of health to health inequities. The review revealed wide inequities within and across countries. Challenges identified included low political commitment, inadequacy of inequity data and weak intersectoral collaboration.

In a technical meeting on social determinants of health and health inequities prior to the 61st Session of the Regional Committee, Member States concluded that the five key health priorities in the region cannot be effectively tackled without addressing the social determinants of health. They requested WHO to provide clear strategic directions and guidance to strengthen intersectoral action and whole-of-government policies and address health inequities. Following a regional consultation held in the Islamic Republic of Iran in early 2015, four countries are currently participating in a pilot project to conduct an in-depth analysis on social determinants of health as a starting point.

Health and the environment

In 2013 the Regional Committee endorsed a regional strategy on health and the environment and framework for action 2014–2019. Although only nine countries indicated environmental health as a priority in 2014–2015, most countries of the Region conducted activities related to protecting public health from environmental risks. The risk-based assessment and management approach of the WHO guidelines on drinking-water quality and wastewater reuse was promoted and adapted to serve the specific regional and national needs. So far, 15 countries have updated their national standards for drinking-water quality in accordance with the guidelines, and a pilot project on wastewater use in agriculture was carried out in Jordan. Preventative water safety plans are adopted in eight countries and 11 countries strengthened their national monitoring of the water and sanitation sector under the framework of the UN-Water Global Analysis and Assessment of Sanitation and Water (GLAAS). All countries participated in the WHO/UNICEF Joint Monitoring Programme on water and sanitation the outcome of which shows that the large majority of countries have achieved or are on-track to achieve the targets of MDG 7 on water and sanitation.

The public health response to climate change and air pollution was discussed in the technical meetings prior to the 61st Session of the Regional Committee, as well as at a regional expert consultation. Member States are committed to tackling these environmental health risks within the context of the public health system, in partnership with other stakeholders. Environmental and occupational health standards for accreditation of health care facilities were developed and adopted by the GCC countries.

Development of guidelines for food safety, legislation and promotion of the global Codex Alimentarius were carried out in the Region in 2014. Several countries strengthened their capacity in the area of food safety sampling, inspection and control. A regional food safety assessment initiative was launched, which aims to profile up to 16 countries by end of September 2015. The aim is to assess strengths and weaknesses in the national food safety systems and to identify the priority actions required to address gaps identified. This “farm-to-fork” initiative will augment the capacity of countries to prevent, detect and manage foodborne health risks and outbreaks.

To support emergency preparedness and response in the Region, regional revolving stocks of key environmental health supplies were established in Pakistan and United Arab Emirates, while many countries are now making use of the disease early warning system (DEWS) to monitor and predict environment-related diseases. Capacity-building was conducted for health service providers in eight countries on response to chemical accidents and on trauma care following exposure to harmful chemical agents. Scientific resources and training materials were made available in several languages. National preparedness and response capacities for chemical, radionuclear and food safety events were strengthened in line with the International Health Regulations (2005).