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For more than 2 years, WHO’s Eastern Mediterranean Region (EMR), a very diverse yet dynamic region of 22 countries, has made significant efforts, pulling together all its resources, to manage COVID-19 pandemic and contain its massive impact on health systems, economies and societies. By end of September 2022, the region had reported more than 23 million COVID-19 cases and over 348 000 associated deaths (case fatality ratio, CFR 1.5%).1 Overall, 46% of Region’s total population is fully vaccinated.
Being home to multiple protracted emergencies, vulnerable economies and fragile health systems, EMR response to this ‘pandemic of century’ can be summarised as complex, diverse, challenging yet largely effective. The region has learnt several lessons from this pandemic.2–5 The pandemic experience has uncovered gaps in overall capacity for preparedness and response to emergencies, but more visibly exposed weaknesses in health systems capacities and health infrastructure. The pandemic has resulted in noticeable delays to reach the health-related Sustainable Development Goals (SDGs) targets such as the universal health coverage (UHC).6 7
As we see the pandemic declining, there is an urgent need to take stock of pandemic response and chart an action agenda to revitalise momentum towards realisation of EMR Vision 2023, an ambitious agenda adopted in 2018, which guides the work of the WHO in EMR.8 This will facilitate fast forwarding recovery and rebuilding for a healthier and better prepared EMR by 2030, that is, the year to reach United Nations (UN) set SDGs to which all countries have made a commitment.
Evolution of COVID-19 pandemic and public health response
The EMR represents 3.8% of the COVID-19 cases and 5.3% of the deaths reported globally (figure 1).1 To date, the largest number of confirmed cases in the region were reported from the Islamic Republic of Iran, followed by Iraq, Jordan, Pakistan, Lebanon and Morocco. The Islamic Republic of Iran reported the highest number of deaths due to COVID-19, followed by Pakistan, Tunisia, Iraq, Egypt and Morocco. However, some of the region’s fragile or conflict affected countries, such as Afghanistan, Somalia, Sudan, the Syrian Arab Republic and Yemen, recorded the highest CFRs in the region, indicating, likely, less testing and limited access to optimal clinical management.
Weekly distribution of COVID-19 cases and case fatality ratio (CFR) in the Eastern Mediterranean Region, week 5 of 2020 to week 36 of 2022.
The EMR response to the pandemic remains unique compared with other WHO regions. Here, drivers of transmission have included mass gatherings such as religious gatherings, fragility and active conflicts, labour migration, variations in enforcement of travel restriction measures, and country demographics. With 9 major humanitarian emergencies, 102 million people needing humanitarian assistance (which is 37% of the global total) and 32.3 million people forcibly displaced,9 the region, understandably, had a lot to tackle besides the pandemic. Diversity of context also resulted in varying levels of implementation and adherence to public health and social measures among countries.
In recent months several countries, using expert missions from WHO, have conducted intra-action reviews with an aim to review pandemic response, documenting what worked, what did not and identifying ways for improvement. The reviews provide valuable information on several fronts to enhance ongoing response to the pandemic and simultaneously enhance preparedness, that is, need for multisectoral coordination and better, overall, governance, enhanced surveillance, integrated and digitised information systems to provide basis for evidence-informed decisions, better management of supplies/supply chains and necessity for better mechanisms for community engagement and communications.
The pandemic has highlighted the importance of the political and health leadership ensuring sustained investments in health emergency preparedness, as well as maintaining strong regional and global collaborations.10 Coordinated by WHO, the ministerial group on COVID-19 worked to promote information sharing and collaborative regional action. Countries with efficient governance structures and commitment from the highest levels of government managed to successfully limit societal impact and move towards pandemic control. However, the high turnover of political leaders such as ministers of health and public health workforce was observed in several countries.
The response efforts in most countries were based on inclusivity, where vulnerable and at-risk populations were prioritised, and migrants, refugees and internally displaced people were provided access to diagnostics, therapeutics and vaccination. Rapid scale up was seen in testing capacities across the region with more than 600 national and subnational laboratories and 15 countries performing sequencing. However, testing and reporting patterns varied significantly across 22 countries. Furthermore, lack of harmonised strategies and limitations in information sharing raise questions on documentation of cases, deaths and other response indicators.
Early application of public health and social measures, suspension of mass gatherings at the beginning of the pandemic, such as the downsizing and suspension of annual Muslim pilgrimage of Hajj and Umrah, was seen as appreciable measures of regional and global significance. The existing systems and emergency management expertise gained through influenza sentinel surveillance and preparedness for Middle East respiratory syndrome since 2012 outbreak was effectively utilised in COVID-19 response. Countries such as those in Gulf Cooperation Council followed by most middle-income countries performed well in vaccinating populations. Shortage of vaccines, however, was observed due to the limited supply of vaccines through COVAX mechanisms, high global demand and inequity among countries. Fragile and conflict vulnerable affected (FCV) countries such as Afghanistan, Iraq, Libya, Somalia, Sudan, the Syrian Arab Republic and Yemen, until September 2022, were yet to reach 20% of full vaccination coverage for their populations.
Beyond COVID-19 for a healthier, resilient future
While we pass through fall 2022 and though the COVID-19 pandemic remains a concern, we are starting to see signs of recovery. WHO has updated its guidance for countries in view of the need to reduce the circulation of the SARS-CoV-2 virus by protecting individuals, especially vulnerable individuals and to prevent, diagnose and treat COVID-19 to reduce deaths, disease and long-term consequences.11 Similarly, to the rest of the world, number of COVID-19 cases have been declining in EMR, as are related hospital admissions and fatalities. One of the top priorities in the region is to increase vaccination coverage, as 54% of population remains unvaccinated. There are low vaccination rates in some countries and significant differences in vaccination coverage exist between high-income and low-income countries. At this point, mobilising collective efforts to increase COVID-19 vaccine coverage in the region is required, so that all countries could reach at least 40% coverage and prevent additional morbidity and mortality in the event another COVID-19 wave hits the world.
As we move out of the COVID-19 pandemic, we need to prepare for the next major disease outbreak based on past 20 years trend of increasing frequency of outbreaks of emerging and re-emerging infectious diseases. Factors such as climate change and conflict are further exacerbating the complexity of disease prevention and control landscape particularly in EMR. Moving on, countries in the region need to invest in building resilient health systems that can deliver essential health services without interruption to ensure UHC and withstand future emergencies. This calls for a paradigm shift in health systems thinking and preparedness for emergencies. Before COVID-19 pandemic, Vision 2023 had identified advancing UHC and enhancing emergency preparedness among four strategic priorities for health and development in the Region,8 the pandemic has aptly reinforced the wisdom behind this prioritization.
WHO Regional Office for the Eastern Mediterranean (EMRO) together with ministries of health and partner organisations, is spearheading efforts to redefine the agenda for healthier and resilient future in the region. A package of seven regional priorities and accompanying plan of action was presented to the 69th session of the Regional Committee for the Eastern Mediterranean, annual gathering of Ministers of health and stakeholders, which was held in Cairo during October 2022. Figure 2 demonstrates a theory of change to guide regional and national health systems in building resilient health systems towards UHC and health security in the region.
Theory of change to guide regional and national health systems in building resilient health systems towards UHC and health security in EMR. EMR, Eastern Mediterranean Region; UHC, universal health coverage.
The suggested strategic priorities are set around the premise that UHC and health security are two sides of the same coin. The priority set includes strengthening health emergency and disaster risk management, optimising ministries of health and public health institutions, promoting primary care, strengthening health workforce, promoting financial protection and equity, increasing access to medicine, vaccines and health products and fostering integrated approach in policy planning and execution for resilient health systems. We believe that to effectively realise these priorities, action is needed on several fronts by Governments, Ministries of health, WHO, partner organisations and communities. The priorities draw lessons from pandemic response and inspiration from the EMR 2023 vision which is calling for solidarity and action, and the SDGs agenda. For example, more than 23 global reviews of the COVID-19 response have identified gaps and provided recommendations to strengthen systems and enhance preparedness (figure 3).12 Out of these reviews, majority recommendations pertain to leadership and governance, followed by systems, tools, financing and equity. Action agenda for healthier and resilient EMR pragmatically absorbs global recommendations with regional adaptation.
Mass vaccination campaign site in Baghdad, Iraq, November 2021. WHO Iraq/Mustafa Altamimi.
Epidemic and pandemic facilitating pathogens flourish in settings of fragility, disorder as we saw during COVID-19 pandemic.13 The conditions in EMR countries, particularly those facing FCV, provide ideal environment for disease outbreaks, epidemics to potentially thrive and pandemics to escalate. Building effective systems for UHC and health security require non-traditional investment such as in One Health, digital health and health and well-being agenda. During the 69th Regional Committee, WHO, ministers and stakeholders agreed to application of One Health approach in countries through tailored implementation, informed by joint risk assessment and prioritisation. It is critical to improve accessibility, quality, efficiency and cost-effectiveness of national health systems, enhancing healthcare delivery and systems through seamless connectivity and access to health information. A regional strategy on digital health was adopted. Governments have a responsibility for the health of their people, which can only be fulfilled by the provision of adequate health and social measures through a whole-of-government, whole-of-society approach. The Regional Committee also adopted a Framework on Well-being and Health Promotion with the premise that multisectoral action on the social, environmental, political and other determinants of health is essential to create inclusive, equitable, economically productive, healthy societies and foster well-being.
COVID-19 pandemic has shown that where sufficient resources, cooperation and organisation were applied, it was managed more efficiently. Where disarray, division and poverty reign, it has thrived.13 Pursuing beyond COVID-19, a healthier and better prepared EMR requires a past wise and future conscious thinking. As part of this reflection and action endeavour by WHO EMRO, we are publishing a joint BMJ Global Health special issue series. We believe that application of learning in public health response gained during COVID-19 will not only facilitate ending the acute phase of the ongoing pandemic but will also strengthen our resolve to achieve Health for All by All and prepare countries for possible pandemics to come.
Data availability statement
Data is freely accessible through WHO website.
Ethics statements
Patient consent for publication
Acknowledgments
Authors would like to acknowledge Wasiq Khan, Team Lead WHO Health Emergencies Programme and Victoria Belorgeot, Consultant
WHO Health Emergencies Programme for review of this manuscript.
Footnotes
Twitter @DrRanaHajjeh
Contributors All authors equally contributed to writing this editorial.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.