Background The COVID-19 pandemic has significantly disrupted health systems in the Eastern Mediterranean Region (WHO-EMRO), where over half of the countries are affected by armed conflict. Active humanitarian and refugee crises have led to mass population displacement and increased health system fragility. This has exacerbated pre-existing resource gaps and increased competition for meager resources. With large proportions of vulnerable populations - refugees, migrants, and internally displaced people (IDPs) - their explicit consideration in planning documents is critical if equitable priority setting is to be realized during the pandemic. We examine what and how priority setting (PS) was included in national COVID-19 pandemic plans within the region.

Methods An analysis of COVID-19 pandemic response and preparedness planning documents from a sample of twelve purposively selected countries in WHO-EMRO. We assessed the degree to which documented PS processes adhere to twenty established quality indicators of effective PS from Kapiriri & Martin’s framework.

Results While all reviewed plans addressed some aspect of PS, none included all quality parameters. Yemen’s plan included the most quality parameters (12), while Egypt’s addressed the least (4). Publicity of priorities was common to all plans. The next mostly commonly identified parameter was use of evidence to guide planning and PS. When considering equity as a PS criterion, despite the high concentration of refugees, migrant, and IDPs in the region, only a quarter of the plans prioritized these populations.

Discussion When setting priorities in health emergencies, context is paramount. In areas experiencing conflict and crisis, PS can be an undemocratic and challenging process. Health system fragmentation is key contributor to COVID-19 inequities experienced across the EMRO region. Limited prioritization of vulnerable groups like refugees, migrant, and IDPs in planning documents, will have long-term health implications and exacerbate the disproportionate burden of COVID illness and death for these groups.