ANNUAL REPORT 2019 HEALTH FOR ALL WHO Library Cataloguing in Publication Data World Health Organization. Regional Office for the Eastern Mediterranean World Health Organization annual report 2019 WHO Country Office Lebanon: health for all / World Health Organization. Regional Office for the Eastern Mediterranean p. ISBN: 978-92-9022-320-7 ISBN: 978-92-9022-321-4 (online) 1. Delivery of Health Care 2. Universal Health Insurance 3. Population Health - Lebanon 4. Disaster Planning 5. Emergencies 6. Security Measures I. Title II. Regional Office for the Eastern Mediterranean (NLM Classification: WA 300) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited. 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Cover photos credit: WHO Lebanon Design: The Limelight Productions - www.limelightprod.com WHO LEBANON THANKS ITS DONORS FOR THEIR GENEROUS SUPPORT TO ITS ACTIVITIES IN 2019 (by alphabetical order) BMG German Funds Bureau of Population, Refugees, and Migration European Union Government of the State of Kuwait Kuwait Fund for Arab Economic Development The Global Fund to Fight AIDS, Tuberculosis and Malaria In 2019, Lebanon witnessed an increased rise in health and humanitarian needs. The ongoing political instability and insecurity, as well as the consequences of the protracted conflict in the neighbouring Syrian Arab Republic, have led to a further burdening of the health system in Lebanon. By the last quarter of 2019, Lebanon was facing an unprecedented economic and financial crisis, jeopardizing access to and availability of health services, and further impairing the coping capacities of already-vulnerable Lebanese and refugees. Unemployment rates grew enormously, threatening social stability. The year also witnessed an ongoing measles outbreak in the country and ended with the global threat of the coronavirus disease (COVID-19) outbreak in China by December. Nevertheless, 2019 was also marked by important achievements in public health in Lebanon. The country sustained its polio-free status, access to primary health care for vulnerable populations was maintained, health system strengthening interventions were accelerated, and the early warning and alert system was fully automated and expanded. For the first time in the country, data on causes of death were made available through the hospital-based births and deaths registry, and data on prevalence of antimicrobial resistance were also made available. Preparedness for chemical, biological and radionuclear hazards response was completed with the establishment of the fourth HAZMAT team in the South, after Beirut, North and Bekaa in previous years. Dr Iman Shankiti WHO Representative in Lebanon foreword Despite the social unrest that began in October 2019 following the financial crisis, the measles campaign was launched in December 2019. Critical interventions, such as the development of a barcode system, the automation of medications pricing, the introduction of people-centred care at the primary health care level and the generation of evidence for policy development through initiating a series of surveys and studies were accelerated in 2019. Thanks to the generous support of donors, the commitment of the Ministry of Public Health, and the valuable contribution of all health partners, WHO was able to provide the support needed to the health sector in spite of all the considerable challenges encountered in 2019. Against all the odds, Lebanon remains an example of health system resilience and continues to effectively deliver essential preventative and curative health care services to the community. 32 Annual Report 2019WHO Lebanon Country Office 1 700 people living with HIV continue to receive treatment from the National AIDS Program. WHO supported the development of standard operating procedures for the surveillance and management of ten diseases. Severe acute respiratory infection surveillance continues in eight sentinel sites. WHO engaged in the health systems development support through critical projects funded by EU Madad Fund, including: a barcode system for pharmaceutical products, an electronic medical records, and others. > 200 000 people are able to access safe, affordable and high-quality essential medications for the treatment of chronic conditions. 1 000 000 children aged between 6 months and 10 years were targeted by the national measles campaign. > 240 staff from 130 hospital laboratories across Lebanon were trained on enhancing the quality of microbiology laboratory data. ≈ 1 000 staff from 500 public schools were trained on how to report communicable diseases using the District Health Information System 2 (DHIS2) software. Person-centred palliative care services were established at three medical centres.2019 AT A GLANCE A road map for SDG 3 + Plan of action was developed in a participatory approach. 5 studies to generate information for policy support through the Policy Support Observatory were launched. PRIORITY AREA 1: HEALTH COVERAGE: DEVELOP HEALTH SYSTEMS TOWARDS UNIVERSAL HEALTH COVERAGE P. 18 PRIORITY AREA 2: PROTECT HEALTH: DEVELOP AND MAINTAIN EMERGENCY PREPAREDNESS AND HEALTH SECURITY P. 28 PRIORITY AREA 3: HEALTH PRIORITIES: IMPROVE HEALTH AND WELL-BEING ACROSS THE LIFE COURSE P. 34 ACCELERATING ACTION ON SDGS: THE SDG 3+ GLOBAL ACTION PLAN ROAD MAPP. 14 COUNTRY OVERVIEWP. 10 OVERVIEW OF FUNDINGP. 12 ENGAGING WITH YOUTH: A WORLD HEALTH ASSEMBLY SIMULATIONP. 15 WHO’S VISION AND MISSIONP.08 THE WAY FORWARDP. 45 CELEBRATING GLOBAL HEALTH DAYSP. 16 OPERATIONAL PRESENCEP. 13 ACRONYMS & ABBREVIATIONS AFP AMR AUB CCCL DHIS2 EU EWARS GPW IHR NCDs SDG WHO Acute Flaccid Paralysis Antimicrobial Resistance American University of Beirut Children’s Cancer Center of Lebanon District Health Information System version 2 European Union Early Warning, Alert and Response System General Programme of Work International Health Regulations Noncommunicable Diseases Sustainable Development Goal World Health Organization table of contents 76 Annual Report 2019WHO Lebanon Country Office who’s mission and vision WHO’s strategic direction for the next five years has been delineated in the Thirteenth General Programme of Work 2019–2023.1 GPW 13 is based on the Sustainable Development Goals (SDGs) and is structured around three key strategic priorities: • ensuring healthy lives and well-being for all at all ages; • achieving universal health coverage; • addressing health emergencies and promoting healthier populations. In turn, these priorities are linked to three bold targets: • one billion more people to benefit from universal health coverage; • one billion more people better protected from health emergencies; • one billion more people enjoying better health and well-being. Three strategic shifts support the key priorities: • stepping up leadership; • driving public health impact in every country; • focusing global public goods on impact. WHO is committed to ensuring gender equality, equity and rights-based approaches to health that enhance participation, build resilience and empower communities. 1 Thirteenth general programme of work 2019–2023. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/324775/WHO- PRP-18.1-eng.pdf, accessed 26 April 2020). ENSURING HEALTHY LIVES AND PROMOTING WELL-BEING FOR ALL AT ALL AGES BY: STRATEGIC PRIORITIES AND GOALS 1 BILLION more people benefitting from universal health coverage ACHIEVING UNIVERSAL HEALTH COVERAGE 1 BILLION more people better protected from health emergencies ADDRESSING HEALTH EMERGENCIES 1 BILLION more people enjoying better health and well-being PROMOTING HEALTHIER POPULATIONS MISSION KEEP THE WORLD SAFE PROMOTE HEALTH SERVE THE VULNERABLE 98 Annual Report 2019WHO Lebanon Country Office Source: Vital Data Observatory, Ministry of Public Heath (24 March 2020) Table 1. Maternal and neonatal mortality in Lebanon, 2019 Lebanese Non-Lebanese Total Maternal mortality ratio per 100 000 live births 6.1 23.7 13.8 Neonatal mortality rate per 1 000 live births 4.4 6.3 5.2 In 2019, the population of Lebanon was estimated to be around 6.7 million. The population includes: 4 485 389 Lebanese residents1country overview Unemployment rates before 2019 were estimated to be close to 30% and reached around 50% by the end of 2019. The United Nations estimated that in 2018 around 28.5% of Lebanese and around 68% of refugees were living below the poverty line.1 With the current deteriorating economic situation and fiscal crisis in the country, it is estimated that more than 70% of Lebanese could soon be living under the poverty line. The impact of the continuous exacerbation of the Syrian crisis on Lebanon’s socioeconomic and political stability remains heavy, as Lebanon continues to be the country with the highest per capita number of refugees worldwide. As a consequence, environmental degradation and the threat of outbreaks constitute significant health risks in Lebanon. The health profile of Lebanon is characterized by a high burden of noncommunicable diseases (NCDs), including cancers. NCDs remain the top cause of mortality in the population and contribute to a total of 91% of the health burden. Cardiovascular diseases comprise around half of this overall burden.2 Nevertheless, Lebanon remains in an epidemiological transition, with communicable diseases such as waterborne and vaccine-preventable diseases still prevalent. Despite the rise in the incidence rates of both tuberculosis and HIV, the country maintains a low prevalence for these two diseases. The improvements for mother and child health are maintained, while mental health needs are on the rise. 1 Population estimates based on the latest baseline data and age proportions available from the Central Administration of Statistics in addition to birth and death records available from the Ministry of Interior and Municipalities. 2 Operational data portal: refugee situations [website]. Geneva: United Nations High Commissioner for Refugees (UNHCR); 2019 (https://data2.unhcr.org/en/ situations/syria/location/71, accessed March 2020). 3 UN Lebanon annual report 2018: working together for a secure, stable and prosperous future. Beirut: United Nations Lebanon; 2019 (https://www.un.org.lb/library/ assets/Annual%20UN%20Lebanon%20Report%202018%20ENGLISH-123819.pdf, accessed 26 April 2020). 4 Noncommunicable diseases country profiles 2018 (Lebanon). Geneva: World Health Organization; 2018 (https://www.who.int/nmh/countries/lbn_en.pdf, accessed 24 April 2020). 914 648 registered Syrians2 ≈ 500 000 non-registered refugees ≈ 500 000 long-term Palestinian refugees ≈ 300 000 migrant workers from South-East Asia and North Africa The main population characteristics are summarized as follows: 1.4 Lebanese population growth rate 7.4 infant mortality rate per 1000 live births in 2018 25% of the Lebanese population is under 15 years of age 10% of the Lebanese population is older than 65 years of age Table 1 shows the maternal morality ratio and neonatal mortality rate in Lebanon in 2019. Lighting of the Baalbek Temple for the occasion of the world patient safety day. © WHO Lebanon / Y. Dghaidy 1110 Annual Report 2019WHO Lebanon Country Office OPERATIONAL PRESENCEOVERVIEW OF FUNDING Table 2 shows the funding for each respective area of work, while Table 3 gives a breakdown of the different funding sources. The total budget received for 2019 was US$ 10 017 134 WHO is the leading agency for public health within the United Nations system, with the primary role of directing and coordinating international health. In Lebanon, WHO is involved in ensuring that all persons residing within Lebanon have access to good quality health care. WHO’s main areas of work encompass: health system strengthening; promoting health through the life course; NCDs and communicable diseases; and preparedness, surveillance and response. WHO works with many partners including the Lebanese authorities, humanitarian and development partners, donors, nongovernmental organizations, academia, WHO collaborating centres and the private sector. The main objectives of WHO support are to: • lead coordination of the health sector response; • better position health in United Nations debates and decisions, and advocate for health in the humanitarian agenda; • provide support to strengthen the health system towards universal health coverage; • provide technical assistance on key public health issues; • provide timely, up-to-date information on health trends, health systems and needs and response; • prevent, detect and respond rapidly to infectious disease outbreaks. WHO Lebanon also provides operational support in technical expert missions as well as regional workshops: Table 3. Breakdown of funding sources Area of work Main donors HIV/AIDS The Global Fund (through the Middle East Response 2 grant) Health system strengthening and universal health coverage EU, through the EU Regional Trust Fund in response to the Syrian crisis (EU Madad Fund) European Commission Government of Japan Access to chronic medications EU, through the EU Regional Trust Fund in response to the Syrian crisis (EU Madad Fund) Bureau of Population, Refugees, and Migration Access to acute medications Government of Kuwait Antimicrobial resistance BMG German Funds Measles campaign Kuwait Fund for Arab Economic Development (KFAED) Area of work Funding (US$) Communicable disease prevention and control 1 785 325 NCDs and mental health prevention and control 280 424 Health promotion through the life course 154 422 Health system strengthening 859 357 Polio (special programme) 240 000 Operational support (corporate activities/enabling functions) 1 007 242 Pandemic influenza preparedness (special programme) 320 800 Emergency funding (including outbreak and crisis response) 5 369 564 Table 2. Funding per area of work 25 23 technical support missions to the country on different topics such as health governance, immunization, central public health laboratory, environmental health, waste management and others. regional workshops and missions on different topics such as health information systems, surveillance and outbreak response, environmental health, pharmaceuticals and others. 1312 Annual Report 2019WHO Lebanon Country Office WHO supported the University of Saint Joseph in organizing and hosting the first WHO World Health Assembly simulation in Lebanon and the Eastern Mediterranean Region. This unique initiative gathered 38 students from various universities across Lebanon to discuss pertinent issues in the field of global mental health. Students represented a range of different majors, including medical and health sciences, law and other areas of study. During the 3-day simulation exercise, the students took on the roles of delegates and showcased the use of their skills in the diplomacy roles of either a WHO Member State delegate, a nongovernmental organization representative or a press correspondent. The main goals of the simulation were to introduce a model of experience-based learning and student engagement in global health diplomacy, allowing students to develop leadership, public speaking, conflict resolution and debate skills. During the simulation, participants discussed different facets of mental health and suggested realistic resolutions. 1 Stronger collaboration, better health: global action plan for healthy lives and well-being for all. Geneva: World Health Organization; 2019 (https://www.who.int/ publications-detail/stronger-collaboration-better-health-global-action-plan-for-healthy-lives-and-well-being-for-all, accessed 26 April 2020). SDG 3 to “Ensure healthy lives and promote well-being for all at all ages” is critical for the achievement progress on the 2030 Agenda for Sustainable Development. SDG 3 is linked to almost 50 targets, referred to as the health- related SDG targets. In order to progress towards the health-related targets, WHO has coordinated a global initiative that gathers 12 organizations engaged in health, development and humanitarian response. The aim was to develop a global action plan for healthy lives and well-being for all1 to accelerate progress towards realizing universal health coverage and the health-related SDG targets. Lebanon is one of the countries where this initiative is being piloted. In 2019, WHO Lebanon conducted a series of meetings with health and development partners and an SDG 3+ road map was proposed, feeding into the Global Action Plan that was launched during the United Nations General Assembly high-level meetings in September 2019. ACCELERATING ACTION ON SDGS: THE SDG 3+ GLOBAL ACTION PLAN ROAD MAP ENGAGING WITH YOUTH: A WORLD HEALTH ASSEMBLY SIMULATION The plan is called, “Stronger Collaboration, Better Health” for a reason. Although collaboration is the path, impact is the destination. The release of this plan is the beginning, not the end, of that path. Dr Tedros Adhanom Ghebreyesus Director-General of WHO Energizer exercise during the world health assembly simulation. © WHO Lebanon / F. Choufany 1514 Annual Report 2019WHO Lebanon Country Office Every year, WHO recognizes and celebrates various global public health days. These celebrations offer valuable platforms with great potential to raise public awareness about health issues and mobilize community support. In 2019, WHO Lebanon focused on the following health days. CELEBRATING GLOBAL HEALTH DAYS WORLD ANTIBIOTIC AWARENESS WEEK WHO Lebanon organized the World Antibiotic Awareness Week in partnership with the Ministry of Public Health, the Modern University for Business and Science, the Lebanese Medical Students’ International Committee, and the private sector, spanning 11 shopping shopping malls across the country. Booths were set up in shopping malls and supplied with posters, flyers and interactive props. Trained front-liners reached out to mallgoers about antimicrobial resistance. More than 16 000 persons were approached. This activity was accompanied by a media campaign (TV and radio spot) focusing on three main messages: caregivers consulting physicians before buying antibiotics; pharmacists not selling antibiotics without a prescription; and physicians prescribing antibiotics only when necessary. 10-24 NOV WORLD AIDS DAY On the occasion of World AIDS Day, the National AIDS Program organized a 1-day workshop in collaboration with WHO to introduce the annual World AIDS Conference theme and review the achievements of 2019. 1 DEC WORLD PATIENT SAFETY DAY On the first-ever World Patient Safety Day, WHO Lebanon marked the occasion by lighting up in orange the Baalbek Temple and nine hospitals around the country, as well as the Ministry of Public Health and Syndicate of Hospitals respective buildings. The hospitals that joined the call for patient safety are: Hôtel-Dieu de France, Haykal Hospital, Chtoura Hospital, Haroun Hospital, Bekaa Hospital, Hammoud Hospital University Medical Center, Bellevue Medical Center, Hôpital Libanais Geitaoui and Rafik Hariri University Hospital. 17 SEP WORLD MENTAL HEALTH DAY WHO supports the National Mental Health Programme at the Ministry of Public Health in its yearly national awareness campaigns for mental health. The campaign for 2019 addressed mental health in the workplace under the slogan “Don’t miss the opportunity”. A charter was developed and presented an opportunity for managers and business owners to showcase their commitment towards improving well-being and mental health within their respective workplaces. Participating agencies signed the charter during a publicized launching event. 10 OCT WORLD HEALTH DAY The theme for World Health Day in 2019 was Universal Health Coverage. WHO Lebanon launched a social media campaign on this occasion. In addition, a yearly School Children’s Art Competition is launched by the WHO Regional Office for the Eastern Mediterranean for this occasion. In 2019, over 400 students from Lebanese and United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) schools participated in the competition, and four students won awards for their artwork. 7 APR WORLD NO TOBACCO DAY On the occasion of World No Tobacco Day 2019, WHO continued its advocacy efforts with the Government of Lebanon to ban smoking in public places and implement Law No. 174. To commemorate this day, the WHO Country Office sheathed the facade of its office building, as well as that of the Ministry of Public Health, with large “No Smoking” banners. 31 MAY 1716 Annual Report 2019WHO Lebanon Country Office priority area 1 protect health:DEVELOP HEALTH SYSTEMS TOWARDS UNIVERSAL HEALTH COVERAGE Universal health coverage is a vision that aims for all people and communities having access to quality health services, where and when they need them, and without suffering financial hardship. Advancing universal health coverage was identified as a strategic priority in WHO’s GPW 13, and as a priority in Vision 2023 for the Eastern Mediterranean Region, as well as in the Ministry of Public Health vision for Lebanon. Great progress has been made in Lebanon in developing the health system towards universal health coverage. In 2019, WHO continued to support the Lebanese health system through strengthening the health system building blocks (Fig. 1). SERVICE DELIVERY WHO is supporting the Ministry of Public Health in adopting an integrated people-centred health services approach within the national primary health care network. People-centred care is an approach that considers the people using health and social services as equal partners in their health and health care. A people-centred service places the people using health and social services as well as their families/carers at the centre of the decisions. People-centred care relies on four main principles: In 2019, WHO conducted a baseline assessment at seven primary health care centres and two hospitals in which the piloting of people-centred care is planned to be carried out. One of the key findings showed that some staff at the assessed health facilities have already begun implementing some aspects of people-centred care prior to piloting the approach. WHO will work further with primary health care centres in order to standardize and institutionalize the people-centred approach. This will be done through multiple interventions including team re- profiling, service reorganization and implementation of different health care service initiatives. People-centred groups will be established to provide feedback on health care service design. This will be complemented with training of 40 medical doctors on the family practice approach through the online training hosted by the American University of Beirut (AUB) and the Lebanese University. In addition, WHO has initiated the development of an e-learning module for nurses in collaboration with the Order of Nurses in Lebanon and AUB’s nursing school. Source: Everybody’s business: strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva, World Health Organization, 2007 http://www.who.int/healthsystems/strategy/everybodys_business.pdf, accessed 26 April 2020 Fig. 1. The building blocks of a health system: aims and desirable attributes Health Information Systems Improved health (level and equity) Responsiveness Improved efficiency Social and financial risk protection ACCESS COVERAGE QUALITY SAFETY Financing Leadership/ Governance OVERAL GOALS / OUTCOMESYSTEM BUILDING BLOCKS Access to essiential medicines Service Delivery Health Workforce care is coordinatedcare is personalised care enables people to live a fulfilling life people are treated with dignity, compassion & respect HEALTH WORKFORCE An adequate and competent health workforce is critical for universal health coverage. WHO provided support at the strategic level as well as through capacity-building and direct contracting. Assessment of human resources at the Ministry of Public Health WHO strategic support in 2019 focused on assessing the human resources capacity at the Ministry of Public Health. The Ministry has been operating under severe shortages of human resources, which, in turn, have been exacerbated by a government decision to freeze recruitment over the past 12 years. Beneficiary doing blood sugar test at a primary health care centre. © WHO Lebanon / G. Bell 2120 Annual Report 2019WHO Lebanon Country Office Filling the gap in critical programmatic functions WHO was able to address the gaps in several critical programmes at the Ministry of Public Health through outsourcing human resources, which resulted in the smooth implementation of the various programmes. In 2019, a total of 39 persons supported the Ministry of Public Health centrally and peripherally. The support was provided to various departments; namely, the Epidemiological Surveillance Unit (for acute flaccid paralysis (AFP) and measles), the Health Systems and Accreditation department, the National Tuberculosis Program, the Primary Health Care department and the Statistics department, among others. Training and capacity-building WHO supported the training and capacity-building of health workers on various topics, including: 418 staff from 382 primary health care centres and dispensaries were trained on the rational use of medications and good medication management practices at the primary health care level; ~ 25 participants from various fields, including social work, mental health and law, were trained on assessing the quality and human rights aspects of facilities providing mental health care, using the WHO QualityRights tool kit; > 100 focal points, health care and social workers, and outreach and on-site volunteers were trained on the latest WHO HIV testing, counselling and treatment guidelines. In addition, WHO supported the participation of 54 national experts and academicians in regional and global meetings, training sessions and conferences organized by WHO during 2019. EMPLOYMENT TYPE The majority were full timers Surveyed employees by employement type permanent employees contracts (mainly renewable yearly) daily workers temporary workers 95.3% 25% 54% 17% 4% GEOGRAPHIC DISTRIBUTION Surveyed employees by gender 8%Beirut Mount Lebanon 32% 12% North 7% Bekaa 20% South 21%Nabatieh central administration19% regional centres81% DEMOGRAPHICS 41.5% 58.5% Surveyed employees by age group between 36 and 50 years of age 16% 35 years old or younger 30% between 51 and 60 years of age 36% above 60 years of age 18% Surveyed employees by area of residence Surveyed employees by operational office In partnership with the Lebanese University and with funding from the EU Madad Fund, WHO conducted a survey of all current Ministry of Public Health employees (fixed and contractual). The main results of the survey are given below. 2322 Annual Report 2019WHO Lebanon Country Office Barcode system In order to ensure high levels of quality, safety and efficacy of drugs, the Ministry of Public Health is working to establish a track and trace system for imported and locally manufactured pharmaceuticals. For this purpose, the Ministry of Public Health, with the support of WHO, initiated the development of a National Barcode Information System for pharmaceuticals in Lebanon using a GS1 two-dimensional barcode. This printed barcode is placed on all packages and allows for all stakeholders to be linked through a common information system. Through the EU Madad Fund’s health system strengthening component, WHO provided the support needed for the expansion and roll-out of the national GS1 barcode system for pharmaceuticals. Support included adjusting the software based on the findings of a pilot phase, and entailed: • issuing the regulations and guidelines needed for implementing the GS1 barcode system; • implementing the system at the central drug warehouse; • expanding the GS1 barcode system at the national level over one year by provision of critical IT software and hardware support, as well as training and capacity-building for Ministry of Public Health teams; • starting serialization in line with international standards. With support from several donors, including the EU Madad Fund, the Bureau of Population, Refugees, and Migration and Kuwait, WHO was able to secure around US$ 8 million to procure the required quantities of essential medicines for chronic and acute conditions in order to avoid any interruption of stocks. This support benefited a total of 92 000 vulnerable refugees and host community patients with chronic conditions, as well as some 350 000 patients with acute conditions. In 2019, a total of 100 primary health care centres benefiting from the chronic medications programme were visited and monitored, using a checklist prepared in consultation with the Ministry of Public Health. HEALTH INFORMATION SYSTEMS The findings of an assessment of the current health information system in Lebanon, conducted by WHO, highlighted significant strengths of the system as well as myriad opportunities for improvement (Table 4). The assessment identified 57 cross-cutting priority actions to enhance health information system operations across all functional areas. Table 4. Health information system strengths and opportunities for improvement STRENGTHS OPPORTUNITIES FOR IMPROVEMENT • Creating and adopting a unique identifier (biometric, national ID, or medical record number) to enable linkages of electronic platforms • Establishing nationwide interoperability standards and health information exchange • Developing dashboards for data dissemination and use • Developing standard operating procedures for data review and validation, as well as for regular supportive supervision for quality assurance • Vital statistics unit at Ministry of Public Health working on consolidating and analysing data • Civil registration and vital statistics assessment highlighting data sharing with the Ministry of Interior and Municipalities • Setting a defined list of priority diseases and standard case definitions under the current national surveillance system ACCESS TO ESSENTIAL MEDICINES WHO undertakes a wide range of activities to help ensure that all people living in Lebanon have access to essential, safe, high-quality and affordable medical products. Fig. 2. Total number of beneficiaries registered in the chronic medications programme (2016–2019) 2016 2017 2018 2019 158 000 170 769 185 231 203 760 Since 1996, a chronic medications programme, jointly operated by Ministry of Public Health and the Young Men’s Christians Association, has provided adequate and sufficient treatment to patients suffering from NCDs. WHO has been supporting the implementation of this programme in a network of 450 health facilities since 2012, through funds from the European Union and other donors. More than 200 000 beneficiaries were registered in 2019 (Fig. 2). WHO staff conducting monthly monitoring visits to facilities benefiting from the chronic medications programme to ensure that medications are stored and managed correctly. © WHO Lebanon / G. Bell 2524 Annual Report 2019WHO Lebanon Country Office LEADERSHIP AND GOVERNANCE Lebanon’s Health Vision 2030 In preparation for the development of Lebanon’s Health Vision 2030, and as part of the EU Madad Fund’s health system strengthening component, WHO initiated a series of studies and surveys with the aim of generating data to inform the development of health policies. The main studies and surveys initiated include: COMBATTING ANTIMICROBIAL RESISTANCE Antimicrobial resistance, caused by excessive and inappropriate use of antibiotics, reduces the effectiveness and number of options for antibiotic treatment, leading to increased morbidity, mortality and health care expenditures. In 2019, WHO continued its support in fighting antimicrobial resistance in Lebanon through costing and developing an implementation plan for antimicrobial resistance. The action plan was endorsed by the Ministry of Public Health. Lebanon’s National Antimicrobial Resistance Action Plan is based on WHO’s Global Action Plan on Antimicrobial Resistance. The plan covers five axes: awareness, surveillance, infection prevention and control, antibiotics use, budget planning and fundraising. The following activities have been achieved in 2019. During the meeting on electronic health record readiness. © WHO Lebanon Training of staff in hospital laboratories With the support of WHO and in partnership with the Ministry of Public Health, the research laboratory at the University of Saint Joseph and the microbiology laboratory at the American University of Beirut, a microbiology proficiency testing exercise was implemented in preparation for the establishment of a national laboratory External Quality Assurance System to enhance the quality of microbiology laboratory data. The training was attended by around 240 participants from 130 hospital laboratories across Lebanon. Conducting a survey on antibiotic use in hospitals Collecting data on antibiotic use and hospital-acquired infections are among the main targets of the National Antimicrobial Resistance Action Plan. As part of its support, WHO, in conjunction with the Ministry of Public Health, conducted a point prevalence survey on antibiotic use in hospitals in Lebanon. In addition, the WHO Regional Office for the Eastern Mediterranean supported the training of 22 medical supervisors and 44 data collectors from 22 hospitals across Lebanon. A total of 2700 questionnaires were filled by the hospitals and sent for analysis at the Regional Office. The data generated from this survey will inform national policies to promote appropriate use of antimicrobials and strengthen national- and facility-level infection prevention and control programmes. During the launching of the proficiency testing. © WHO Lebanon / L. Batlouny • provider practice survey; • nongovernmental organization profiling; • electronic health record feasibility; • nongovernmental organization mapping; • Ministry of Public Health human resources surveys; • diagnostics benchmarking; • nursing demographics and practice survey. In parallel, and in partnership with the University of Saint Joseph, WHO supported a health system analysis using the Health in Transition tool. Policy Support Observatory WHO continued its support for the Policy Support Observatory throughout 2019. The operational staff was recruited, two project advisory committee meetings were held, and international experts conducted two technical support missions. Five out of the 24 projects planned for 2019–2022 were initiated and are currently on track. WHO support was also extensively involved in the preparatory work for the National Health Forum, initially planned for December 2019. Support encompassed the identification of themes, the drafting of technical documents, the preparation of briefs for speakers, the development of specific material (audio-visual, infographics, etc.) and the coordination of logistics. The preparatory work was completed; however, due to the prevailing circumstances of political and social instabilities, the Forum was adjourned to a later date in 2020. Head of technical team at WHO Lebanon discussing the health system strengthening. © WHO Lebanon 2726 Annual Report 2019WHO Lebanon Country Office protect health: DEVELOP AND MAINTAIN EMERGENCY PREPAREDNESS AND HEALTH SECURITY priority area 2 EMERGENCY PREPAREDNESS AND HEALTH SECURITY In 2019, WHO continued its support to the Government of Lebanon in emergency preparedness and readiness for responding to all hazards. Hazardous materials training and drill in the South of Lebanon In line with the International Health Regulations (IHR) (2005) plan of action, WHO trained medical teams with the aim of establishing a HAZMAT team in South and Nabatieh governorates. WHO also procured equipment and trained health and non-health teams on safe response to chemical, biological and radionuclear hazards. Operationalizing the Public Health Emergency Operations Centre In 2019, WHO supported the development of an action plan for the Public Health Emergency Operations Centre that was established at Rafik Hariri University Hospital in 2007 (also with WHO support). WHO worked with the Ministry of Public Health and the Disaster Risk Management Unit established at the Prime Minister’s Office to upgrade the national Emergency Operations Centre with information and communication technologies and technical guidance. Field testing of the newly developed WHO handbook for ground crossings A team of experts from WHO headquarters, regional and country offices along with ministry officials from several countries visited the Masnah border crossing on 24 July 2019. The visit aimed at field-testing the Handbook for public health capacity-building at ground crossings and cross-border collaboration. The exercise will serve as the definitive legal framework to ensure global health security, especially on ground crossings for public health safety. DISEASE PREPAREDNESS AND SURVEILLANCE The epidemiological surveillance system at the Ministry of Public Health relies on health outlets such as hospitals, medical centres and laboratories as primary data sources. The data received are crucial to the analysis of communicable disease trends for surveillance, early detection of outbreaks and timely response. Improving data reporting In 2019, WHO continued its support to the national surveillance system and the Early Warning, Alert and Response System (EWARS). WHO supported the procurement of information technology equipment, staff recruitment and the training of around 1000 staff from 500 public schools on how to report communicable diseases using the District Health Information System 2 (DHIS2) software. The introduction of DHIS2 improved timeliness and completeness of reporting, which reached by the end of 2019: 82% and 94% respectively in hospitals 58% and 87% in laboratories 65% and 78% in medical centres 32% and 42% in schools Furthermore, WHO supported the development of standard operating procedures for the surveillance and management of 10 diseases: mumps, diphtheria, cholera, rabies, acquired rubella, congenital rubella syndrome, seasonal influenza, novel influenza, tetanus and tetanus neonatorum. Strengthening pandemic influenza preparedness In 2019, WHO continued its support to severe acute respiratory infection surveillance in eight sentinel sites. This was implemented in collaboration with the Epidemiological Surveillance Unit at the Ministry of Public Health and the National Influenza Center located at Rafik Hariri University Hospital. WHO support included: • procuring laboratory reagents, consumables and equipment; • training of staff on several technical areas (such as influenza sequencing); • quality assurance; • production of educational material and protocols for monitoring and evaluation; • participating in scientific conferences; • strengthening the human-animal interface through collaboration between the Ministry of Public Health and Ministry of Agriculture. WHO team member during the visit to the Masnah border. © WHO Lebanon / H. Habib 3130 Annual Report 2019WHO Lebanon Country Office Enhancing AFP and poliovirus environmental surveillance WHO provided human resources support in the form of secondment of 15 staff members to the Ministry of Public Health to support AFP active surveillance. In addition, WHO contributed to the development of awareness materials for health workers on AFP surveillance. These efforts helped to maintain indicators for AFP active surveillance above required standards. Supplementary to AFP surveillance in the National Programme for Poliovirus Eradication, WHO provided support to the Ministry of Public Health for sustaining monthly environmental surveillance to detect poliovirus (wild poliovirus, vaccine-derived poliovirus and Sabin polioviruses). WHO support included: • providing necessary kits and supplies to collect specimens; • technical support; • shipment and testing of the specimens collected. Responding to the measles outbreak In 2019, WHO supported the Ministry of Public Health in rapid risk assessment of the measles outbreak. Support included: laboratory support through procurement of reagents and supplies for confirmation of genotyping; capacity-building of around 100 staff from the Ministry of Public Health and nongovernmental organizations to enhance measles reporting; raising US$ 4.5 million for the implementation of the national measles campaign. As a response to the measles outbreak, a campaign was launched by the Ministry of Public Health in December 2019, with the support of WHO and the United Nations Children’s Fund (UNICEF), targeting around 1 million children aged between 6 months and 10 years. The campaign will continue into May 2020. Addressing new peak of leishmania cases In 2013, at the beginning of the Syrian crisis and the resulting influx of large numbers refugees into Lebanon, a peak in the number of positive leishmania cases was observed. Another peak occurred again in 2019. In response, WHO trained around 60 physicians working at emergency departments in public hospitals on the diagnosis of leishmaniasis and on adequate referral. Awareness sessions were also conducted with local nongovernmental organizations and with 175 local authorities from municipalities across Lebanon. WHO and AFP teams conducting joint visit and specimen collection. © WHO Lebanon / G. Bell Child receiving vaccine during the national measles campaign. © WHO Lebanon / G. Bell 3332 Annual Report 2019WHO Lebanon Country Office priority area 3 health priorities:IMPROVE HEALTH AND WELL-BEING ACROSS THE LIFE COURSE IMPROVING HUMAN CAPITAL ACROSS THE LIFE COURSE Health promotion in schools in disadvantaged areas WHO supported the implementation of the National School Health Program in five schools located in two rural areas in the South and Bekaa regions, in collaboration with the Modern University Business School and the AUB’s Champs Fund as implementing partners. The National School Health Program encompasses three main components: In this project, a total of 822 students from different cycles in the five schools were screened for medical conditions, and students aged 12 years and above who participated in sports activities were offered cardiac screening. An electronic version of the medical screening file, developed with WHO support, was used for a total of 700 students. The electronic record allows easy access to medical data and rapid generation of reports for the individual schools. Concurrently, 200 students benefited from the eHealth modules on physical activity, anti- tobacco, reproductive health and HIV, and road safety that were developed and adapted by WHO Lebanon. In addition, three health days for parents were organized, during which 296 of the students’ parents attended sessions on physical activity, nutrition and communicating with adolescents and children. In parallel, the healthy school initiative guidelines, recently developed by WHO in consultation with the Ministry of Public Health and the school health programme’s focal team, were piloted in the five schools. The guidelines constitute a comprehensive assessment and evaluation of the different aspects of a school that would determine its categorization into one of three “healthy school” levels: basic, advanced or excellent. Promoting hand hygiene for school children WHO supported the International Theatre, an educational entertainment mobile theatre, in performing an interactive puppet show about hand hygiene for children in schools across Lebanon. The purpose of the performance was to explain the concept of good hygiene, demonstrate personal hygiene practices, advocate for water conservation and help to prevent influenza and other communicable diseases. The performance was staged at six schools located in different regions in Lebanon (Beirut, the North, Mount Lebanon and the South), and consisted of a puppet show, an interactive session with questions and answers, and an entertaining educational song about handwashing that children were encouraged to memorize and practice. The project reached a total of 1536 students, who were actively engaged during show. The performance was highly welcomed by the management teams of the schools as well as greatly enjoyed by the students. Development of a guidebook for early detection of tumours in children WHO offered technical and financial support to the Children’s Cancer Center of Lebanon (CCCL) for the development of a guidebook for medical doctors about early detection of tumours among children. The guidebook has been developed to provide medical doctors with the information needed to act when a malignancy is suspected. The guidebook was printed with the support of WHO and disseminated by the CCCL to medical doctors in different regions in Lebanon. Bringing palliative care to the forefront of patient support WHO has been engaged in the development of palliative care in Lebanon since 2016, as part of WHO support to implement people-centred care, namely, ensuring the continuum of care. In 2019, WHO’s contribution focused on replicating the proposed model of palliative care, based on a mobile palliative care team within a hospital, to ensure hospice and home care for end-of-life patients. The palliative care initiative was expanded in partnership with a specialized nongovernmental organization, SANAD. The project encompassed three components: health education school environmentmedical screening Cardiac screening in collaboration with Champs fund. © WHO Lebanon / G. Bell 3736 Annual Report 2019WHO Lebanon Country Office Working with media to fight stigma related to mental health The National Mental Health Programme at the Ministry of Public Health was established in 2014 with strong advocacy and support from WHO. Throughout 2019, the National Mental Health Programme continued to benefit from this support. In this context, a practical guide for media professionals on the coverage of mental health and substance use was developed, to promote informed and responsible reporting about mental health, and thus fight stigma related to mental disorders. finalizing the establishment of a hospital-based palliative care service at Rafik Hariri University Hospital in Beirut; establishing a home-based palliative care service at Ain Wazein Medical Village hospital in Mount Lebanon; and supporting the CCCL team in conducting support groups. The project was successful in finalizing the establishment of a palliative care service at the Rafik Hariri University Hospital through different training and shadowing stages. A noticeable culture change has been observed, with many oncologists now readily referring patients to the palliative care service. Patients are increasingly benefiting from the services of the well-trained multidisciplinary palliative care team. At Ain Wazein Medical Village, the palliative care team has been trained on home-based palliative care and a palliative care system has been established. As part of the third component of the project, the capacity of CCCL’s team members was upgraded for running and leading support group discussions for their staff in order to alleviate the stressors of their work that often cause staff burnout. In parallel, WHO has supported a costing exercise to determine the reimbursement scheme that the Ministry of Public Health will offer for hospitals and nongovernmental organizations providing palliative care services. PREVENTING NCDS AND PROMOTING MENTAL HEALTH Addressing nutrition to improve health Malnutrition in all its forms takes a heavy toll on the health, well-being and sustainable development of Lebanon’s population. NCDs, unhealthy diets and physical inactivity are key contributors to this burden. Following a consultative process, WHO Lebanon supported the Ministry of Public Health in developing a National Nutrition Strategy. The strategy outlines a road map for the improvement of the nutritional situation and outcomes in the Lebanese population. The final strategy document and plan of action will be completed in 2020. In addition, and as part of the global target to eliminate trans-fat from the local food supply, WHO conducted a food composition analysis for the 30 most consumed dishes in the Lebanese diet, as well as for Arabic sweets and some market food products (biscuits, oils, etc.). Food composition analysis in the Industrial Research Institute laboratories. © WHO Lebanon / G. Bell Palliative care service at the Rafik Hariri University Hospital. © WHO Lebanon / H. Habib 3938 Annual Report 2019WHO Lebanon Country Office ACCELERATING ELIMINATION AND ERADICATION OF HIGH-IMPACT COMMUNICABLE DISEASES: HIV With WHO support, and in collaboration with nongovernmental organizations and service providers, the National AIDS Program was able to maximize HIV testing uptake and increase coverage to rural areas across the country. Prevention On-site and outreach sexual health activities were conducted, including HIV testing, counselling, referrals, psychosocial support and other related services. > 9 000 rapid HIV tests were conducted and 214 positive cases were detected in 2019. ~ 2 000 HIV self-tests were conducted. This is an innovative testing methodology that partially leapfrogs associated stigma and discrimination by ensuring the privacy of users. > 80 000 condoms were distributed. > 100 social workers were trained on HIV and sexually transmitted infection basics, as well as on counselling and partner notification. Through intensified decentralized testing at the community level, 2500 persons living with HIV are now aware of their status in Lebanon in 2019. Treatment The National AIDS Program provided antiretroviral treatment to more than 1700 persons living with HIV. With the support of the International Organization for Migration and through the Global Fund to Fight AIDS, Tuberculosis and Malaria, the National AIDS Program was able to provide treatment and cover the costs of necessary laboratory tests for close to 150 non-Lebanese persons living with HIV. A total of 214 new cases were started on treatment in 2019, while all persons living with HIV in Lebanon received continuous treatment as per the latest guidelines without any stock interruption. During 2019, the antiretroviral treatment guidelines were updated and adapted according to the most current international recommendations, and in particular the WHO consolidated guidelines (July 2019). These guidelines take into consideration the current epidemiology in Lebanon as well as the availability of drugs and laboratory testing capacities. PROTECTING THE HUMAN RIGHTS OF PERSONS WITH PSYCHOSOCIAL DISABILITIES In February 2019, Al-Fanar Psychiatric Hospital in Lebanon was closed down following allegations of serious human rights violations against beneficiaries, such as inadequate standards of living, lack of hygiene and suboptimal treatment, among other abuses. WHO Lebanon and the National Mental Health Programme at the Ministry of Public Health were successful in advocating for rights of the beneficiaries as well as the use of the WHO QualityRights tool for assessing and improving the quality and human rights aspects of mental health services. Prior to its closure, Al-Fanar hospital hosted about 166 people (70% males and 30% females, the majority of which were Lebanese nationals). Following its closure, the people at Al-Fanar hospital were transferred to four different facilities in the country. Emergency needs were addressed; namely, the treatment of lice and scabies, securing personal hygiene and clothing items, screening for tuberculosis and provision of necessary preventive treatment and other screening tests, in addition to hospitalization for emergency mental health and medical treatment. During the QualityRights assessment conducted in mental health facilities. © WHO Lebanon / G. Bell 4140 Annual Report 2019WHO Lebanon Country Office Research studies The test–treat–retain cascade analysis was updated in Lebanon in 2019. The main findings are: 94.7% of people living with HIV were found to be aware of their status (compared to 68.6% in 2015); 68.5% were found to be enrolled in care (compared to 61.7% in 2015); and 59.3% were virally suppressed (compared to 35.4% in 2015). ADDRESSING ENVIRONMENTAL HEALTH Ministry of Public Health water laboratories assessment WHO supported the assessment of water laboratories in eight public hospitals. The aim was to evaluate the functionalities of the water laboratories, and to propose the necessary corrective measures. The recommendations of the assessment included: • developing guidelines on water sampling techniques and testing; • provision of equipment and reagents for chemical and physical testing; • capacity-building on water analysis, water sampling techniques and drinking water quality surveillance of different staff involved in these activities; • addressing water laboratory software. A study on the prevalence of sexually transmitted infections and associated risky behaviours was conducted among men who have sex with men. The results showed a high lifetime prevalence of: Gonorrhoea 21.4% Human papillomavirus 17.4% Chlamydia 13.4% across a sample of men who have sex with men, with a strikingly low mean age. A high-risk behavioural profile was also detected across the sample. Fig. 3. Test–treat–retain cascade 2019 findings = 68.5% of all people living with HIV 94.7% aware of their HIV status 72.4% virally suppressed = 59.3% of all people living with HIV 91.9% on HIV treatment of which of which Joint workshop on environmental health A joint environmental health workshop took place between the United Nations, the European Union and the World Bank. Recommendations from the workshop included updating the existing environmental health strategy, taking into account the following actions: • aligning ongoing environment priorities with the SDGs; • strengthening early warning, monitoring and surveillance for different environmental health hazards; • estimating the economic and social impact of environmental risks on health; • advocating for environmental risk mitigation in all programmes with clear follow-up mechanisms; • enhancing coordination and leadership. Beneficiary receiving HIV medication and health education at the National Aids Program centre. © WHO Lebanon / G. Bell Visit to the water laboratories. © WHO Lebanon / G. Bell 4342 Annual Report 2019WHO Lebanon Country Office In 2017, the WHO Framework Convention on Tobacco Control established a knowledge hub for waterpipe tobacco smoking at the AUB. In 2019, the hub continues to implement activities that aim at curbing the epidemic of tobacco use, including the burden of waterpipe smoking. These activities include enhancing awareness on the use of waterpipe health warning labels, as well as on the toxicant contents of waterpipe smoke, and on the health effects of waterpipe tobacco smoking and the economics of tobacco consumption. National academic institutions that were declared smoke-free Following the declaration of the AUB in 2018, the University of Saint Joseph and the Lebanese University- Central Administration declared their campuses smoke-free in 2019. This is the result both of continuous advocacy led by WHO and commitment of the Ministry of Public Health to encourage more institutions apply tobacco control Law No. 174. the way forward Amid the complex and critical situation in Lebanon, WHO will continue its support to the health sector in general and specifically to the Ministry of Public Health. Strengthening the health system will be further supported through the projects under the EU Madad Fund (until 2022), with additional funds received to cover existing gaps in medicines for acute and chronic conditions. Support to health system strengthening with a focus on universal health coverage under the EU-Luxembourg projects will continue. Similarly, the support to mental health under a project funded by the Agence Française de Développement will be pursued through to 2022, with a focus on advocacy and rights, with the development of a modular university training curriculum for mental health management and leadership. The SDG 3+ Global Action Plan road map will be further developed into a project to be supported through a multi-donor trust fund. Moreover, support to strengthening emergency preparedness and response will continue, especially in the light of the coronavirus disease (COVID-19) pandemic. Health security, within the IHR (2005) requirements, will be further reinforced. Re-establishing a central public health laboratory and expanding the capacity and automation of the central drug warehouse are both critical issues that will require priority support. Specific attention will be given to health care access, and in particular to good quality care. This will be carried out through the expansion of people-centred primary care by ensuring quality care through capacity-building and audits. Mobilizing resources for critical interventions will be intensified, particularly in the light of the evolving financial crisis. Further expansion of the WHO Country Office team with staff and/or United Nations volunteers is underway to better respond to the escalating needs for technical and logistics support. Training on air quality monitoring In collaboration with the AUB Nature Conservation Center, WHO through its Regional Centre for Environmental Health Action organized a 2-day training workshop on health impact assessment of air pollution in Lebanon. The workshop feeds into the application of the air quality and health road map, which addresses air pollution, climate change and the sustainable development agenda. The workshop was part of the overall framework for the environmental health risks programme. As the objective of the framework is to address environmental health degradation in the country, collecting evidence on the health impacts of air pollution is essential. Water assessment WHO supported the assessment of drinking water by conducting the UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water country survey in 2019. The survey focused specifically on policies and national targets, with water, sanitation and hygiene finance as a major theme. WHO continues its advocacy against tobacco use in Lebanon A team of national experts was trained on the WHO Tobacco Taxation Simulation Model. Following this, a tobacco taxation study was conducted to generate evidence for advocacy. The main recommendation was to tax locally produced tobacco products as well as imported tobacco products. 45Annual Report 201944 WHO Lebanon Country Office WHO staff signing the WHO values charter. © WHO Lebanon / H. Habib World Health Organization - Lebanon P.O. Box 11-5391 Beirut, Lebanon www.emro.who.int/countries/lbn/ emwroleb@who.int WHOLebanonISBN 978-92-9022-321-4
ANNUAL REPORT 2019 HEALTH FOR ALL Sales, rights and licensing. Third-party materials. General disclaimers. Cover photos credit: WHO Lebanon Design: WHO LEBANON THANKS ITS DONORS FOR THEIR GENEROUS SUPPORT TO ITS ACTIVITIES IN 2019 WHO Library Cataloguing in Publication Data World Health Organization. Regional O ce for the Eastern Mediterranean World Health Organization annual report 2019 WHO Country O ce Lebanon: health for all / World Health Organization. Regional O ce for the Eastern Mediterranean p. ISBN: 978-92-9274-683-4 ISBN: 978-92-9274-684-1 (online) 1. Delivery of Health Care 2. Universal Health Insurance 3. Population Health - Lebanon 4. Disaster Planning 5. Emergencies 6. Security Measures I. Title II. Regional O ce for the Eastern Mediterranean (NLM Classi cation: WA 300) is publication was originally published under ISBN: 978-92-9022-320-7, 978-92-9022-321-4 In 2019, Lebanon witnessed an increased rise in health and humanitarian needs. The ongoing political instability and insecurity, as well as the consequences of the protracted conflict in the neighbouring Syrian Arab Republic, have led to a further burdening of the health system in Lebanon. By the last quarter of 2019, Lebanon was facing an unprecedented economic and financial crisis, jeopardizing access to and availability of health services, and further impairing the coping capacities of already-vulnerable Lebanese and refugees. Unemployment rates grew enormously, threatening social stability. The year also witnessed an ongoing measles outbreak in the country and ended with the global threat of the coronavirus disease (COVID-19) outbreak in China by December. Nevertheless, 2019 was also marked by important achievements in public health in Lebanon. The country sustained its polio-free status, access to primary health care for vulnerable populations was maintained, health system strengthening interventions were accelerated, and the early warning and alert system was fully automated and expanded. For the first time in the country, data on causes of death were made available through the hospital-based births and deaths registry, and data on prevalence of antimicrobial resistance were also made available. Preparedness for chemical, biological and radionuclear hazards response was completed with the establishment of the fourth HAZMAT team in the South, after Beirut, North and Bekaa in previous years. Dr Iman Shankiti WHO Representative in Lebanon foreword Despite the social unrest that began in October 2019 following the financial crisis, the measles campaign was launched in December 2019. Critical interventions, such as the development of a barcode system, the automation of medications pricing, the introduction of people-centred care at the primary health care level and the generation of evidence for policy development through initiating a series of surveys and studies were accelerated in 2019. Thanks to the generous support of donors, the commitment of the Ministry of Public Health, and the valuable contribution of all health partners, WHO was able to provide the support needed to the health sector in spite of all the considerable challenges encountered in 2019. Against all the odds, Lebanon remains an example of health system resilience and continues to effectively deliver essential preventative and curative health care services to the community. 32 Annual Report 2019WHO Lebanon Country Office 1 700 people living with HIV continue to receive treatment from the National AIDS Program. WHO supported the development of standard operating procedures for the surveillance and management of ten diseases. Severe acute respiratory infection surveillance continues in eight sentinel sites. WHO engaged in the health systems development support through critical projects funded by EU Madad Fund, including: a barcode system for pharmaceutical products, an electronic medical records, and others. > 200 000 people are able to access safe, affordable and high-quality essential medications for the treatment of chronic conditions. 1 000 000 children aged between 6 months and 10 years were targeted by the national measles campaign. > 240 staff from 130 hospital laboratories across Lebanon were trained on enhancing the quality of microbiology laboratory data. ≈ 1 000 staff from 500 public schools were trained on how to report communicable diseases using the District Health Information System 2 (DHIS2) software. Person-centred palliative care services were established at three medical centres.2019 AT A GLANCE A road map for SDG 3 + Plan of action was developed in a participatory approach. 5 studies to generate information for policy support through the Policy Support Observatory were launched. PRIORITY AREA 1: HEALTH COVERAGE: DEVELOP HEALTH SYSTEMS TOWARDS UNIVERSAL HEALTH COVERAGE P. 18 PRIORITY AREA 2: PROTECT HEALTH: DEVELOP AND MAINTAIN EMERGENCY PREPAREDNESS AND HEALTH SECURITY P. 28 PRIORITY AREA 3: HEALTH PRIORITIES: IMPROVE HEALTH AND WELL-BEING ACROSS THE LIFE COURSE P. 34 ACCELERATING ACTION ON SDGS: THE SDG 3+ GLOBAL ACTION PLAN ROAD MAPP. 14 COUNTRY OVERVIEWP. 10 OVERVIEW OF FUNDINGP. 12 ENGAGING WITH YOUTH: A WORLD HEALTH ASSEMBLY SIMULATIONP. 15 WHO’S VISION AND MISSIONP.08 THE WAY FORWARDP. 45 CELEBRATING GLOBAL HEALTH DAYSP. 16 OPERATIONAL PRESENCEP. 13 ACRONYMS & ABBREVIATIONS AFP AMR AUB CCCL DHIS2 EU EWARS GPW IHR NCDs SDG WHO Acute Flaccid Paralysis Antimicrobial Resistance American University of Beirut Children’s Cancer Center of Lebanon District Health Information System version 2 European Union Early Warning, Alert and Response System General Programme of Work International Health Regulations Noncommunicable Diseases Sustainable Development Goal World Health Organization table of contents 76 Annual Report 2019WHO Lebanon Country Office who’s mission and vision WHO’s strategic direction for the next five years has been delineated in the Thirteenth General Programme of Work 2019–2023.1 GPW 13 is based on the Sustainable Development Goals (SDGs) and is structured around three key strategic priorities: • ensuring healthy lives and well-being for all at all ages; • achieving universal health coverage; • addressing health emergencies and promoting healthier populations. In turn, these priorities are linked to three bold targets: • one billion more people to benefit from universal health coverage; • one billion more people better protected from health emergencies; • one billion more people enjoying better health and well-being. Three strategic shifts support the key priorities: • stepping up leadership; • driving public health impact in every country; • focusing global public goods on impact. WHO is committed to ensuring gender equality, equity and rights-based approaches to health that enhance participation, build resilience and empower communities. 1 Thirteenth general programme of work 2019–2023. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/324775/WHO- PRP-18.1-eng.pdf, accessed 26 April 2020). ENSURING HEALTHY LIVES AND PROMOTING WELL-BEING FOR ALL AT ALL AGES BY: STRATEGIC PRIORITIES AND GOALS 1 BILLION more people benefitting from universal health coverage ACHIEVING UNIVERSAL HEALTH COVERAGE 1 BILLION more people better protected from health emergencies ADDRESSING HEALTH EMERGENCIES 1 BILLION more people enjoying better health and well-being PROMOTING HEALTHIER POPULATIONS MISSION KEEP THE WORLD SAFE PROMOTE HEALTH SERVE THE VULNERABLE 98 Annual Report 2019WHO Lebanon Country Office Source: Vital Data Observatory, Ministry of Public Heath (24 March 2020) Table 1. Maternal and neonatal mortality in Lebanon, 2019 Lebanese Non-Lebanese Total Maternal mortality ratio per 100 000 live births 6.1 23.7 13.8 Neonatal mortality rate per 1 000 live births 4.4 6.3 5.2 In 2019, the population of Lebanon was estimated to be around 6.7 million. The population includes: 4 485 389 Lebanese residents1country overview Unemployment rates before 2019 were estimated to be close to 30% and reached around 50% by the end of 2019. The United Nations estimated that in 2018 around 28.5% of Lebanese and around 68% of refugees were living below the poverty line.1 With the current deteriorating economic situation and fiscal crisis in the country, it is estimated that more than 70% of Lebanese could soon be living under the poverty line. The impact of the continuous exacerbation of the Syrian crisis on Lebanon’s socioeconomic and political stability remains heavy, as Lebanon continues to be the country with the highest per capita number of refugees worldwide. As a consequence, environmental degradation and the threat of outbreaks constitute significant health risks in Lebanon. The health profile of Lebanon is characterized by a high burden of noncommunicable diseases (NCDs), including cancers. NCDs remain the top cause of mortality in the population and contribute to a total of 91% of the health burden. Cardiovascular diseases comprise around half of this overall burden.2 Nevertheless, Lebanon remains in an epidemiological transition, with communicable diseases such as waterborne and vaccine-preventable diseases still prevalent. Despite the rise in the incidence rates of both tuberculosis and HIV, the country maintains a low prevalence for these two diseases. The improvements for mother and child health are maintained, while mental health needs are on the rise. 1 Population estimates based on the latest baseline data and age proportions available from the Central Administration of Statistics in addition to birth and death records available from the Ministry of Interior and Municipalities. 2 Operational data portal: refugee situations [website]. Geneva: United Nations High Commissioner for Refugees (UNHCR); 2019 (https://data2.unhcr.org/en/ situations/syria/location/71, accessed March 2020). 3 UN Lebanon annual report 2018: working together for a secure, stable and prosperous future. Beirut: United Nations Lebanon; 2019 (https://www.un.org.lb/library/ assets/Annual%20UN%20Lebanon%20Report%202018%20ENGLISH-123819.pdf, accessed 26 April 2020). 4 Noncommunicable diseases country profiles 2018 (Lebanon). Geneva: World Health Organization; 2018 (https://www.who.int/nmh/countries/lbn_en.pdf, accessed 24 April 2020). 914 648 registered Syrians2 ≈ 500 000 non-registered refugees ≈ 500 000 long-term Palestinian refugees ≈ 300 000 migrant workers from South-East Asia and North Africa The main population characteristics are summarized as follows: 1.4 Lebanese population growth rate 7.4 infant mortality rate per 1000 live births in 2018 25% of the Lebanese population is under 15 years of age 10% of the Lebanese population is older than 65 years of age Table 1 shows the maternal morality ratio and neonatal mortality rate in Lebanon in 2019. Lighting of the Baalbek Temple for the occasion of the world patient safety day. © WHO Lebanon / Y. Dghaidy 1110 Annual Report 2019WHO Lebanon Country Office OPERATIONAL PRESENCEOVERVIEW OF FUNDING Table 2 shows the funding for each respective area of work, while Table 3 gives a breakdown of the different funding sources. The total budget received for 2019 was US$ 10 017 134 WHO is the leading agency for public health within the United Nations system, with the primary role of directing and coordinating international health. In Lebanon, WHO is involved in ensuring that all persons residing within Lebanon have access to good quality health care. WHO’s main areas of work encompass: health system strengthening; promoting health through the life course; NCDs and communicable diseases; and preparedness, surveillance and response. WHO works with many partners including the Lebanese authorities, humanitarian and development partners, donors, nongovernmental organizations, academia, WHO collaborating centres and the private sector. The main objectives of WHO support are to: • lead coordination of the health sector response; • better position health in United Nations debates and decisions, and advocate for health in the humanitarian agenda; • provide support to strengthen the health system towards universal health coverage; • provide technical assistance on key public health issues; • provide timely, up-to-date information on health trends, health systems and needs and response; • prevent, detect and respond rapidly to infectious disease outbreaks. WHO Lebanon also provides operational support in technical expert missions as well as regional workshops: Table 3. Breakdown of funding sources Area of work Main donors HIV/AIDS The Global Fund (through the Middle East Response 2 grant) Health system strengthening and universal health coverage EU, through the EU Regional Trust Fund in response to the Syrian crisis (EU Madad Fund) European Commission Government of Japan Access to chronic medications EU, through the EU Regional Trust Fund in response to the Syrian crisis (EU Madad Fund) Bureau of Population, Refugees, and Migration Access to acute medications Government of Kuwait Antimicrobial resistance BMG German Funds Measles campaign Kuwait Fund for Arab Economic Development (KFAED) Area of work Funding (US$) Communicable disease prevention and control 1 785 325 NCDs and mental health prevention and control 280 424 Health promotion through the life course 154 422 Health system strengthening 859 357 Polio (special programme) 240 000 Operational support (corporate activities/enabling functions) 1 007 242 Pandemic influenza preparedness (special programme) 320 800 Emergency funding (including outbreak and crisis response) 5 369 564 Table 2. Funding per area of work 25 23 technical support missions to the country on different topics such as health governance, immunization, central public health laboratory, environmental health, waste management and others. regional workshops and missions on different topics such as health information systems, surveillance and outbreak response, environmental health, pharmaceuticals and others. 1312 Annual Report 2019WHO Lebanon Country Office WHO supported the University of Saint Joseph in organizing and hosting the first WHO World Health Assembly simulation in Lebanon and the Eastern Mediterranean Region. This unique initiative gathered 38 students from various universities across Lebanon to discuss pertinent issues in the field of global mental health. Students represented a range of different majors, including medical and health sciences, law and other areas of study. During the 3-day simulation exercise, the students took on the roles of delegates and showcased the use of their skills in the diplomacy roles of either a WHO Member State delegate, a nongovernmental organization representative or a press correspondent. The main goals of the simulation were to introduce a model of experience-based learning and student engagement in global health diplomacy, allowing students to develop leadership, public speaking, conflict resolution and debate skills. During the simulation, participants discussed different facets of mental health and suggested realistic resolutions. 1 Stronger collaboration, better health: global action plan for healthy lives and well-being for all. Geneva: World Health Organization; 2019 (https://www.who.int/ publications-detail/stronger-collaboration-better-health-global-action-plan-for-healthy-lives-and-well-being-for-all, accessed 26 April 2020). SDG 3 to “Ensure healthy lives and promote well-being for all at all ages” is critical for the achievement progress on the 2030 Agenda for Sustainable Development. SDG 3 is linked to almost 50 targets, referred to as the health- related SDG targets. In order to progress towards the health-related targets, WHO has coordinated a global initiative that gathers 12 organizations engaged in health, development and humanitarian response. The aim was to develop a global action plan for healthy lives and well-being for all1 to accelerate progress towards realizing universal health coverage and the health-related SDG targets. Lebanon is one of the countries where this initiative is being piloted. In 2019, WHO Lebanon conducted a series of meetings with health and development partners and an SDG 3+ road map was proposed, feeding into the Global Action Plan that was launched during the United Nations General Assembly high-level meetings in September 2019. ACCELERATING ACTION ON SDGS: THE SDG 3+ GLOBAL ACTION PLAN ROAD MAP ENGAGING WITH YOUTH: A WORLD HEALTH ASSEMBLY SIMULATION The plan is called, “Stronger Collaboration, Better Health” for a reason. Although collaboration is the path, impact is the destination. The release of this plan is the beginning, not the end, of that path. Dr Tedros Adhanom Ghebreyesus Director-General of WHO Energizer exercise during the world health assembly simulation. © WHO Lebanon / F. Choufany 1514 Annual Report 2019WHO Lebanon Country Office Every year, WHO recognizes and celebrates various global public health days. These celebrations offer valuable platforms with great potential to raise public awareness about health issues and mobilize community support. In 2019, WHO Lebanon focused on the following health days. CELEBRATING GLOBAL HEALTH DAYS WORLD ANTIBIOTIC AWARENESS WEEK WHO Lebanon organized the World Antibiotic Awareness Week in partnership with the Ministry of Public Health, the Modern University for Business and Science, the Lebanese Medical Students’ International Committee, and the private sector, spanning 11 shopping shopping malls across the country. Booths were set up in shopping malls and supplied with posters, flyers and interactive props. Trained front-liners reached out to mallgoers about antimicrobial resistance. More than 16 000 persons were approached. This activity was accompanied by a media campaign (TV and radio spot) focusing on three main messages: caregivers consulting physicians before buying antibiotics; pharmacists not selling antibiotics without a prescription; and physicians prescribing antibiotics only when necessary. 10-24 NOV WORLD AIDS DAY On the occasion of World AIDS Day, the National AIDS Program organized a 1-day workshop in collaboration with WHO to introduce the annual World AIDS Conference theme and review the achievements of 2019. 1 DEC WORLD PATIENT SAFETY DAY On the first-ever World Patient Safety Day, WHO Lebanon marked the occasion by lighting up in orange the Baalbek Temple and nine hospitals around the country, as well as the Ministry of Public Health and Syndicate of Hospitals respective buildings. The hospitals that joined the call for patient safety are: Hôtel-Dieu de France, Haykal Hospital, Chtoura Hospital, Haroun Hospital, Bekaa Hospital, Hammoud Hospital University Medical Center, Bellevue Medical Center, Hôpital Libanais Geitaoui and Rafik Hariri University Hospital. 17 SEP WORLD MENTAL HEALTH DAY WHO supports the National Mental Health Programme at the Ministry of Public Health in its yearly national awareness campaigns for mental health. The campaign for 2019 addressed mental health in the workplace under the slogan “Don’t miss the opportunity”. A charter was developed and presented an opportunity for managers and business owners to showcase their commitment towards improving well-being and mental health within their respective workplaces. Participating agencies signed the charter during a publicized launching event. 10 OCT WORLD HEALTH DAY The theme for World Health Day in 2019 was Universal Health Coverage. WHO Lebanon launched a social media campaign on this occasion. In addition, a yearly School Children’s Art Competition is launched by the WHO Regional Office for the Eastern Mediterranean for this occasion. In 2019, over 400 students from Lebanese and United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) schools participated in the competition, and four students won awards for their artwork. 7 APR WORLD NO TOBACCO DAY On the occasion of World No Tobacco Day 2019, WHO continued its advocacy efforts with the Government of Lebanon to ban smoking in public places and implement Law No. 174. To commemorate this day, the WHO Country Office sheathed the facade of its office building, as well as that of the Ministry of Public Health, with large “No Smoking” banners. 31 MAY 1716 Annual Report 2019WHO Lebanon Country Office priority area 1 protect health:DEVELOP HEALTH SYSTEMS TOWARDS UNIVERSAL HEALTH COVERAGE Universal health coverage is a vision that aims for all people and communities having access to quality health services, where and when they need them, and without suffering financial hardship. Advancing universal health coverage was identified as a strategic priority in WHO’s GPW 13, and as a priority in Vision 2023 for the Eastern Mediterranean Region, as well as in the Ministry of Public Health vision for Lebanon. Great progress has been made in Lebanon in developing the health system towards universal health coverage. In 2019, WHO continued to support the Lebanese health system through strengthening the health system building blocks (Fig. 1). SERVICE DELIVERY WHO is supporting the Ministry of Public Health in adopting an integrated people-centred health services approach within the national primary health care network. People-centred care is an approach that considers the people using health and social services as equal partners in their health and health care. A people-centred service places the people using health and social services as well as their families/carers at the centre of the decisions. People-centred care relies on four main principles: In 2019, WHO conducted a baseline assessment at seven primary health care centres and two hospitals in which the piloting of people-centred care is planned to be carried out. One of the key findings showed that some staff at the assessed health facilities have already begun implementing some aspects of people-centred care prior to piloting the approach. WHO will work further with primary health care centres in order to standardize and institutionalize the people-centred approach. This will be done through multiple interventions including team re- profiling, service reorganization and implementation of different health care service initiatives. People-centred groups will be established to provide feedback on health care service design. This will be complemented with training of 40 medical doctors on the family practice approach through the online training hosted by the American University of Beirut (AUB) and the Lebanese University. In addition, WHO has initiated the development of an e-learning module for nurses in collaboration with the Order of Nurses in Lebanon and AUB’s nursing school. Source: Everybody’s business: strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva, World Health Organization, 2007 http://www.who.int/healthsystems/strategy/everybodys_business.pdf, accessed 26 April 2020 Fig. 1. The building blocks of a health system: aims and desirable attributes Health Information Systems Improved health (level and equity) Responsiveness Improved efficiency Social and financial risk protection ACCESS COVERAGE QUALITY SAFETY Financing Leadership/ Governance OVERAL GOALS / OUTCOMESYSTEM BUILDING BLOCKS Access to essiential medicines Service Delivery Health Workforce care is coordinatedcare is personalised care enables people to live a fulfilling life people are treated with dignity, compassion & respect HEALTH WORKFORCE An adequate and competent health workforce is critical for universal health coverage. WHO provided support at the strategic level as well as through capacity-building and direct contracting. Assessment of human resources at the Ministry of Public Health WHO strategic support in 2019 focused on assessing the human resources capacity at the Ministry of Public Health. The Ministry has been operating under severe shortages of human resources, which, in turn, have been exacerbated by a government decision to freeze recruitment over the past 12 years. Beneficiary doing blood sugar test at a primary health care centre. © WHO Lebanon / G. Bell 2120 Annual Report 2019WHO Lebanon Country Office Filling the gap in critical programmatic functions WHO was able to address the gaps in several critical programmes at the Ministry of Public Health through outsourcing human resources, which resulted in the smooth implementation of the various programmes. In 2019, a total of 39 persons supported the Ministry of Public Health centrally and peripherally. The support was provided to various departments; namely, the Epidemiological Surveillance Unit (for acute flaccid paralysis (AFP) and measles), the Health Systems and Accreditation department, the National Tuberculosis Program, the Primary Health Care department and the Statistics department, among others. Training and capacity-building WHO supported the training and capacity-building of health workers on various topics, including: 418 staff from 382 primary health care centres and dispensaries were trained on the rational use of medications and good medication management practices at the primary health care level; ~ 25 participants from various fields, including social work, mental health and law, were trained on assessing the quality and human rights aspects of facilities providing mental health care, using the WHO QualityRights tool kit; > 100 focal points, health care and social workers, and outreach and on-site volunteers were trained on the latest WHO HIV testing, counselling and treatment guidelines. In addition, WHO supported the participation of 54 national experts and academicians in regional and global meetings, training sessions and conferences organized by WHO during 2019. EMPLOYMENT TYPE The majority were full timers Surveyed employees by employement type permanent employees contracts (mainly renewable yearly) daily workers temporary workers 95.3% 25% 54% 17% 4% GEOGRAPHIC DISTRIBUTION Surveyed employees by gender 8%Beirut Mount Lebanon 32% 12% North 7% Bekaa 20% South 21%Nabatieh central administration19% regional centres81% DEMOGRAPHICS 41.5% 58.5% Surveyed employees by age group between 36 and 50 years of age 16% 35 years old or younger 30% between 51 and 60 years of age 36% above 60 years of age 18% Surveyed employees by area of residence Surveyed employees by operational office In partnership with the Lebanese University and with funding from the EU Madad Fund, WHO conducted a survey of all current Ministry of Public Health employees (fixed and contractual). The main results of the survey are given below. 2322 Annual Report 2019WHO Lebanon Country Office Barcode system In order to ensure high levels of quality, safety and efficacy of drugs, the Ministry of Public Health is working to establish a track and trace system for imported and locally manufactured pharmaceuticals. For this purpose, the Ministry of Public Health, with the support of WHO, initiated the development of a National Barcode Information System for pharmaceuticals in Lebanon using a GS1 two-dimensional barcode. This printed barcode is placed on all packages and allows for all stakeholders to be linked through a common information system. Through the EU Madad Fund’s health system strengthening component, WHO provided the support needed for the expansion and roll-out of the national GS1 barcode system for pharmaceuticals. Support included adjusting the software based on the findings of a pilot phase, and entailed: • issuing the regulations and guidelines needed for implementing the GS1 barcode system; • implementing the system at the central drug warehouse; • expanding the GS1 barcode system at the national level over one year by provision of critical IT software and hardware support, as well as training and capacity-building for Ministry of Public Health teams; • starting serialization in line with international standards. With support from several donors, including the EU Madad Fund, the Bureau of Population, Refugees, and Migration and Kuwait, WHO was able to secure around US$ 8 million to procure the required quantities of essential medicines for chronic and acute conditions in order to avoid any interruption of stocks. This support benefited a total of 92 000 vulnerable refugees and host community patients with chronic conditions, as well as some 350 000 patients with acute conditions. In 2019, a total of 100 primary health care centres benefiting from the chronic medications programme were visited and monitored, using a checklist prepared in consultation with the Ministry of Public Health. HEALTH INFORMATION SYSTEMS The findings of an assessment of the current health information system in Lebanon, conducted by WHO, highlighted significant strengths of the system as well as myriad opportunities for improvement (Table 4). The assessment identified 57 cross-cutting priority actions to enhance health information system operations across all functional areas. Table 4. Health information system strengths and opportunities for improvement STRENGTHS OPPORTUNITIES FOR IMPROVEMENT • Creating and adopting a unique identifier (biometric, national ID, or medical record number) to enable linkages of electronic platforms • Establishing nationwide interoperability standards and health information exchange • Developing dashboards for data dissemination and use • Developing standard operating procedures for data review and validation, as well as for regular supportive supervision for quality assurance • Vital statistics unit at Ministry of Public Health working on consolidating and analysing data • Civil registration and vital statistics assessment highlighting data sharing with the Ministry of Interior and Municipalities • Setting a defined list of priority diseases and standard case definitions under the current national surveillance system ACCESS TO ESSENTIAL MEDICINES WHO undertakes a wide range of activities to help ensure that all people living in Lebanon have access to essential, safe, high-quality and affordable medical products. Fig. 2. Total number of beneficiaries registered in the chronic medications programme (2016–2019) 2016 2017 2018 2019 158 000 170 769 185 231 203 760 Since 1996, a chronic medications programme, jointly operated by Ministry of Public Health and the Young Men’s Christians Association, has provided adequate and sufficient treatment to patients suffering from NCDs. WHO has been supporting the implementation of this programme in a network of 450 health facilities since 2012, through funds from the European Union and other donors. More than 200 000 beneficiaries were registered in 2019 (Fig. 2). WHO staff conducting monthly monitoring visits to facilities benefiting from the chronic medications programme to ensure that medications are stored and managed correctly. © WHO Lebanon / G. Bell 2524 Annual Report 2019WHO Lebanon Country Office LEADERSHIP AND GOVERNANCE Lebanon’s Health Vision 2030 In preparation for the development of Lebanon’s Health Vision 2030, and as part of the EU Madad Fund’s health system strengthening component, WHO initiated a series of studies and surveys with the aim of generating data to inform the development of health policies. The main studies and surveys initiated include: COMBATTING ANTIMICROBIAL RESISTANCE Antimicrobial resistance, caused by excessive and inappropriate use of antibiotics, reduces the effectiveness and number of options for antibiotic treatment, leading to increased morbidity, mortality and health care expenditures. In 2019, WHO continued its support in fighting antimicrobial resistance in Lebanon through costing and developing an implementation plan for antimicrobial resistance. The action plan was endorsed by the Ministry of Public Health. Lebanon’s National Antimicrobial Resistance Action Plan is based on WHO’s Global Action Plan on Antimicrobial Resistance. The plan covers five axes: awareness, surveillance, infection prevention and control, antibiotics use, budget planning and fundraising. The following activities have been achieved in 2019. During the meeting on electronic health record readiness. © WHO Lebanon Training of staff in hospital laboratories With the support of WHO and in partnership with the Ministry of Public Health, the research laboratory at the University of Saint Joseph and the microbiology laboratory at the American University of Beirut, a microbiology proficiency testing exercise was implemented in preparation for the establishment of a national laboratory External Quality Assurance System to enhance the quality of microbiology laboratory data. The training was attended by around 240 participants from 130 hospital laboratories across Lebanon. Conducting a survey on antibiotic use in hospitals Collecting data on antibiotic use and hospital-acquired infections are among the main targets of the National Antimicrobial Resistance Action Plan. As part of its support, WHO, in conjunction with the Ministry of Public Health, conducted a point prevalence survey on antibiotic use in hospitals in Lebanon. In addition, the WHO Regional Office for the Eastern Mediterranean supported the training of 22 medical supervisors and 44 data collectors from 22 hospitals across Lebanon. A total of 2700 questionnaires were filled by the hospitals and sent for analysis at the Regional Office. The data generated from this survey will inform national policies to promote appropriate use of antimicrobials and strengthen national- and facility-level infection prevention and control programmes. During the launching of the proficiency testing. © WHO Lebanon / L. Batlouny • provider practice survey; • nongovernmental organization profiling; • electronic health record feasibility; • nongovernmental organization mapping; • Ministry of Public Health human resources surveys; • diagnostics benchmarking; • nursing demographics and practice survey. In parallel, and in partnership with the University of Saint Joseph, WHO supported a health system analysis using the Health in Transition tool. Policy Support Observatory WHO continued its support for the Policy Support Observatory throughout 2019. The operational staff was recruited, two project advisory committee meetings were held, and international experts conducted two technical support missions. Five out of the 24 projects planned for 2019–2022 were initiated and are currently on track. WHO support was also extensively involved in the preparatory work for the National Health Forum, initially planned for December 2019. Support encompassed the identification of themes, the drafting of technical documents, the preparation of briefs for speakers, the development of specific material (audio-visual, infographics, etc.) and the coordination of logistics. The preparatory work was completed; however, due to the prevailing circumstances of political and social instabilities, the Forum was adjourned to a later date in 2020. Head of technical team at WHO Lebanon discussing the health system strengthening. © WHO Lebanon 2726 Annual Report 2019WHO Lebanon Country Office protect health: DEVELOP AND MAINTAIN EMERGENCY PREPAREDNESS AND HEALTH SECURITY priority area 2 EMERGENCY PREPAREDNESS AND HEALTH SECURITY In 2019, WHO continued its support to the Government of Lebanon in emergency preparedness and readiness for responding to all hazards. Hazardous materials training and drill in the South of Lebanon In line with the International Health Regulations (IHR) (2005) plan of action, WHO trained medical teams with the aim of establishing a HAZMAT team in South and Nabatieh governorates. WHO also procured equipment and trained health and non-health teams on safe response to chemical, biological and radionuclear hazards. Operationalizing the Public Health Emergency Operations Centre In 2019, WHO supported the development of an action plan for the Public Health Emergency Operations Centre that was established at Rafik Hariri University Hospital in 2007 (also with WHO support). WHO worked with the Ministry of Public Health and the Disaster Risk Management Unit established at the Prime Minister’s Office to upgrade the national Emergency Operations Centre with information and communication technologies and technical guidance. Field testing of the newly developed WHO handbook for ground crossings A team of experts from WHO headquarters, regional and country offices along with ministry officials from several countries visited the Masnah border crossing on 24 July 2019. The visit aimed at field-testing the Handbook for public health capacity-building at ground crossings and cross-border collaboration. The exercise will serve as the definitive legal framework to ensure global health security, especially on ground crossings for public health safety. DISEASE PREPAREDNESS AND SURVEILLANCE The epidemiological surveillance system at the Ministry of Public Health relies on health outlets such as hospitals, medical centres and laboratories as primary data sources. The data received are crucial to the analysis of communicable disease trends for surveillance, early detection of outbreaks and timely response. Improving data reporting In 2019, WHO continued its support to the national surveillance system and the Early Warning, Alert and Response System (EWARS). WHO supported the procurement of information technology equipment, staff recruitment and the training of around 1000 staff from 500 public schools on how to report communicable diseases using the District Health Information System 2 (DHIS2) software. The introduction of DHIS2 improved timeliness and completeness of reporting, which reached by the end of 2019: 82% and 94% respectively in hospitals 58% and 87% in laboratories 65% and 78% in medical centres 32% and 42% in schools Furthermore, WHO supported the development of standard operating procedures for the surveillance and management of 10 diseases: mumps, diphtheria, cholera, rabies, acquired rubella, congenital rubella syndrome, seasonal influenza, novel influenza, tetanus and tetanus neonatorum. Strengthening pandemic influenza preparedness In 2019, WHO continued its support to severe acute respiratory infection surveillance in eight sentinel sites. This was implemented in collaboration with the Epidemiological Surveillance Unit at the Ministry of Public Health and the National Influenza Center located at Rafik Hariri University Hospital. WHO support included: • procuring laboratory reagents, consumables and equipment; • training of staff on several technical areas (such as influenza sequencing); • quality assurance; • production of educational material and protocols for monitoring and evaluation; • participating in scientific conferences; • strengthening the human-animal interface through collaboration between the Ministry of Public Health and Ministry of Agriculture. WHO team member during the visit to the Masnah border. © WHO Lebanon / H. Habib 3130 Annual Report 2019WHO Lebanon Country Office Enhancing AFP and poliovirus environmental surveillance WHO provided human resources support in the form of secondment of 15 staff members to the Ministry of Public Health to support AFP active surveillance. In addition, WHO contributed to the development of awareness materials for health workers on AFP surveillance. These efforts helped to maintain indicators for AFP active surveillance above required standards. Supplementary to AFP surveillance in the National Programme for Poliovirus Eradication, WHO provided support to the Ministry of Public Health for sustaining monthly environmental surveillance to detect poliovirus (wild poliovirus, vaccine-derived poliovirus and Sabin polioviruses). WHO support included: • providing necessary kits and supplies to collect specimens; • technical support; • shipment and testing of the specimens collected. Responding to the measles outbreak In 2019, WHO supported the Ministry of Public Health in rapid risk assessment of the measles outbreak. Support included: laboratory support through procurement of reagents and supplies for confirmation of genotyping; capacity-building of around 100 staff from the Ministry of Public Health and nongovernmental organizations to enhance measles reporting; raising US$ 4.5 million for the implementation of the national measles campaign. As a response to the measles outbreak, a campaign was launched by the Ministry of Public Health in December 2019, with the support of WHO and the United Nations Children’s Fund (UNICEF), targeting around 1 million children aged between 6 months and 10 years. The campaign will continue into May 2020. Addressing new peak of leishmania cases In 2013, at the beginning of the Syrian crisis and the resulting influx of large numbers refugees into Lebanon, a peak in the number of positive leishmania cases was observed. Another peak occurred again in 2019. In response, WHO trained around 60 physicians working at emergency departments in public hospitals on the diagnosis of leishmaniasis and on adequate referral. Awareness sessions were also conducted with local nongovernmental organizations and with 175 local authorities from municipalities across Lebanon. WHO and AFP teams conducting joint visit and specimen collection. © WHO Lebanon / G. Bell Child receiving vaccine during the national measles campaign. © WHO Lebanon / G. Bell 3332 Annual Report 2019WHO Lebanon Country Office priority area 3 health priorities:IMPROVE HEALTH AND WELL-BEING ACROSS THE LIFE COURSE IMPROVING HUMAN CAPITAL ACROSS THE LIFE COURSE Health promotion in schools in disadvantaged areas WHO supported the implementation of the National School Health Program in five schools located in two rural areas in the South and Bekaa regions, in collaboration with the Modern University Business School and the AUB’s Champs Fund as implementing partners. The National School Health Program encompasses three main components: In this project, a total of 822 students from different cycles in the five schools were screened for medical conditions, and students aged 12 years and above who participated in sports activities were offered cardiac screening. An electronic version of the medical screening file, developed with WHO support, was used for a total of 700 students. The electronic record allows easy access to medical data and rapid generation of reports for the individual schools. Concurrently, 200 students benefited from the eHealth modules on physical activity, anti- tobacco, reproductive health and HIV, and road safety that were developed and adapted by WHO Lebanon. In addition, three health days for parents were organized, during which 296 of the students’ parents attended sessions on physical activity, nutrition and communicating with adolescents and children. In parallel, the healthy school initiative guidelines, recently developed by WHO in consultation with the Ministry of Public Health and the school health programme’s focal team, were piloted in the five schools. The guidelines constitute a comprehensive assessment and evaluation of the different aspects of a school that would determine its categorization into one of three “healthy school” levels: basic, advanced or excellent. Promoting hand hygiene for school children WHO supported the International Theatre, an educational entertainment mobile theatre, in performing an interactive puppet show about hand hygiene for children in schools across Lebanon. The purpose of the performance was to explain the concept of good hygiene, demonstrate personal hygiene practices, advocate for water conservation and help to prevent influenza and other communicable diseases. The performance was staged at six schools located in different regions in Lebanon (Beirut, the North, Mount Lebanon and the South), and consisted of a puppet show, an interactive session with questions and answers, and an entertaining educational song about handwashing that children were encouraged to memorize and practice. The project reached a total of 1536 students, who were actively engaged during show. The performance was highly welcomed by the management teams of the schools as well as greatly enjoyed by the students. Development of a guidebook for early detection of tumours in children WHO offered technical and financial support to the Children’s Cancer Center of Lebanon (CCCL) for the development of a guidebook for medical doctors about early detection of tumours among children. The guidebook has been developed to provide medical doctors with the information needed to act when a malignancy is suspected. The guidebook was printed with the support of WHO and disseminated by the CCCL to medical doctors in different regions in Lebanon. Bringing palliative care to the forefront of patient support WHO has been engaged in the development of palliative care in Lebanon since 2016, as part of WHO support to implement people-centred care, namely, ensuring the continuum of care. In 2019, WHO’s contribution focused on replicating the proposed model of palliative care, based on a mobile palliative care team within a hospital, to ensure hospice and home care for end-of-life patients. The palliative care initiative was expanded in partnership with a specialized nongovernmental organization, SANAD. The project encompassed three components: health education school environmentmedical screening Cardiac screening in collaboration with Champs fund. © WHO Lebanon / G. Bell 3736 Annual Report 2019WHO Lebanon Country Office Working with media to fight stigma related to mental health The National Mental Health Programme at the Ministry of Public Health was established in 2014 with strong advocacy and support from WHO. Throughout 2019, the National Mental Health Programme continued to benefit from this support. In this context, a practical guide for media professionals on the coverage of mental health and substance use was developed, to promote informed and responsible reporting about mental health, and thus fight stigma related to mental disorders. finalizing the establishment of a hospital-based palliative care service at Rafik Hariri University Hospital in Beirut; establishing a home-based palliative care service at Ain Wazein Medical Village hospital in Mount Lebanon; and supporting the CCCL team in conducting support groups. The project was successful in finalizing the establishment of a palliative care service at the Rafik Hariri University Hospital through different training and shadowing stages. A noticeable culture change has been observed, with many oncologists now readily referring patients to the palliative care service. Patients are increasingly benefiting from the services of the well-trained multidisciplinary palliative care team. At Ain Wazein Medical Village, the palliative care team has been trained on home-based palliative care and a palliative care system has been established. As part of the third component of the project, the capacity of CCCL’s team members was upgraded for running and leading support group discussions for their staff in order to alleviate the stressors of their work that often cause staff burnout. In parallel, WHO has supported a costing exercise to determine the reimbursement scheme that the Ministry of Public Health will offer for hospitals and nongovernmental organizations providing palliative care services. PREVENTING NCDS AND PROMOTING MENTAL HEALTH Addressing nutrition to improve health Malnutrition in all its forms takes a heavy toll on the health, well-being and sustainable development of Lebanon’s population. NCDs, unhealthy diets and physical inactivity are key contributors to this burden. Following a consultative process, WHO Lebanon supported the Ministry of Public Health in developing a National Nutrition Strategy. The strategy outlines a road map for the improvement of the nutritional situation and outcomes in the Lebanese population. The final strategy document and plan of action will be completed in 2020. In addition, and as part of the global target to eliminate trans-fat from the local food supply, WHO conducted a food composition analysis for the 30 most consumed dishes in the Lebanese diet, as well as for Arabic sweets and some market food products (biscuits, oils, etc.). Food composition analysis in the Industrial Research Institute laboratories. © WHO Lebanon / G. Bell Palliative care service at the Rafik Hariri University Hospital. © WHO Lebanon / H. Habib 3938 Annual Report 2019WHO Lebanon Country Office ACCELERATING ELIMINATION AND ERADICATION OF HIGH-IMPACT COMMUNICABLE DISEASES: HIV With WHO support, and in collaboration with nongovernmental organizations and service providers, the National AIDS Program was able to maximize HIV testing uptake and increase coverage to rural areas across the country. Prevention On-site and outreach sexual health activities were conducted, including HIV testing, counselling, referrals, psychosocial support and other related services. > 9 000 rapid HIV tests were conducted and 214 positive cases were detected in 2019. ~ 2 000 HIV self-tests were conducted. This is an innovative testing methodology that partially leapfrogs associated stigma and discrimination by ensuring the privacy of users. > 80 000 condoms were distributed. > 100 social workers were trained on HIV and sexually transmitted infection basics, as well as on counselling and partner notification. Through intensified decentralized testing at the community level, 2500 persons living with HIV are now aware of their status in Lebanon in 2019. Treatment The National AIDS Program provided antiretroviral treatment to more than 1700 persons living with HIV. With the support of the International Organization for Migration and through the Global Fund to Fight AIDS, Tuberculosis and Malaria, the National AIDS Program was able to provide treatment and cover the costs of necessary laboratory tests for close to 150 non-Lebanese persons living with HIV. A total of 214 new cases were started on treatment in 2019, while all persons living with HIV in Lebanon received continuous treatment as per the latest guidelines without any stock interruption. During 2019, the antiretroviral treatment guidelines were updated and adapted according to the most current international recommendations, and in particular the WHO consolidated guidelines (July 2019). These guidelines take into consideration the current epidemiology in Lebanon as well as the availability of drugs and laboratory testing capacities. PROTECTING THE HUMAN RIGHTS OF PERSONS WITH PSYCHOSOCIAL DISABILITIES In February 2019, Al-Fanar Psychiatric Hospital in Lebanon was closed down following allegations of serious human rights violations against beneficiaries, such as inadequate standards of living, lack of hygiene and suboptimal treatment, among other abuses. WHO Lebanon and the National Mental Health Programme at the Ministry of Public Health were successful in advocating for rights of the beneficiaries as well as the use of the WHO QualityRights tool for assessing and improving the quality and human rights aspects of mental health services. Prior to its closure, Al-Fanar hospital hosted about 166 people (70% males and 30% females, the majority of which were Lebanese nationals). Following its closure, the people at Al-Fanar hospital were transferred to four different facilities in the country. Emergency needs were addressed; namely, the treatment of lice and scabies, securing personal hygiene and clothing items, screening for tuberculosis and provision of necessary preventive treatment and other screening tests, in addition to hospitalization for emergency mental health and medical treatment. During the QualityRights assessment conducted in mental health facilities. © WHO Lebanon / G. Bell 4140 Annual Report 2019WHO Lebanon Country Office Research studies The test–treat–retain cascade analysis was updated in Lebanon in 2019. The main findings are: 94.7% of people living with HIV were found to be aware of their status (compared to 68.6% in 2015); 68.5% were found to be enrolled in care (compared to 61.7% in 2015); and 59.3% were virally suppressed (compared to 35.4% in 2015). ADDRESSING ENVIRONMENTAL HEALTH Ministry of Public Health water laboratories assessment WHO supported the assessment of water laboratories in eight public hospitals. The aim was to evaluate the functionalities of the water laboratories, and to propose the necessary corrective measures. The recommendations of the assessment included: • developing guidelines on water sampling techniques and testing; • provision of equipment and reagents for chemical and physical testing; • capacity-building on water analysis, water sampling techniques and drinking water quality surveillance of different staff involved in these activities; • addressing water laboratory software. A study on the prevalence of sexually transmitted infections and associated risky behaviours was conducted among men who have sex with men. The results showed a high lifetime prevalence of: Gonorrhoea 21.4% Human papillomavirus 17.4% Chlamydia 13.4% across a sample of men who have sex with men, with a strikingly low mean age. A high-risk behavioural profile was also detected across the sample. Fig. 3. Test–treat–retain cascade 2019 findings = 68.5% of all people living with HIV 94.7% aware of their HIV status 72.4% virally suppressed = 59.3% of all people living with HIV 91.9% on HIV treatment of which of which Joint workshop on environmental health A joint environmental health workshop took place between the United Nations, the European Union and the World Bank. Recommendations from the workshop included updating the existing environmental health strategy, taking into account the following actions: • aligning ongoing environment priorities with the SDGs; • strengthening early warning, monitoring and surveillance for different environmental health hazards; • estimating the economic and social impact of environmental risks on health; • advocating for environmental risk mitigation in all programmes with clear follow-up mechanisms; • enhancing coordination and leadership. Beneficiary receiving HIV medication and health education at the National Aids Program centre. © WHO Lebanon / G. Bell Visit to the water laboratories. © WHO Lebanon / G. Bell 4342 Annual Report 2019WHO Lebanon Country Office In 2017, the WHO Framework Convention on Tobacco Control established a knowledge hub for waterpipe tobacco smoking at the AUB. In 2019, the hub continues to implement activities that aim at curbing the epidemic of tobacco use, including the burden of waterpipe smoking. These activities include enhancing awareness on the use of waterpipe health warning labels, as well as on the toxicant contents of waterpipe smoke, and on the health effects of waterpipe tobacco smoking and the economics of tobacco consumption. National academic institutions that were declared smoke-free Following the declaration of the AUB in 2018, the University of Saint Joseph and the Lebanese University- Central Administration declared their campuses smoke-free in 2019. This is the result both of continuous advocacy led by WHO and commitment of the Ministry of Public Health to encourage more institutions apply tobacco control Law No. 174. the way forward Amid the complex and critical situation in Lebanon, WHO will continue its support to the health sector in general and specifically to the Ministry of Public Health. Strengthening the health system will be further supported through the projects under the EU Madad Fund (until 2022), with additional funds received to cover existing gaps in medicines for acute and chronic conditions. Support to health system strengthening with a focus on universal health coverage under the EU-Luxembourg projects will continue. Similarly, the support to mental health under a project funded by the Agence Française de Développement will be pursued through to 2022, with a focus on advocacy and rights, with the development of a modular university training curriculum for mental health management and leadership. The SDG 3+ Global Action Plan road map will be further developed into a project to be supported through a multi-donor trust fund. Moreover, support to strengthening emergency preparedness and response will continue, especially in the light of the coronavirus disease (COVID-19) pandemic. Health security, within the IHR (2005) requirements, will be further reinforced. Re-establishing a central public health laboratory and expanding the capacity and automation of the central drug warehouse are both critical issues that will require priority support. Specific attention will be given to health care access, and in particular to good quality care. This will be carried out through the expansion of people-centred primary care by ensuring quality care through capacity-building and audits. Mobilizing resources for critical interventions will be intensified, particularly in the light of the evolving financial crisis. Further expansion of the WHO Country Office team with staff and/or United Nations volunteers is underway to better respond to the escalating needs for technical and logistics support. Training on air quality monitoring In collaboration with the AUB Nature Conservation Center, WHO through its Regional Centre for Environmental Health Action organized a 2-day training workshop on health impact assessment of air pollution in Lebanon. The workshop feeds into the application of the air quality and health road map, which addresses air pollution, climate change and the sustainable development agenda. The workshop was part of the overall framework for the environmental health risks programme. As the objective of the framework is to address environmental health degradation in the country, collecting evidence on the health impacts of air pollution is essential. Water assessment WHO supported the assessment of drinking water by conducting the UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water country survey in 2019. The survey focused specifically on policies and national targets, with water, sanitation and hygiene finance as a major theme. WHO continues its advocacy against tobacco use in Lebanon A team of national experts was trained on the WHO Tobacco Taxation Simulation Model. Following this, a tobacco taxation study was conducted to generate evidence for advocacy. The main recommendation was to tax locally produced tobacco products as well as imported tobacco products. 45Annual Report 201944 WHO Lebanon Country Office WHO staff signing the WHO values charter. © WHO Lebanon / H. Habib P.O. Box 11-5391 Beirut, Lebanon www.emro.who.int/countries/lbn/ emwroleb@who.int WHOLebanon 9789292746841