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Abstract
National public health institutes (NPHIs) are crucial to the effectiveness of public health systems, including delivering essential public health functions and generating evidence for national health policies, strategies and plans. Currently, there is a significant lack of information regarding NPHI or NPHI-like organisations in Eastern Mediterranean Region (EMR) countries, including how they fit into their broader health systems governance landscape. NPHIs exist in 12 out of 22 EMR countries, yet there is no official International Association of National Public Health Institutes (IANPHI) regional network for the EMR, despite established IANPHI networks in four other regions. In 2022, the WHO’s Eastern Mediterranean Regional Office led a study comprising an online survey and key informant interviews, which synthesised expert insights and summarised recommendations to strengthen the health systems governance-related role of NPHIs in EMR countries. Study participants included current and former high-level representatives of NPHIs, the government (eg, Ministries of Health, health regulatory authorities), multilateral organisations or non-governmental organisations focusing on health, and others identified as senior health systems governance experts from EMR. Insights and recommendations from experts varied widely, but there were also many common elements and overlaps. These included the need for enhancing NPHI functionalities and collaborative efforts with the public health sector (eg, Ministry of Health, Health Council) in health policy and decision-making formulation and implementation. This, in turn, requires advancing NPHI’s fit-for-purpose and sustainable governance and financing arrangements, improving the accessibility and transparency of health data for NPHIs, strengthening engagement and collaboration between NPHIs and other health system actors (including the private sector), and promoting a more prominent role for NPHIs in the development and implementation of public health-related policies and legislation. While many excellent insights and thoughtful strategic guidance are provided, further adaptation may be needed to implement the proposed recommendations in different EMR country contexts going forward.
- health policies and all other topics
- health policy
- public health
- COVID-19
- health services research
Data availability statement
Data are available on reasonable request. All data from the survey and key informant interviews is available on reasonable request. As per the research protocol, any organisations or individuals named in interview or survey data, will be removed and replaced with an anonymised term.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
National public health institutes (NPHIs) are essential components of robust health systems, whose roles, responsibilities and capacities were severely tested during the COVID-19 pandemic.
There is very little information available about NPHIs across the Eastern Mediterranean Region (EMR), particularly how they are mandated and function in EMR countries.
WHAT THIS STUDY ADDS
This study provides insights from EMR health systems experts from the field, including the situation during the COVID-19 pandemic, regarding NPHI contributions within their countries’ health systems.
Additionally, recommendations for establishing and strengthening the role of NPHIs within and across EMR country health systems are synthesised and shared.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
In the wake of the COVID-19 pandemic, this study provides evidence and recomendations to guide decision-makers in EMR countries on how to promote and enhance NPHI roles and responsibilities within their country contexts going forward.
Introduction
The COVID-19 pandemic has heavily burdened the health systems worldwide and placed many national institutions responsible for public health under severe stress.1–3 In many countries, this is the national public health institute (NPHI), which is defined by the International Association of National Public Health Institutes (IANPHI) as ‘a government agency or closely networked group of agencies that provides science-based leadership, expertise and coordination for a country’s public health activities’.4 5 NPHIs are a central component of strong public health systems, crucial in delivering essential public health functions (EPHFs) and generating evidence for health policies, strategies and plans.5 6
The Eastern Mediterranean Region (EMR) comprises 22 countries (ie, 21 Member States and the occupied Palestinian territory) and is home to approximately 9% of the world population.7 Prior to the outbreak of COVID-19, many EMR countries were already experiencing protracted humanitarian crises leading to the forced displacement of millions, and the reemergence of vaccine-preventable diseases resulting in further weakening of health systems.7 According to the IANPHI, there are official NPHIs (referred to as members) in 12 of the 22 EMR countries (ie, Afghanistan, Islamic Republic of Iran, Jordan, Libya, Morocco, occupied Palestinian territory, Pakistan, Saudi Arabia, Somalia, Sudan, Syria and Tunisia), including 3 in Morocco.8 IANPHI has four regional networks (ie, Africa, Asia, Europe, and Latin America and the Caribbean), but there is no IANPHI regional network for the EMR.9 Despite basic information about the official NPHIs in EMR countries being available on the IANPHI’s website, there is no information on their mandates, roles and responsibilities and governance arrangements. Moreover, current empirical evidence suggests a significant lack of knowledge regarding the governance arrangements of official NPHIs or NPHI-like organisations in EMR countries and how they fit into the broader health systems governance landscape.6 10 11 For the purpose of this study, NPHIs are classified by their IANPHI membership, while NPHI-like organisations are those that closely align with the IANPHI’s standardised NPHI definition and core attributions and functions, without having official IANPHI membership.
In 2022, the WHO’s Regional Office for the Eastern Mediterranean (WHO/EMRO) finalised a regional health systems governance mapping exercise: ‘Health Systems Governance Regional Review: Identifying Gaps, Bottlenecks and Suggested Way Forward in the Eastern Mediterranean Region’11. The review highlighted that more detailed information is needed about the health systems governance environments in EMR countries, including whether there is an official NPHI or NPHI-like organisation, as well as their related health governance arrangements, core functions and roles and responsibilities during the COVID-19 pandemic.11 Accordingly, an online survey and key informant interviews were conducted to explore options for strengthening the health systems governance-related role of NPHIs in EMR countries. Study participants included current and former high-level representatives of NPHIs, the government (eg, Ministries of Health, health regulatory authorities), multilateral organisations or non-governmental organisations focusing on health, and others identified as senior health systems governance experts from EMR.
The findings and the proposed strategic directions (online supplemental appendix 1) were shared and discussed at a WHO/EMRO-hosted Health Systems Governance Regional Technical Consultation on 25-28 October 202112; and an Inter-country Meeting on Strengthening Health Systems Governance to Advance Universal Health Coverage and Health Security in the Eastern Mediterranean Region on 28-30 November 2022.13 A review of WHO/EMRO’s EPHF list was also completed in 2022 to analyse gaps in alignment with key global health priorities, and account for country experiences during the COVID-19 pandemic.14
Supplemental material
This paper summarises the governance arrangements, core functions and roles and responsibilities (including during the COVID-19 pandemic) for NPHIs in EMR countries. It provides expert insights and summary recommendations to strengthen NPHIs’ role in health systems governance in EMR countries, including the delivery of EPHFs and the generation of evidence for health policies, strategies and plans going forward.
Methods
The study includes a survey and key informant interviews. The survey questions were based on the IANPHI’s NPHI Core Functions and Attributes,5 adapted from the Staged Development Tool,15 and applied a COVID-19 lens. This was meant to identify and fill gaps in the WHO/EMRO’s understanding of the health systems governance landscape, specifically the governance arrangements, functions, and roles and responsibilities of NPHIs in EMR countries. In addition, representatives from the IANPHI and Eastern Mediterranean Public Health Network (EMPHNET) were consulted and involved in peer-reviewing the survey.
The analysed survey data were then used to inform the key informant interviews. The survey participants were NPHI representatives and other relevant EMR country health systems experts identified by WHO/EMRO, WHO Country Offices and the EMPHNET. The interviews’ key informants included a core group of NPHI representatives and other senior health systems experts from the survey participants. The key informant interviews aimed to validate the data collected in the survey, as well as provide additional understanding of the country contexts and NPHI-relevant governance arrangements, functions, and roles and responsibilities during the COVID-19 pandemic.
The survey (online supplemental appendix 2) was uploaded to the SurveyMonkey platform for participants’ convenience. Key informant interviews were conducted by the WHO/EMRO Governance of Health Systems (GHS) team via Microsoft Teams using a semistructured interview guide (online supplemental appendix 3).
Supplemental material
Supplemental material
The following steps were completed for this NPHI study:
Based on the preliminary NPHI-relevant evidence review, a detailed research protocol (including a survey and an interview guide) was prepared and submitted to the WHO/EMRO Ethical Review Committee in November 2021. Full ethical clearance was received in December 2021.
Survey
The survey was based on the NPHI Core Functions and Attributes and adapted from the Staged Development Tool, using a COVID-19 lens.
Survey participants were identified by the WHO/EMRO GHS team, in collaboration with the IANPHI and EMPHNET (selection process and criteria are detailed below).
The survey was shared virtually via SurveyMonkey with selected participants. Participants were required to sign an informed consent (online supplemental appendix 4) before completing the survey.
Collected survey data were analysed and organised into pivot tables using Microsoft Excel. The results of the data analysis were also used to inform and adapt the key informant interviews.
Key informant interviews
The interview guide was developed as part of the detailed research protocol. It was adapted from survey questions to further investigate and get additional insights into the country contexts, as well as NPHI-relevant governance arrangements, functions, and roles and responsibilities during the COVID-19 pandemic.
Key informants for the interviews were identified and contacted through WHO/EMRO GHS team head (the selection process and criteria are detailed below). Key informants were provided with a participant information sheet explaining the study objectives, scope, methodology and time frame, and the implication for the informant (ie, what is expected of them). Informed consent was required to participate in the interview.
Interview data were coded and analysed using thematic analysis to identify patterns in the data, draw the most useful information and increase the study’s generalisability. This was ultimately summarised in an Excel document.
Summarised survey and key informant data were consolidated and further analysed.
Draft findings were shared with relevant health systems experts, WHO/EMRO technical units and WHO Country Office focal points to validate and endorse.
Supplemental material
Patient and public involvement
No patients were involved in this study. Study participants were identified health systems experts and key informants residing, working or having previously worked in EMR countries. More information about the study participants, including the selection process, is described below.
Study participant selection criteria
Individuals were invited to participate in the survey and/or key informant interviews if they reside, work or have worked in EMR countries, including for a NPHI, the government (eg, ministries of health, health regulatory authorities), multilateral organisations or NGOs focusing on health, or are identified as senior health systems governance experts. These individuals had proven experiential knowledge, through their positions, of the health systems governance environments in EMR countries, especially during the COVID-19 pandemic. In addition, all study participants had to have the ability to speak English, Arabic or French. Lastly, all participants had to give informed consent to have the information they provided included in the study.
Results
Survey
Overall, the online survey link was shared with 55 EMR health systems experts from 12 January 2022 to 17 February 2022. 29 experts completed the survey, from 10 of the 22 EMR countries. All completed surveys were analysed using Excel, and responses were organised into pivot tables where possible. Below is a summary of the synthesised results, arranged in following key thematic areas.
Mandate, core functions and attributes
The mandates of NPHIs in EMR countries vary widely according to respondents, ranging from being responsible for the coordinated efforts in responding to all public health issues in a country to simply advising the government and the health sector on public health issues. However, in a general sense, all NPHIs are mandated to be engaged in and contribute to the public health activities in their country in some form or another. Given the varied nature of the reported NPHIs mandates, the NPHI core functions and attributes are also quite mixed. Figures 1 and 2 provide an overview of the survey findings related to NPHI’s core functions and relevant attributes in the EMR.
NPHIs core functions: roles and responsibilities. NPHI, national public health institute.
NPHI core attributes: roles and responsibilities. NPHI, national public health institute.
Governance arrangements and financing
The NPHI-related governance arrangements are quite diverse across the EMR. For example, 12/29 expert respondents from this study classified the NPHI in their country as having an autonomous government structure, 2/29 described their NPHI as having an autonomous non-governmental structure that either is transitioning to be managed by the government or is operating closely with the government/MOH. In comparison, 15/29 described the NPHI in their country as ‘other’, while specifying it is part of the MOH. For the NPHI’s official affiliation to the MOH in their country, 18/29 respondents reported the NPHI’s functions are completely within the MOH governance structure, 6/29 reported its functions and structure are independent of the MOH, while 4/29 reported its structure is within the MOH governance structure but it functions independently (1 respondent reported none of the above and did not specify). See figure 3 for an overview. For NPHI financing arrangements, only 15/29 respondents reported that NPHIs in their countries are funded adequately through sustainable domestic financing sources to fulfil their mandate.
NPHI affiliation with the Ministry of Health (MOH). NPHI, national public health institute.
Health data/information and collaboration
From a health data and information access perspective, 18/29 respondents reported that NPHIs have the authority to access all relevant health information and data collected outside of their institute. Regarding the authority to share analysed public health information and data with different stakeholders, respondents reported the NPHI can share with other government agencies (23/29), parliamentarians (12/29), academia (21/29) and the general public (19/29). Four respondents reported that the NPHI in their country cannot share information with any of the aforementioned stakeholders. In terms of NPHI collaboration with the private sector, 15/29 respondent experts reported that NPHIs in their countries engage with the private health sector (including profit or non-profit).
Health policy and legislation
Only 8/29 survey respondents reported that the NPHI in their country have the authority to contribute to and/or enforce public health-related legislation related to issues such as COVID-19 mask-wearing, smoke-free public places and more. Respondents from some EMR countries added that the NPHI does not directly propose or enforce policies or legislation, but rather they contribute to legislation and/or policies through participation on committees or in an advisory capacity to the MOH.
Role during the COVID-19 pandemic
Survey participants described various roles regarding the NPHI in their country during the COVID-19 pandemic. However, public health research, surveillance and laboratory activities, risk communications and education, and the provision of technical support and advice to inform public health guidance in their countries are the most described roles for NPHIs during COVID-19. Moreover, most survey respondents from the participating EMR countries also reported the inclusion of the NPHI in high-level committees aimed at guiding and coordinating the COVID-19 response in their countries.
Key informant interviews
35 health systems experts were invited to participate in key informant interviews from 23 February 2022 to 3 April 2022. Ultimately, 20 key informants from 12 EMR countries took part in the interviews. All key informant interviews were recorded and transcribed, and the data were analysed through thematic analysis. In line with the survey results, interview data was analysed and organised in similar subcategories as above to ensure consistency. Themes in each subsection are introduced below and further distilled in the discussion.
Mandate, core functions and attributes
The interviews with experts yielded similar results to that of the survey with regard to the varying mandates of NPHIs in the region. Experts from all 12 participating EMR countries reported various mandates, including, but not limited to, the generation of public health research, provision of training for human resources development, public health surveillance, and health promotion and prevention. For example, the most common mandates identified are ‘conducting of public health research’ and the ‘provision of training for human resources development’, as experts in 9/12 EMR countries have identified either both or one function(s) as the primary mandate(s) of the NPHIs in their countries. In comparison, the NPHI in Iraq is reported to have an overarching mandate of governing and coordinating action on all public health activities in the country. In addition, in the Jordanian context, the MOH is registered as an NPHI.
The mandate (of the NPHI in the occupied Palestinian territory) is to provide evidence-based support…for policy-makers. Since the area of focus (of the NPHI) is health, the main partner is MOH…the NPHI is also hosted by MOH physically. The role (of the NPHI) is to provide evidence supporting national registries, and surveillance systems for national health information, as well as providing applied research.
—Key informant from the occupied Palestinian territory
Governance arrangements and financing
The experts interviewed delineated similar NPHIs governance arrangements to that of the survey findings. For instance, experts in 9/12 EMR countries classified NPHIs as part of the organisational structure of the MOH, while experts in 1/12 EMR countries classified NPHI as an independent government structure that is affiliated with the MOH. However, in the context of the occupied Palestinian territory, NPHI is classified as an independent non-governmental structure operated by WHO on a temporary basis until national capacities are built. However, the institute’s leadership is planned to be transferred to the government (ie, the director of the NPHI will be the Prime Minister, whereas the Minister of Health will be the Director of the Board). The NPHI-like organisation in Egypt also has a different affiliation since it is classified as part of the Ministry of Higher Education (MOHE). As for the NPHIs’ official affiliation to the MOH in their countries, experts in 9/12 countries reported that the NPHI’s functions are completely within the MOH governance structure, whereas expert(s) in 1/12 EMR countries reported that some of the typical NPHI’s functions are divided between the MOH (conducting of public health research and delivery of training for human resources development) and the MOHE (setting training curriculum).
The NIHR is affiliated to the MOH, but it is not part of the MOH. It is an independent body that carries out activities which are dictated from the MOH. In terms of functions, mission and activities carried out by the institute, they are totally dependent on MOH. All funds for the NIHR come from MOH and all activities are conducted at the request of MOH. However, as for the structure of NIHR, it is somehow an independent body. It has an independent board, and it has independent authority to make contracts, etc.
- Key informant from Islamic Republic of Iran
Regarding financing arrangements, experts from 6/12 EMR countries reported that their NPHI funding is not sustainable or enough to fulfil its mandate, roles and responsibilities. Included among these EMR countries are those in conflict, such as Yemen and Sudan, where it was reported that there is little to no available national funding to support public health programmes. In addition, two countries facing major economic issues (ie, Lebanon and Afghanistan) report extreme scarcity of sustainable funds for their NPHIs. On the other hand, experts from 6 of the 12 EMR countries report they have sufficient funding to fulfil their mandate; however, a maldistribution and misuse of some funds are reported for two of these countries. Key informants reported in 9/12 EMR countries that their funds come directly from the MOH or the MOF (via the MOH). Nearly all EMR countries were reported to have received supplementary funding from international organisations (ie, World Bank, WHO, UNICEF, European Investment Bank), NGOs, other international donors (ie, Norwegian Government) or international and national grants.
There is a high level of scarcity of funds right now. Sometimes there is no water in the building (where the NPHI is located), sometimes no electricity, and other things. Especially in the last 7 months issues have been piling up. So, yes, financing is critical issue for (the) NPHI both nationally and internationally.
- Key informant from Afghanistan
Health data/information
In terms of access to health data and information, experts in 8/12 EMR countries reported that NPHIs have the authority to access all relevant health information and data collected outside of their institute. In comparison, experts in 2/12 EMR countries delineated that NPHIs in their countries are required to submit official requests to the MOH to access relevant health information and data collected outside of their institute. As for the authority to share public health information and data collected within their institute with relevant stakeholders, experts in 3/12 EMR countries elaborated that NPHIs share their information and data with stakeholders on receiving official requests, whereas experts in 5/12 EMR countries reported that NPHIs share some of their information and data on online dashboards or in published reports for public access, but require official requests by relevant stakeholders to access more in-depth data and information. It is worth mentioning that in the Moroccan context, experts outlined that the NPHI shares all its information and data with relevant stakeholders but did not identify the modalities for data sharing. Also, in the Yemeni context, experts elaborated that the NPHI shares its information and data with an existing health surveillance system which decides the modalities of data sharing and usage.
Our institution has accessibility to all data, even if they are confidential because we are part of the Ministry of Health. We use this data to provide evidence, and decision makers can make a decision based on evidence.
- Key Informant from Morocco
Collaboration
The delegation of authority from the federal/national level to the governorate/province level varied across the 12 EMR countries participating in the in-depth interviews. Experts in 3/12 EMR countries revealed that NPHIs have no direct relations to subnational health units/departments in the different governorates/provinces; instead, central-local relations are coordinated through a directorate/department at the MOH or a provincial coordination unit/department. In comparison, experts in 6/12 EMR countries elaborated that NPHIs have subnational offices or focal points at the governorate/province level to facilitate the coordination of national-level activities. Nevertheless, in the context of countries affected by war and humanitarian crises like the occupied Palestinian territory and Yemen, NPHIs’ delegation of authority from central to local levels is limited due to political fragmentation and internal divisions. The NPHI in Yemen, being affiliated with the MOH in Sana’a, has focal points only within public health departments in the country’s northern governorates. As for the NPHI in the occupied Palestinian territory, it is located within WHO offices in the West Bank and the Gaza Strip in unit-like structures, with each setting having its own priorities based on the area’s specific challenges. It is not clear, however, whether these two-unit structures will be governed as separate entities or as one on the planned transition in NPHI leadership to the government. Moreover, in describing NPHIs' multisectoral efforts, experts in 1/12 EMR countries reported that the NPHI’s collaboration with other ministries is coordinated by the MOH, while experts in 8/12 EMR countries reported that NPHIs directly collaborate with other ministries, and experts in 2/12 EMR countries outlined that NPHIs’ collaboration with other ministries is limited/constrained. With regard to NPHI collaboration with the private sector (profit or non-profit) in their countries, experts in 8/12 EMR countries reported that NPHIs engage with the private health sector. In comparison, experts in 4/12 EMR countries delineated that NHPIs do not engage with the private health sector. However, experts in three out of the aforementioned four EMR countries with NHPIs, that reportedly do not engage with the private health sector, demonstrated increased engagement of NPHIs in their countries with the private health sector (for profit) during the COVID-19 pandemic.
The Public Health Institute was working on a micro policy for health financing and family medicine, and they were pretty much championing and leading on the efforts, so they would reach out to, for example the Ministry of Social Development, the National Health Insurance Fund, and the Ministry of Education. So, they would actually reach out to these different ministries or entities or stakeholders independent of the Federal Minister of Health.
- Key Informant from Sudan
Experts from 11 EMR countries reported that the NPHI, or NPHI-like organisation contributes to public health policy formulation in their countries. This included in an advisory/support role to the MOH in 9/11 EMR countries, which, in turn, would propose the legislation more formally, or a leadership role (no information for Yemen on this question), or a higher-level role in 2/11 countries, which includes proposing legislation and policies directly and/or directly led ministerial committees for the formulation of public health policies. Key informants from 5/11 EMR countries reported that the NPHI played a more significant role in policy formulation during COVID-19, while 1/11 reported their role was non-existent. Overall, little information was known and subsequently provided by key informants regarding the monitoring or enforcement of public health legislation/policies.
NIH (National Institute for Health) does have power to propose policies and legislations, especially during COVID-19, but also for antimicrobial resistanace (AMR). Proposals are dependent on data, and this is a huge gap, not just from the health sector but from other related sectors as well. The process is that the Head of NIH meets with MOH (officially known as the Ministry of National Health Services Regulations and Coordination) and other ministers every month; he is assigned a health priority, or he proposes one (both ways) …therefore advise national MOH and the provinces for policies and legislation, not as implementers.
- Key Informant from Pakistan
Role during COVID-19 pandemic
Key informants in nearly every participating EMR countries reported that, during the COVID-19 pandemic, their NPHIs were involved in at least some health promotion and risk communications, public health surveillance (ie, supporting laboratories, disease testing, vaccines) and epidemiological data analysis, health policy and intervention research (including health technology assessment), and health workforce training. Most key informants reported that the NPHI in their country was part of a high-level public health-related committee specifically set up to coordinate COVID-19 public health activities and/or analyse and make recommendations (nationally and subnationally). At the very least, key informants from all 12 participating EMR countries reported the NPHI in their country was engaged during the decision-making process to contribute their technical expertise. However, key informants from at least four EMR countries (ie, Afghanistan, Morocco, Pakistan and Sudan) reported that the NPHI could have been better used to further support and guide the public health response to COVID-19. Interestingly, most EMR countries were forced into a closer working relationship with the private sector. This has helped many NPHIs recognise their value and even stated the intention to engage the private sector more regularly in the future beyond COVID-19.
One of the main institutes (referring to the NPHI) involved in the public health surveillance and response to COVID-19. It supported the preparation of the COVID-19 response plan and guided related public health strategies, such as testing strategies. In collaboration with surveillance units at governorate levels, it collected nationwide data on COVID-19, and pursued contact tracing. It implemented activities to strengthen COVID-19 surveillance including capacity building activities of staff. It implemented the first national household survey on COVID-19 infections. It was part of the nationwide COVID-19 response mechanism, which included all the different departments of MOH. It also played a role in the COVID-19 vaccination.
- Key Informant from Tunisia
Role going forward
While recommendations going forward for NPHIs or NPHI-like organisations did vary widely, several criteria are consistent throughout nearly all key informant responses (see table 1 below for summary recommendations). These included that the NPHI should be providing science-based guidance and support for the coordination of countries’ public health activities; fully assigned, empowered and legally supported to deliver all the NPHI core functions as outlined by the IANPHI; adequately and sustainably financed domestically, directly from Ministries of Finance (MOF); assigned a more considerable leadership and partnership management role for health-related stakeholders, particularly for health policy and legislation processes; designated a larger implementation and monitoring and evaluation role for public health activities; represented on all public health-related ministerial and parliamentary committees; and appointed additional responsibilities in regard to public health training and capacity-building of health professionals. Overall, there was general agreement that the NPHI should be autonomous, with key informants from 10/12 EMR countries expressing that the NPHI should be either fully autonomous or semiautonomous. Ultimately, key informants from nearly all EMR countries reported that there is considerable interest and political appetite to officially establish a NPHI or strengthen the role of existing NPHIs in their country.
NPHI summary recommendations from key informant interviews
There is a need for a national public health institute that can strengthen collaboration and coordination across the different health stakeholders and actors. This institute should be affiliated with MOH to ensure that its interventions are effective and timely. It should also work with NGOs. The mandate of this institute should be generating research, providing training, monitoring the epidemiological situation, proposing legislation, and engaging with regional level institutions and partners. The presence of a public health institute at a regional level can support public health efforts at a country level.
- Key informant from Yemen
Ideally governance and structural arrangements for the NPHI should include MOH, several ministries and other stakeholders, with leadership from the Prime Minister or higher authority. To create a committee like governing structure even.
- Key informant from Egypt
Discussion
Overall, the survey and key informant interviews provided many interesting expert insights into the NPHIs and NPHI-like organisations across the EMR, including their governance arrangements, functions, roles and responsibilities during the COVID-19 pandemic, and recommendations going forward. Using similar questions and well-aligned methods for the survey and key informant interviews allowed us to consistently identify a number of central themes to consider when establishing NPHIs or strengthening the role of existing NPHIs in EMR countries. In addition, having the key informant interviews allowed us to probe further and for EMR health systems governance experts from the field to provide deeper insights. Below we further discuss these expert insights and central themes for consideration, as well as the broader limitations of this study.
In both the survey and key informant interviews, it was found that the mandates of NPHIs in EMR countries varied significantly. The political contexts in different countries in the region, particularly those in emergencies, cause limitations regarding what the NPHI mandate can entail.16 While all NPHIs or NPHI-like organisations in the EMR contribute to the public health activities in their country, few, if any, meet all the NPHI core functions and attributes outlined by the IANPHI.5 A growing body of evidence also suggests the MOH’s assumed roles and responsibilities in EMR countries continue to expand. Hence, it makes the NPHI’s support of roles and responsibilities related to public health activities even more important.17–19 Furthermore, many countries worldwide are transitioning to more of a participatory health systems governance approach, where the MOH engages and empowers more relevant stakeholders to contribute to health policy and decision-making.20 21
The study participants clarified that many governance and financing arrangements are not fit for purpose for NPHIs, or NPHI-like organisations, to fulfil their mandate. This was particularly true during the COVID-19 pandemic, but also more generally when comparing the existing arrangements to the IANPHI definition of an NPHI. Moreover, serious infrastructure and unsustainable funding issues also persist for NPHIs and NPHI-like organisations in many EMR countries, causing additional risks and potential threats to public health going forward. Having fit-for-purpose governance and financing arrangements for health system actors, including NPHIs, is crucial to ensure their most effective performance and sustainability.22 ,23 23 24 Additionally, in this study, some subgroups emerged with similar NPHI internal governance arrangements, including emergency countries such as Yemen and the occupied Palestinian territory, where there are essentially distinct NPHI units for different parts of the country due to geopolitical contexts. The situation in the occupied Palestinian territory is compounded by the fact that their NPHI is currently led by WHO, despite being intended to become a governmental organisation by law. However, by 1 January 2025, full leadership of the NPHI in the occupied Palestinian territory will ultimately transition to the government.
Study participants often described relevant health data and information as not accessible or freely shared. Experts also reported considerable data fragmentation regarding where health data and information is stored (ie, among several different public sector entities, within the private health sector in some EMR countries). In addition, public health data and information need to be more transparent and readily available for stakeholders, including the general public. Data and information are essential to evidence-based health decision-making and building stronger stakeholder partnerships, particularly in emergencies.25 26 Furthermore, access to official information is critical for combating misinformation and disinformation, as exemplified in the COVID-19 pandemic and related infodemic.27
Collaboration and meaningful engagement with relevant health systems stakeholders, including the private health sector, need to be strengthened overall. Experts reported the private sector was a key stakeholder contributing to the COVID-19 response, despite some reporting no private sector engagement prior to the pandemic. However, this enhanced collaboration needs to also ensure that all health system actors, including the private sector, are held accountable for their actions to protect citizens and advance the public–private sector relationship going forward.28 Institutionalising the participation of all relevant stakeholders, including the private sector, is essential to building stronger partnerships and enhancing the sustainability of the health decision-making process overall.29 Moreover, there could also be more collaboration between the NPHIs within the region. The establishment of an Eastern Mediterranean regional network of NPHIs, supported by the IANPHI, could foster NPHI collaboration across the EMR to share expertise, experiences and best practices.9
Experts from most EMR countries reported NPHIs as playing either advisory or support roles for the MOH in the proposal of health policies and legislation. NPHIs in two countries are even reported to have a direct role in proposing legislation and policies and/or directly leading ministerial committees for the formulation of public health policies (ie, Iraq and Pakistan). As NPHIs should be mandated to provide science-based leadership, expertise and coordination for a country’s public health activities, they ought to be engaged and contribute to the health policy and legislative process.5 6 Furthermore, evidence shows that NPHIs are key in generating evidence for health policies, which are central to national health and socioeconomic development.5 6
The COVID-19 pandemic overwhelmed even the most mature health systems. In 2021, The Independent Panel for Pandemic Preparedness and Response found that countries with the most success in managing the disease have strong governance systems, employed whole-of-government and whole-of-society approaches, and ensured to include active cooperation of the experts and expert organisations.30 Survey and key informant interview participants from most EMR countries report that the NPHI or NPHI-like organisation in their countries played a contributing role during COVID-19. Nevertheless, they also stated that these organisations were not used well enough during the pandemic and that they could have played more of a technical leadership role. These insights are great lessons learnt, and further show the way forward in many countries is to ensure that roles and responsibilities are assigned to appropriate actors, who are in turn empowered to fulfil these roles.
Recommendations from key informant experts had a lot of variation, but there were also a lot of common themes which aligned well with the IANPHI’s NPHI core functions and attributes. These commonalities include the NPHI being a fully empowered, autonomous and sustainably funded provider of science-based guidance and support for countries’ public health activities. This also included an expanded NPHI leadership and partnership management role in engaging health-related stakeholders. Experts envisioned NPHIs in the EMR would also be more prominently engaged in an advisory role for the health policy and legislation processes, represented on all public health-relevant ministerial and parliamentary committees, and actively involved in the implementation and monitoring and evaluation of public health activities. Additional recommended responsibilities for NPHIs in the EMR included a more prominent role in the provision of public health training and capacity-building of their country’s health workforce. The need for an NPHI with these aforementioned functions is crucial for effective public health system performance.6 10 In line with this, key informants from nearly all participating EMR countries felt strongly that there is significant interest and political support to establish a NPHI or enhance the role of the existing NPHI in their country. This political will is essential for the success of any proposed governance reforms and to improve public health outcomes in EMR countries.16
While this study produced many expert insights for NPHIs in the EMR, there were some limitations. Some survey respondents and key informants from EMR countries reported on more than one NPHI or NPHI-like organisations (ie, Morocco and Tunisia). Differences were tracked, but in some instances, it was difficult to conclude on a particular NPHI focus area for that country. Some survey respondents and key informants were from countries without an official NPHI and were asked to give their insights on the entity most closely resembling an NPHI (based on the IANPHI’s NPHI definition). Similarly, not all participating health systems governance experts worked directly for or with the NPHI or NPHI-like organisation they were providing insights on. In line with this, experts did not answer some questions fully or adequately, limiting the pool of responses for analysis. Lastly, there was a possibility for study participant selection bias as all survey and key informant interview invitees were identified by WHO/EMRO GHS team members, in collaboration with the IANPHI and EMPHNET. Despite these limitations, these study findings may provide a useful entry point to support the establishment and strengthening of NPHIs or NPHI-like organisations and networks in the EMR, as well as other countries and regions with similar contexts.
Conclusion
Understanding a country’s health systems governance environment, including how the public health activities are coordinated, is crucial when establishing or strengthening an existing NPHI. This study provides expert insights about existing NPHIs, or NPHI-like organisations, in EMR countries, including their governance arrangements, functions, roles and responsibilities during the COVID-19 pandemic and specific recommendations going forward. These include enhancing NPHI utilisation by MOHs to bolster support for public health activities, advancing fit-for-purpose and sustainable governance and financing arrangements, improving accessible and transparent health data, strengthening engagement and collaboration with all health system actors (including the private sector), as well as ensuring a more prominent role in the development and implementation of public health-related policies and legislation. Ultimately, most experts independently recommend NPHIs be an autonomous or semiautonomous governmental organisation, fully empowered to provide evidence-based guidance and support for public health activities in EMR countries.
More specific research examining the effectiveness of the different arrangements for each individual NPHI core function and attribute could be useful going forward (eg, which arrangements is most effective for data sharing in EMR countries?). Another key area for future research could be examining and identifying arrangements for the public sector which effectively engage and mobilise the private sector for strengthening universal health coverage and health security in countries. Furthermore, the links between this paper’s recommendations and health systems efficiencies and population health outcomes could also be researched further.
While the health system experts participating in this study provided many insights and thoughtful strategic guidance, some additional consultation is needed to reinforce the proposed recommendations informing WHO/EMRO NPHI strategic guidance and to strengthen its eventual implementation in different EMR country contexts. With a reportedly supportive political environment in most participating EMR countries, further technical consultation and operationalisation of strategic guidance have a strong possibility of being prioritised. Going forward, WHO/EMRO recognises the vital importance of NPHIs to provide evidence-based guidance and support for the delivery of EPHFs. Moreover, WHO/EMRO is committed to comprehensively working with EMR countries to help establish and strengthen existing NPHIs or NPHI-like organisations and networks, with a view to enhancing health systems governance and population health more broadly in their countries and at a regional level.
Data availability statement
Data are available on reasonable request. All data from the survey and key informant interviews is available on reasonable request. As per the research protocol, any organisations or individuals named in interview or survey data, will be removed and replaced with an anonymised term.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by WHO’s Eastern Mediterranean Regional Office Ethical Review Committee. Research protocol submitted in November 2021, with full ethical clearance received in December 2021. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We are very grateful for the contributions and candor of all survey and key informant interview participants. We would like to specifically recognise Sohel Saikat, Ahmed Mandil and Neil Squires for their comments and guidance on the research protocol and article. Lastly, we would like to thank colleagues from WHO Eastern Mediterranean Region Country Offices, the Eastern Mediterranean Public Health Network and the International Association of National Public Health Institutes for their coordination efforts throughout.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Handling editor Seye Abimbola
X @HalaAboutaleb, @sebvangilst, @AwadMATARIA
Contributors The research protocol was designed and cowritten by SvG and HA-T. All interviews were conducted by SvG and HA-T. All survey data collection and analysis was completed by SvG and reviewed by HA-T. All interview analysis was completed by SvG and NM under the supervision and guidance of HA-T. The paper was prepared and written by HA-T, SvG and NM collaboratively. AM made significant contributions to the paper's conception, design, and review process, offering valuable insights on data analysis and interpretation. HA-T is the guarantor of this work and, as such, accepts responsibility for the overall content and conduct of the study, had access to the data, and controlled the decision to publish.
Funding This work was supported by funding from WHO.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.