Strengthening health systems for universal health coverage

In 2015, WHO intensified its support to Member States in order to accelerate progress towards universal health coverage, fulfil the commitments made by the WHO Regional Committee for the Eastern Mediterranean in resolution EM/RC60/R.2 (2013) and implement the regional framework for action on advancing universal health coverage (EM/RC61/R.1). The framework focuses on four key aspects: developing a vision and strategy for universal health coverage; enhancing financial risk protection; expanding the coverage of needed health services; and ensuring expansion and monitoring of population coverage.

Health financing, expanding population coverage and access to services

Despite notable progress, countries continue to grapple with inefficiencies, inequities and challenges to sustainability of financing health systems. Overcoming these obstacles is essential to fulfilling the goals of universal health coverage. In 2015, WHO’s support centred around: pursuing the analysis of health financing systems in countries; undertaking high-level technical reviews of ongoing health system and financing reforms; engaging in policy dialogue to identify country-specific health financing options; and building regional and national capacities in specialized areas of health financing.

The health financing systems of seven countries were analysed using the WHO tool OASIS to assess the institutional and organizational practices with regard to the collection, pooling and purchasing functions of health financing. Two high-level review missions were organized – to the Islamic Republic of Iran to assess the appropriateness and impact of the health transformation plan launched in 2014, and to Tunisia to inform the country’s national health strategy. High-level policy dialogue sessions were organized in four countries to identify health financing options for universal health coverage. Capacity-building efforts focused on strategic purchasing for reforming provider payment methods, and on measuring financial risk protection to monitor progress towards universal health coverage.

An expert consultation and a regional meeting on expanding coverage to informal and vulnerable groups resulted in a draft roadmap for expanding health coverage to the informal sector and vulnerable groups in the Region. Policy briefs on provider payment methods and demand-side financing were produced and disseminated.

The Regional Office initiated strategic collaboration with an extensive network of international experts through the Disease Control Priorities 3 (DCP3) Project to develop a high-priority package of essential services for universal health coverage. The criteria used for inclusion of interventions in this package include evidence of impact, cost-effectiveness, and affordability. The progress of work in this initiative will be reviewed in a special session planned on the margins of the next session of the Regional Committee. Countries have demonstrated progress towards universal health coverage by expressing high-level political commitment, developing a well defined strategy and adopting innovative approaches to mobilize additional resources. There is some evidence of reduction in the share of out-of-pocket spending. The inclusion of universal health coverage as a target of Goal 3 of the Sustainable Development Goals has given further impetus to furthering progress. In 2016–2017 work will particularly focus on exploring innovative means of mobilizing resources, expanding financial risk protection that focuses on the informal and vulnerable segments of the population, reducing wastage of resources through better tracking of expenditure and improving the monitoring of country progress towards universal health coverage.

Health governance and human rights

A regional assessment of the capacity of ministries of health in policy formulation and strategic planning was completed and was followed by a capacity development workshop on strategic planning. The assessment identified some of the gaps in planning. These include: limited staff and skills in the various areas of health policy analysis and planning; multiple health plans with varying degrees of resource commitments; different planning structures within ministries and communications challenges between them; and frequent change in leadership, often affecting continuity of planning priorities.

A regional assessment of external assistance and aid effectiveness was conducted in eight countries, using specific tools and instruments for data collection from governments, development partners (bilateral and multilateral agencies) and nongovernmental organizations. The findings of the study were presented in a high-level consultation with major donors and development partners in early 2016. It is expected that coordination between donors and development partners will be improved by establishing a forum of regional development partners.

The work on health sector regulation, with a focus on the private sector, involved assessment studies in three additional countries. These were followed by a regional capacity development activity and the development of a manual on regulation of the private sector. A regional capacity-building course on human rights and health equity, focusing on the importance of health as a human right and aimed at policy-makers and managers was piloted in Egypt and implemented in Pakistan.

During 2016–2017 focus will be placed on building the institutional capacity of the health policy analysis and planning units in the ministries of health. Particular attention will be given to building the capacity to update health legislation, strengthening the capacity of regulatory bodies for private and public sector institutions, advocating for the value of health as a human right, and coordination among development partners and the efficient use of external assistance in development and humanitarian settings.

Health workforce development

Within the context of strengthening health systems and moving towards universal health coverage, health workforce development is a priority. The health workforce situation in the Region echoes the global trends, with overall shortages in numbers, inequitable distribution, and challenges to quality, retention and performance, accompanied by a diminishing workforce in countries with protracted emergencies. Critical shortages exist in group 3 countries while group 1 countries are heavily reliant on expatriate health workers . Key issues include limited governance capacities, lack of coherent coordination among stakeholders/partners at the national level and lack of reliable information. The diverse situation in the Region means that different countries face different challenges, which have to be addressed accordingly.

To respond to the challenges and priority issues, a draft working document for health workforce development was developed through a series of consultations that have taken place since 2014. The resulting draft strategic framework is aligned with the global strategy on human resources for heath endorsed by the World Health Assembly in May 2016 and will be discussed by Member States on the margins of the Regional Committee in October 2016. 

Strengthening medical education in the Region is of high priority. An assessment of the situation of medical education in different countries was conducted in collaboration with the International Federation of Medical Education, through a survey of medical schools together with a series of consultations on the subject. Based on the outcomes, a regional framework for action on medical education was developed which was endorsed by the Regional Committee. Implementation of the framework will be discussed with ministers of health and higher education in a high-level meeting planned for early 2017. 

A leadership for health programme was launched in early 2015 in collaboration with the Harvard School of Public Health, to strengthen capacity among current and future public health leaders in the Region. The 4-week intensive programme was conducted in two parts, in two locations (Geneva and Muscat). Following the success of the first round, the second round was implemented in November 2015/January 2016.

In the area of nursing and midwifery, a comprehensive review of the challenges and obstacles impeding nursing and midwifery development was conducted. The findings were discussed at a regional forum on the future of nursing and midwifery in the Region, and a subsequent meeting of a group of international experts developed actions to address these challenges. The regional framework for action on strengthening nursing and midwifery 2016–2025 was presented to the ministers of health and senior health officials of Member States of the Region on the margins of the World Health Assembly in May 2016. . A consultation was also held in 2015 to review the regulation of nurses, midwives and allied health professionals. Priorities and options were identified to strengthen regulation with robust policies that will protect the health of the public. 

Understanding of the situation of other health professionals is becoming an increasingly important issue. Tools and instruments have been developed to undertake a survey focusing initially on three groups – medical laboratory professionals, medical imaging professionals and rehabilitative services professionals. The survey, which is the first of its nature in the Region, will be completed in 2016.

The work on improving the quality of medical education through accreditation, among other means, and strengthening nursing and midwifery, through the implementation of the framework for action, will continue. Efforts will be intensified to strengthen national capacities on human resource for health governance, which will be necessary for implementing the regional strategic framework on human resources. Attention will be paid to strengthening the primary care workforce, regulating health workforce education and practice through accreditation and other means, improving health professional education capacities, addressing the challenges of the health workforce during emergencies and improving health workforce information and evidence through health workforce observatories.

Essential medicines and technologies

Access to quality assured and safe medical products (medicines, vaccines and medical devices) is a major challenge in the area of health technologies because of weak national regulatory systems and related functions for safeguarding the quality, safety and effectiveness of medical products circulating in local markets. The regulation of medical products is a priority for countries. 

Harmonization and strengthening of post-market and vigilance regulatory functions for medicines, vaccines and medical devices were specifically promoted during the proceedings of a regional meeting on strengthening pharmacovigilance systems. In addition, regional guidance on how Member States can develop and strengthen the regulation of medical devices through a step-wise approach was developed, based on existing regulatory practices in place in Jordan, Saudi Arabia and Sudan. Substandard/spurious/falsely-labelled/falsified/counterfeit (SSFFC) medical products are a threat to public health in all countries of the Region. Member States are actively participating in the steering committee of the Member States mechanism for combating SSFFC medical products.

Work progressed in the area of good governance for medicines (GGM) with five countries now in phase I, seven in phase II and three in phase III. Support was provided to national task force meetings in Afghanistan and Pakistan to discuss the outcome of the national transparency assessments and to draft their national frameworks. An intercountry meeting was held with phase I countries in which national action plans were developed up to the end of 2016. WHO collaborated closely with national teams in finalizing their national assessment reports. The diversity of the Region and political instability of many countries pose particular challenges. Table 1 shows vulnerability to corruption measures following an analysis of 11 country assessments conducted in 2015.

Table 1. Good governance for medicines: vulnerability to corruption in 11 countries

The regulatory functions of promotion and clinical trials were found to be extremely vulnerable to corruption in five and three countries, respectively. Inspection, selection and registration were found to be moderate to extremely vulnerable to corruption in most of the countries assessed. The presence of political commitment, as evidenced by having medicine laws in place and increased access to medicines, was identified as a common strength in countries. The absence of policies and standard operating procedures for conflict of interest, as well as a lack of collective adoption and implementation of codes of conduct were reported as common gaps in governance. The presence of capable national assessors was identified as a success factor, together with high-level political support leading to institutionalization of GGM in ministries of health.

The importance of building national technical capacities in health technology assessment was highlighted during the pre-session of the Regional Committee. Subsequently several countries requested support in improving or establishing assessment units within their national health systems, while interregional support to the development of programmes in other WHO regions (South-East Asia and Western Pacific) was also requested and the regional network established in 2014 expanded to include countries from those two regions. The network now has over 100 experts and national champions. Capacity-building on improving quality, access and use of medical devices continued, with over 70 staff trained in Afghanistan and Iraq.

A new initiative was launched on identifying low-cost priority medical devices in order to improve user access to quality health care services. During the first phase an inventory of essential medical devices was developed based on regional priorities. The initiative, which will be given priority in 2016–2017, aims to offer a solution to the unmet demand for certain medical devices and will hopefully assist potential donors and manufacturers to make them available at affordable prices. A perception-based survey on availability and affordability of anti-cancer medicines in the Region was completed, in collaboration with the European Society for Medical Oncology. Awareness campaigns were a first activity of the implementation of the global action plan on combating antimicrobial resistance in the Region. The very low availability and accessibility of controlled medicines continues to be of major concern in providing quality services, in the form of appropriate pain management, to patients undergoing cancer treatments or major surgical interventions.

In 2016, the focus will be on strengthening regulatory systems for all medical products through self-assessments followed by expert visits. Support will also be provided to overcome shortages in essential medicines and other medical products and to ensure balance in national policies on availability and accessibility of controlled medicines, especially for palliative care. The low-cost medical devices initiative will identify and compile a compendium of low-cost priority devices which will support countries in procurement. Pharmaceutical sector country profiles will be updated to identify gaps in key areas, such as regulation, policy, technical capacity, human resources and access to medicines. Building on the progress made in health technology policies, focus will be placed on establishing health technology assessment units in ministries of health to support sound decision-making and investment and on establishing medical device regulatory bodies.

Integrated service delivery

The quality of primary health care is a common challenge for all countries of the Region. In some low-income countries geographical access remains a challenge, while affordability is an issue in many low and middle-income countries. Many countries are still struggling to reconfigure primary health care to respond to the disease burden associated with noncommunicable diseases and mental health problems. The unregulated expansion of private health care providers poses additional challenges. In many countries affected by conflict health care systems have been disrupted and this poses serious challenges for access to primary care services.

Ensuring access to quality primary care services for all is an integral element of the strategy to achieve universal health coverage. WHO has adopted family practice as the principal approach to primary care and to promoting person-centred integrated health services in the Region. Equally, the role of community health workers, home health care and healthy cities remains critical to the work on primary health and community care. Several initiatives were supported to increase the production of family physicians and build capacities of existing providers, including the development of a strategy paper on scaling up the production of family physicians in the Region and of a 6-month course on principles and practice of family medicine for general practitioners, in partnership with the American University of Beirut. Country level support included a review of health care provision in several countries of the Region.

Work on the private health sector continued with a regional workshop focused on building country capacity in assessing, regulating and partnering with the private sector. In the area of hospital management a review of public sector hospitals was completed followed by a 10-day course on hospital management. Based on the evaluation and feedback received, the course, which is the first of its kind in the Region, will be offered to countries in 2016. 

In the area of quality and safety, the patient safety assessment tool was revised and a toolkit of essential interventions published. A framework for quality improvement in primary care was developed, independently reviewed by peers and experts and piloted in 40 primary health care facilities in four countries. The tool is ready for use by countries. In addition a tool for assessment of the Patient Safety Friendly Hospital initiative was reviewed and shared with countries during a regional consultation. An expert meeting on the principles and practice of health care accreditation critically reviewed the current evidence and the value of accreditation in improving quality of care. 

The healthy city programme was successfully revived and the city of Sharjah was certified by WHO as the first healthy city in the Region following an external evaluation. WHO will continue to advocate for, and provide technical advice on the expansion of family practice programmes as the overarching strategy for service delivery towards universal health coverage. Support will be provided to improve the management and performance of hospitals and the quality of primary care. Countries in crisis will be supported to enhance health system resilience and ensure availability of health care in emergencies.

Health information systems

As part of efforts to improve mortality statistics, and in line with the regional strategy on civil registration and vital statistics, technical guidance was developed to support countries in designing better mortality statistics systems and a pool of regional experts is being established to deploy to countries to support improvement in mortality statistics, working closely with the Economic and Social Commissions for Western Asia and Africa. Additional comprehensive assessments of civil registration and vital statistics systems were conducted; only three countries have not yet conducted their assessments. WHO is following up with countries with regard to reporting on their implementation plans based on the country priorities identified during the assessments. Technical support was provided in assessing the quality of cause-specific mortality data. Important progress has already been made. During 2015 more than 20 datasets from 12 countries were received and assessed for completeness using standard tools. The current death notification and registration forms used by countries were reviewed against international standards. Capacity-building was supported in death certification and ICD 10 coding in several countries.

As part of efforts to strengthen routine health information systems, to enable countries to report on the 68 regional core indicators endorsed by the Regional Committee in 2104 and the Sustainable Development Goals, a technical consultation was held to agree on the contents of a harmonized assessment tool which will be piloted in the Region in 2016. Capacity-building was supported to promote the use of the health management information system DHIS2 as a platform for data collection, reporting and dissemination. To address the major gaps in reporting indicators that are mainly generated from population-based surveys, tools were developed to support health examination surveys, covering behavioural and biological risk factors, health care unitization, health status and household health expenditure. The survey will be implemented in 2016 in Tunisia with government support.

The work on the 68 core indicators continued with the development of a concise registry of metadata relating to the indicators, in addition to an expanded indicator list which will include the additional global list and indicators of Goal 3 of the Sustainable Development Goals. WHO will continue to support Member States in strengthening their health information systems reporting on the core indicators in the three key components of the health information system – health determinants and risks, health status including morbidity and mortality and health system response – in order to promote effective policy and decision-making processes. The regional health observatory was further enhanced to support better dissemination and use of health statistics in the Region. Comprehensive health profiles, which document the current situation, challenges, gaps, opportunities and way forward in each country and health programme, were developed in collaboration with Member States. They will continue to be updated annually.

Several challenges remain. Cause-specific mortality and ICD coding require further strengthening through continuous training and assessment of data quality. Population-based surveys and health system performance assessments need to be conducted on a regular basis. Countries will be encouraged to develop investment plans to address their capacity needs and to develop national health observatories to provide comprehensive data dissemination at subnational levels to address inequalities in health.

Research development and innovation

A number of important meetings and capacity development activities were held in the area of research development and innovation. The Eastern Mediterranean Advisory Committee on Health Research (EM-ACHR) was re-formulated and met to discuss the role of research in supporting strategic health priorities. It recommended building institutional capacity, supporting institutional research careers, promoting research and ethics for all health professionals, encouraging intersectoral collaborative and joint research (national, regional, international), developing large databases for research and using the research to brief health policy-makers. 

The Eastern Mediterranean Research Ethics Review Committee met in support of ethical review of research funded by WHO which involves human subjects. The meeting focused on ensuring compatibility of its work with international guidelines for review of health research on human subjects; updating the current review process for health research supported by WHO; and addressing new health research challenges, including health policy and systems research. An expert consultation on evidence-based guideline development and adaptation was held and resulted in recommendations aimed at building capacity, meeting the needs of Member States, mapping guideline activities in the Region and developing guidelines for region-specific conditions for which no guidelines exist. The first meeting in more than 10 years of directors of collaborating centres in the Region resulted in the establishment of a network. Forty-five WHO collaborating centres are currently active in the Region.

In collaboration with the Norwegian Knowledge Centre for Health Services, capacity development was supported for researchers, focused on preparation of user-friendly summaries of systematic reviews of health system evidence for policy-makers and stakeholders in low and middle income countries, and of SUPPORT summaries. Eight well prepared summaries addressing main public health problems in the Region resulted. WHO continued to support three grant schemes: research priorities in public health; improved programme implementation through embedded research (iPIER), offered in collaboration with the Alliance for Health Policy and Systems Research; and the tropical disease research small grants scheme.