S4 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Letter from the Editor The year 2008 marks the anniversaries of two auspicious occasions in the history of public health. The first is the 60th anniversary of the founding of the World Health Organization on 7 April 1948, the second the 30th an- niversary of the Declaration of Alma Ata on 12 September 1978. With the establishment of the United Nations (UN) in 1945, it was decided in 1946 to create a single health organization of the UN which would join together and continue the functions previously carried out by the Health Organization of the League of Nations, the Office Interna- tional d’Hygiène Publique (OIHP), and a third across the Atlantic, the Pan American Sanitary Bureau. Thus was the beginning of WHO, but it did not come into formal existence until 7 April 1948, when its constitution was ratified by UN Member States. The preamble to the WHO Constitution illustrates the idealism em- bodied in the establishment of the Organization: that health goes beyond simply the absence of disease or infirmity and is a state of complete physical, mental, and social well-being; that health is a basic human right for all people, irrespective of race, religion, political belief, and economic or social condition; that health is central to the attainment of peace; and that governments have a responsibility for the health of their peoples. The Organization thus has just one objective, clear and simple: the attainment by all peoples of the highest possible level of health. While in the 30 years following the founding of WHO much progress in health was made, there was a growing realization of and dissatisfaction with the inequalities in health status and the provision of health care, particularly among the developing countries. This prompted WHO and UNICEF to convene the International Conference on Primary Health Care at Alma Ata in 1978. At this groundbreaking meeting, primary health care came to the fore and its importance as a means to achieving an acceptable level of health for all was recognized. The meeting culminated in the Declaration of Alma Ata which emphasized, inter alia: the need to reduce inequalities in health status; the link between health and development; the need for community involvement in health care planning and provision; and the responsibility of governments for the health of their peoples. It reaffirmed that health is a human right and the attainment of the highest possible level of health was a paramount social goal, and it clearly stated that primary health care was the key to attaining this goal. Now in 2008, the world is greatly changed since 1948, and even 1978. Unfortunately, inequalities in health status and in access to health care remain and much still needs to be done, but there is now unprecedented interest in health and increasing recognition that health and development are inextricably linked and should be addressed together; hence the focus, Eastern Mediterranean Health Journal, Vol. 14, Special Issue S5 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما for example, on the Millenium Development Goals and the Social Deter- minants of Health. WHO continues to pursue its objective and remains committed to comprehensive primary health care as a means to address the challenges of health in the 21st century. The current special issue provides a brief view of WHO’s work and achievements in the past 60 and 30 years, with particular reference to the Eastern Mediterranean Region. Sixty, or even 30, years of work cannot be condensed into a single issue but we hope the papers presented give some illustration of what WHO has been doing and where it is going in its continuing aspiration to achieve health for all. We would like to thank all the authors in this issue for their valuable contribution. Among the 26 countries that ratified the WHO Constitution, the follow- ing were from the Eastern Mediterranean Region: Iran 23 November 1946 Syria 18 December 1946 Jordan 7 April 1947 Saudi Arabia 26 May 1947 Iraq 23 September 1947 Egypt 16 December 1947 The dates shown indicate the time each country became party to the constitution. S6 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما eëf=ÀºÍ¶>ie ½>¢¸ëN2008>[»Æ?(Í[ɺǻ£¶=ÍVr[¶=_Èe>[I®e>[ªMbËÇ¿j¶=bÉ£¶= äJj¶=bÉ£¶=ÁÇÍÉ>£¶=ÍVr¶=Í»¿ºÐ>n¾Ý7Á>jɾ+¸[ÈfEC1948b[É£¶=>[»Ãɾ>MÆ( ÇMØN¶=ËÇ¿j¶=>IA>?ÁØ¢ÝÁ12¹Ç·È?+»JFi1978* ÌbVJ=¼ºÙ=Ð>n¾DFª½>[¢1945½>[¢ef[¯I(1946Ìb[U=ÆÍ[»¿ºÐ>n[¾C >[º>[ÃEK£·ì[u=[¶=½>[Ã=¸q=ÇIƼvIÁ?η¢(ÍVr¶>Eο£IÌbVJ=¼ºÚ¶ Íɺǻ£¶=ÍVr·¶Ê¶Æb¶=GJ³=Æ(¼ºÙ=ÍFr¢°Fi*ÆÙ=ÍÈ=bF¶=ÌÇì=Åd¸ëNÆ =aÇ[QǶ=hëÉUCTf¶=Æ(ÍÉ>£¶=ÍVr¶=Í»¿×CÊ[f¶7Á>j[ɾ+¸[ÈfEC 1948Í»¿=eÇJiaη¢ÌbVJ=¼ºÙ>EÐ>v¢Ù=¹Æb¶=°ÈbrJE(* [É>£¶=ÍVr[¶=Í[»¿ºeÇJ[iaÍ[Q>FÈaX[uÇIÆ[[ºÍ[[ɶ>N=Ïb[[¶=ÍLb[[j[ \ÇuÇEÍ»¿=Ð>n¾C6Vr¶>ª[af η¢frJ¯I×Íh[R£¶=Æ?zf=½=b£¾=¸[E( ³¶=Ì>ª>£=ÀºÍ¶>UÊÂÊ[ÂÍVr[¶=Æ7ð>[É¢>»JQ=Æð>Éj[«¾Æð>ɾb[EÍ·º>±Ç[¯=b[U? GFj[Eh[ÉÉÁÆa(Á>j[¾C¸[³¶ÍÉ[i>iÙ=Êi>Éj[¶=b[¯J£=Æ?ÀÈb[¶=Æ?±f[£¶=Æ? ½Øj[¶=°[ɯl>[iÙ=Ê[ÂÍVr¶=Æ(ÍÉ¢>»JQ×=ÆÍÈa>rJ®×=¹=ÇUÙ=7>[»²Á? L>ºÇ³=HÇ£n¶=ÍVqÀ¢Í¶ÆÖjº*[U=ÆbÂÍ»¿»·¶Á>²>¿ÂÀºÆX[u=Æb l>¿¶=¤É»|©Ç·F¶=ÇÂÆÉjEÆCÍVr¶=ÀºÀ³ÏÇJjº¤ªe?* F²½èb¯Ig=fUC¼¦eƹ> ßI¶=MØN¶=L=Ç¿j¶=¹Ø]ÍVr¶=í·áKkÉ[i@I ßIb¯ª(ÍÉ>£¶=ÍVr¶=Í»¿ºß¿ßº>ù{>Eε=eaÝ=a=f×=ÆÐ>ÉJiÐ=äf[QÀºÌ=Æ>j[=½=b[£¾= ¥>uÆÙ=>JÈCÆÍÉVr¶=Íɺ>¿¶=Á=b·F¶=>»çÉi×Æ(ÍÉVr¶=ÍÈ>¢f¶=Ð*¤[ªab[®Æ ÀºðزÐ>ÉJi×=´¶cÍÉ>£¶=ÍVr¶=Í»¿º¹Ç[UʶÆb[¶=fÖ[=b[¯£¶¬j[ɾÇɶ=Æ ½>¢>IA>?ÍɶÆÙ=ÍÉVr¶=ÍÈ>¢f¶=1978*=dÂÆ¥>»JQ×=ÍÈ>¢f¶=LebrI½>= Í[ɶÆÙ=ÍÉVr¶=î?Æ(L>[ÈǶÆÙ=¼·[ið>[º>f[®>[ÃJÉ»Â@E¸ àF[àiÏb[UD²C¹Ç[qǶ= ¸·³IÆ(¤É»R·¶ÍVr¶=Àº¹ÇF¯ºÏÇJjº¥>»JQ×=À[º(b[õ²?Ëd¶=>IA>?ÁØ¢DE eǺ?Í·EÌ=Æ>j=½=b£¾=sÉ·¯IÌeÆfuη¢¥>uÆÙ=ÍÉVr¶=7[EEf[¶=Æ Í[É»¿J¶=ÆÍVr[¶=7>[ÃÑ>JÈCÆÍÉVr[¶=Í[È>¢f·¶É[ì^J¶=¤[»J=½>Ã[iCÌeÆf[uÆ7 >ÃEÇ£mÍVqÀ¢L>ºÇ³=ÍɶÆÖjºÆ*bõ²?b®Æð=ab ¥>»JQ×=ÍVr[¶=Á?Î[·¢ >j¾Ý=±Ç¯UÀº°UÁ7ªe?©Ç·EÁ?ÆÊ¢>[»JQ=b[ÂÇ[ÂÀ³ÊVqÏÇJjº¤ ÊjÉÑe7s¾>»²EuÇÇÍÉVr[¶=ÍÈ>¢f¶=Á?η¢\Í[ɶÆÙ=´[¶c©Ç[·E\>[J«ºÊ[ b=* ½>¢ÀÆ(½Çɶ=Æ2008ð=F²ð=§IbÃn¾½>[¢ÄÉ·¢Á>²>»¢>£¶=1948( ½>¢ÄÉ·¢Á>²>»¢¸E1978*ÆÀ³¶¬[iڶǢb[È>[e=f»J[i=>[VQÝ=½=b[£¾= Ù=Ì=Æ>j=¥>uÆÍÉVr¶=ÍÉVr¶=ÍÈ>¢f¶=Ð>JÈCÆ*Ê[§F¿È>[N[³¶=µ>¿Ãª¼MÀºÆ ÄE¥Øìu×=(eÇ[ÃÀ[º¼¦f¶>E½>[»JÂ=ÍVr[¶>E±ÇFj[º[¦Æ(À[º¼¦f[¶=Î[·¢ ×=J¢[f==ʺ>¿J°ÉMǶ=E=f[J¶>EEÊ{>[£J¶=ÌeÆf[uÆÍ[É»¿J¶=ÆÍVr¶=>[»Ã£º Eastern Mediterranean Health Journal, Vol. 14, Special Issue S7 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Á=fÈhU ÍÉ>£¶= ÍVr¶= Í»¿º eÇJia b»J¢= + ÇɾÇÈ1949hÉU ¸]bÈ À³¶Æ ( Á>jɾÀº¤E>j¶=×C°ÉFìJ¶=+¸ÈfE?1948ÀºÍ¶ÆaÁÆfn¢ÆKiÄÉ·¢K®a>qÁ?b£E( (iÇJ=±fm ¼É·®C Àº Íɶ>J¶= ÍJj¶= Á=b·F¶= (¹Æb¶=´·IE Àº Á>²Æ (Ð>v¢Ù= ¹Æb¶= iÇ®EÏfÈÆ_Èe>IeÇJib¶=η¢Í®a>r==f{Ù=C>ÿº¸²½>»v¾=6 Á=fÈC %23ʾ>N¶=ÀÈfnI+»ªÇ¾1946$ ÍÈeÇi %18¹ÆÙ=ÁǾ>²+»jÈa1946$ ÁaeÙ=%7Á>jɾ+¸ÈfE?1947$ ¶=ÍÉEf£¶=ͳ·»=ÍÈaÇ£j%26e>È?+ÇÈ>º1947$ ±=f£¶=%23¹Ç·È?+»JFi1947$ frº %16¹ÆÙ=ÁǾ>²+»jÈa1947$ ð>£ºæK®Æ*[J¶=Ð>[Q>[¿ÂÀºÆ[Í[É«¶Ú¶Í[ÉÑ>Ý=Ê[º=f=Î[·¢¹>[N=¸ÉF[iÎ[·¢hɲf ÍVr[·¶ÍÉ¢>»JQ×=L=ab=Æ*Ç[Ê£j[¶=Í[É>£¶=ÍVr[¶=Í[»¿º¸[q=ÇIÆ©Ç[·E (>ê=b[Â?>¢f¶>E>[ú=hJ¶=e=f»J[i=¤[ºÙ=ÍÉVr[¶=Í[È>[Âe>FJ¢>EÍ·º>n[¶=Í[ɶÆÍ·É[iÆ =ëbrJ¶äbVJ·¶ËÁf¯¶=ÍÉVr¶=L>ÈbU=Ƕ=ÀÈfn£¶=Æ* >¿Èb[È?EËd¶=t>=ab£¶=½b¯ÈÆÍ[¶Ø{CÌhQÇ[ºÎ[·¢ÍVr[¶=Í[»¿º¸[»¢ Jj¶=L=Ç¿j¶=¹Ø]>ÃI=g>CÆÍÉ>£¶=(ÆÍ[q>]Ìe>mC¤ºMØN¶=L=Ç¿j¶=¹Ø] iÇJ=±fm¼É·®Ý*À[ºð>[º>¢[MØMÎ[JUÆ?Ji¹=hJ]=ed£J=ÀºÁ?XÉVq L>VÉuÇJ¶=x£EÄɪͺçb¯=±=eÆÙ=Îì£IÁ?¸º@¾>¿¾?×C(bU=Ææab¢¸»£¶=> ÄEKº>®Í»¿=(EÊv¶=ÍÃQǶ=À¢Æ>ñ>Éiò·ìIÍVr[¶=°É¯VJ¶¼Ñ=b¶=>㠤ɻR·¶* E½b¯J¾Á?(½>J=(èaßÇß¾Æ=Æf³n¶>¤É»Á>¿Jº×ab£¶==dÂH>çJ²äb®>ÀºÅǺ Í»ëÉ®L>»Â>jº* S8 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Preamble to the Constitution of the World Health Organization THE STATES PARTIES to this Constitution declare, in conformity with the Charter of the United Nations, that the following principles are basic to the happiness, harmonious relations and security of all peoples: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, political belief, economic or social condition. The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States. The achievement of any State in the promotion and protection of health is of value to all. Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger. Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development. The extension to all peoples of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health. Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people. Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. ACCEPTING THESE PRINCIPLES, and for the purpose of co-operation among themselves and with others to promote and protect the health of all peoples, the Contracting Parties agree to the present Constitution and hereby establish the World Health Organization as a specialized agency within the terms of Article 57 of the Charter of the United Nations. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S9 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Declaration of Alma Ata The Declaration of Alma Ata was adopted at the International Conference on Primary Health Care, Alma Ata, USSR, 6–12 September 1978 The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most impor- tant world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. II The existing gross inequality in the health status of the people particularly between devel- oped and developing countries as well as within countries is politically, socially and eco- nomically unacceptable and is, therefore, of common concern to all countries. III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social develop- ment and contributes to a better quality of life and to world peace. IV The people have the right and duty to participate individually and collectively in the plan- ning and implementation of their health care. V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of govern- ments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that S10 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Primary health care is essential health care based on practical, scientifically sound and so- cially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfre- liance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. VI will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice. VII Primary health care: 1. Reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience; 2. Addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly; 3. Includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, in- cluding family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs; 4. Involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors; 5. Requires and promotes maximum community and individual self-reliance and participa- tion in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate; 6. Should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need; 7. Relies, at local and referral levels, on health workers, including physicians, nurses, mid- wives, auxiliaries and community workers as applicable, as well as traditional practition- ers as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S11 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly con- cerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world. VIII All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country’s resources and to use available external resources rationally. IX X An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share. The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all health workers and the whole world community to sup- port national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration. S12 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Editorial Thirty years of primary health care in the Eastern Mediterranean Region Belgacem Sabri1 1Director, Division of Health Systems and Services Development, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Belgacem Sabri: sabrib@emro.who.int). The World Health Organization (WHO) is celebrating its 60th anniversary this year which coincides also with the 30th anni- versary of the Declaration of Alma Ata on health for all through primary health care (PHC) [1]. The double celebration will al- low countries around the world, including those of the WHO Eastern Mediterranean Region, to assess the major achievements of PHC reform, to deal with the unfinished agenda and to look to the future taking into consideration the evolving health and non- health scenarios at national, regional and global levels. Since Alma Ata, the health status of people has improved in most countries as reflected in the trend analysis of life expect- ancy and important morbidity and mortality indicators. These health gains have been facilitated by improvements in the major social determinants of health, including literacy, economic development and access to clean water and sanitation. In addition, during this time, more evidence has been generated on the positive linkages between health and development as reflected in sev- eral global publications such as the World Development Report: investing in health and Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health [2,3]. Key poverty reduction strate- gies have advocated increasing investment in health and the development of pro-poor health policies and interventions. The glo- bal efforts culminated in the United Nations (UN) Millenium Summit in 2000 out of which came the Millennium Development Goals that called for actions to improve the lives of the poor and set targets to be met by 2015 [4]. The strong political commitment of policy-makers to the Goals and principles of PHC has had a positive impact on the de- velopment and strengthening of health sys- tems in the Eastern Mediterranean Region. Ministries of health have been restructured in order to accommodate the new integrated and comprehensive approach to service delivery and to focus on decentralization. Many countries have expanded their PHC networks using community health workers, who provide prevention and promotion services and supply essential medicines to treat minor health problems in the com- munity. Efforts have also been made to promote community participation and empowerment and to seek intersectoral collaboration through community-based initiatives centred on health development. All community-based schemes use so- cial and economic determinants as entry points to comprehensive development in- cluding health. The increase in the number of countries using such approaches illus- trates the degree of ownership that com- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S13 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ munities feel of their efforts to improve individual, community and public health services. The WHO Regional Office for the Eastern Mediterranean has been active in networking between developing com- munities inside and outside countries and in trying to make objective evaluations of the integration of the various social, economic and health dimensions of community-based initiatives [5]. The launch of health for all through pri- mary health care in 1978 occurred against an unfavourable economic and political background worldwide and in our Region. The severe economic crisis in the 1980s and major macroeconomic reforms implement- ed in low- and middle-income countries constrained investment in health and public health. The economic support advocated by WHO to implement PHC, the need for which has been further highlighted by the work of the Commission on Macroeconom- ics and Health, has not fully materialized, and many health systems in the Region remain under-funded. Inequity in health care financing has not decreased since Alma Ata as reflected in increasing out-of-pocket spending and reduction of government spending on health [6]. The limited economic and financial support to health systems has not allowed proper implementation of decentralized health systems based on PHC in some countries. Despite commendable efforts by governments, the level of social health protection remains inadequate in low- and middle-income countries of the Region. Re- cent research carried out by WHO globally and in the Region shows a worrying trend of catastrophic ill health expenditure and impoverishment following sickness of one or more household members [6]. Achievement of health goals has also been hampered by the political determi- nants of health represented by war, oc- cupation and civil strife which exist in about a third of the countries of the Region. Man-made disasters, and also droughts and earthquakes, have also negatively affected the development and strengthening of PHC networks, particularly in rural and remote areas. Health systems of the Region are faced with many challenges, including epidemio- logical and demographic transitions, and the challenge of globalization. Our countries are at various levels of transition and most low-income countries are facing the double burden of communicable and noncommuni- cable diseases. The health workforce is not appropriately trained to deal with the impact of this transition, particularly in relation to the promotion of healthy lifestyles and ca- tering for ageing patients and communities. Globalization is having an impact both on lifestyles, through the promotion of un- healthy food, and on health systems, through limited access to health and biomedical technology and migration of skilled health professionals inside and between countries. At the same time some countries of the Region are striving to benefit from new opportunities offered by global economies in view of their comparative advantages in trade in health. These opportunities include health and medical tourism which is being promoted in some countries and the training of health professionals for external markets by other countries. In view of this background and the awareness of the importance of PHC, policy- makers of the Region have reaffirmed their commitment to the values and principles of PHC, as reflected in many Regional Com- mittee resolutions [7]. They have reaffirmed health as a human right and highlighted the importance of intersectoral collaboration in health development. Their strong com- mitment to the Millenium Development Goals has focused on the need to invest in S14 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ health and to direct attention to the social determinants of health. This move was also triggered by WHO’s renewed focus on so- cial determinants through the establishment of the Commission on Social Determinants of Health, a global commission that has worked for 3 years and that will provide WHO and its Member States with concrete and feasible recommendations on including the social determinants approach in health systems. In reviving PHC, countries are building on positive achievements and are trying to mitigate the negative impact of some shortcomings in implementing PHC. Im- proved integration, out-reach programmes and community- and home-based services are now the focus of service delivery. Train- ing of health professionals is being oriented towards meeting community health needs and dealing with the implications of epi- demiological and demographic transitions. Human resources development is scaling up community health workers in some coun- tries where health systems are facing severe challenges including limited funding. Communities are being empowered in order to contribute to their own health de- velopment by promoting healthy lifestyles and physical activity and by involving them in planning and management of health care services. This is being facilitated by the growing and active role played by social society organizations in many countries of the Region. The celebration activities to mark the 30th anniversary of Alma Ata and the 60th anniversary of WHO offer a golden op- portunity to learn important lessons on both the factors that facilitate and those that hamper implementation of PHC in our Region. Sharing experiences and network- ing between countries and professionals will strengthen the Regional move towards better and equitable health development. References 1. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September, 1978 (http://www.who.int/hpr/NPH/docs/dec- laration_almaata.pdf, accessed 3 June 2008). 2. World Development Report 1993: in- vesting in health. Washington DC, World Bank, 1993. 3. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva, World Health Or- ganization, 2001. 4. UN Millenium Development Goals (http:// www.un.org/millenniumgoals/, accessed 3 June 2008). 5. Community based initiatives [website] (http://www.emro.who.int/cbi/index.htm, accessed 3 June 2008). 6. The impact of health expenditure on households and options for alternative financing. Technical paper presented at the 51st Session of the Regional Com- mittee for the Eastern Mediterranean, September 2004 (http://www.emro.who. int/RC51/media/EMRC5104.doc, ac- cessed 16 June 2008). 7. Resolutions of the Regional Committee (http://www.emro.who.int/governance/ resolutions.htm, accessed 3 June 2008). Eastern Mediterranean Health Journal, Vol. 14, Special Issue S15 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Editorial Health protection and promotion Haifa Husni Madi1 and Syed Jaffar Hussain2 1Director of Health Protection and Promotion; 2Regional Adviser, Healthy Lifestyle Promotion, Division of Health Protection and Promotion, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Syed Jaffar Hussain: hussains@emro.who.int). Evolution of health promotion: a stand-alone concept or building on primary health care? The origin and evolution of health promo- tion is complex, and no single driver is re- sponsible [1]. The predominant belief (and understanding) revolves mostly around the fact that health promotion as a public health component was introduced in 1986 by the World Health Organization (WHO) in Ot- tawa [2], paving the way for the subsequent health promotion movement. However, health promotion, as a conceptual framework, stimu- lating a shift in thinking began around 1978 when “primary health care” was adopted at the Alma-Ata conference as the principal mechanism for health care delivery [3]. The Alma-Ata Declaration underlined the WHO strategy of “Health for all by the year 2000” (1977) [4]. It crucially recognized that health improvements would not occur just by devel- oping more health services or by imposing public health solutions and heralded a shift in power from the providers of health services to the consumers of those services and the wider community [1]. The primary health care initiative became the driving force for comprehensive health development over the following 2 decades, and provided the right environment for the concept of health promo- tion to develop and grow. During the early 1980s, the term “health promotion” was increasingly used by a new wave of public health activists who were dissatisfied with the rather traditional and top-down approaches of “health educa- tion” and “disease prevention” [1]. This, however, generated a debate among the global public health community about the various theories and concepts of prevention, education and promotion. Whereas the term “health protection” existed long before that, and was considered to be consistent with the disease perspective and focused attention on prevention of disease risk factors and diseases [5], it has since been reinforced through the primary health care and health promotion approaches. The debate prompted WHO to call a spe- cial meeting in late 1984 in Copenhagen to provide some clarity and direction. This led to the first substantive document on health promotion [6]. Two years later the first con- ference on “health promotion” in Ottawa defined the term as “the process of enabling people to increase control over, and to im- prove, their health” in the Ottawa Charter, which is still considered the most valid principle of furthering health promotion in the 21st century [2]. The definition has its roots in earlier initiatives such as the Alma- Ata Declaration, which introduced political action, social understanding, and economic policy to the concept of health promotion [3]. The Ottawa Charter further legitimized health promotion as it emphasized the need for intersectoral collaboration and equity in health [2]. The call for action for health S16 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ promotion referred to 5 strategies: building healthy policy, creating supportive environ- ments, strengthening community action, developing personal skills, and reorienting health services. The Ottawa conference is often regarded as a milestone in the field of health promotion because a vision and a strategy to advocate health promotion were developed and effectively brought to the attention of the public. In the ensuing 2 decades, the key achieve- ment of Ottawa 1986 was to legitimize the vision of health promotion by clarifying the key concepts, highlighting the conditions and resources required for health, and identifying key actions and basic strategies to pursue the WHO policy of “health for all”. Importantly, the Charter that emerged also identified the prerequisites for health, including peace, a stable ecosystem, social justice and equity, and resources such as education, food and in- come. It highlighted the role of organizations, systems and communities as well as individual behaviours and capacities, in creating choices and opportunities for better health [1]. Since the first conference in Ottawa, WHO has been instrumental in organizing subse- quent global conferences on health promotion in partnership with national governments and associations. These mostly focused on each of Ottawa’s 5 health promotion strate- gies. The Second International Conference on Health Promotion in Adelaide, Australia in 1988 explored in greater depth “building healthy policy”. The focus of the Third Inter- national Conference on Health Promotion in Sundsvall, Sweden, in 1991 was on “creating supportive environments”. This particular conference was the first where the notion was put across how environments (physical, social, economic, or political) can be made more supportive of health. The Fourth Inter- national Conference on Health Promotion held in Jakarta, Indonesia, in 1997 reviewed the impact of the Ottawa Charter and engaged new players to meet global challenges. The evidence presented showed that health promo- tion strategies can contribute to improvement in health and the prevention of diseases in developing and developed countries alike. Five priorities were identified in the Jakarta Declaration on Health Promotion into the 21st Century: promote social responsibility for health, increase investments for health development, consolidate and expand partner- ships for health, increase community capacity and empower the individual and secure an infrastructure for health promotion. These were confirmed in May 1998 through the World Health Assembly Resolution on Health Promotion (WHA 51.12). Despite the evolution of health promotion over the decades and the progress being made through these successive conferences as well as through the parallel initiatives WHO was taking, 2 important challenges remained. The first was to demonstrate, and communicate more widely to developing countries, that health promotion policies and practices can make a difference to health and quality of life. The second was even more important: that ac- tion for health promotion can achieve greater equity in health and can close the health gap between population groups [1]. That is why the Fifth Global Conference on Health Promotion in Mexico in 2000 primarily focused on health inequalities both within and between coun- tries. This conference resulted in the Mexico Ministerial Statement for the Promotion of Health: from ideas to action, which affirmed the contribution of health promotion strategies in sustaining local, national and international actions in health [7]. At the dawn of the new millennium, it was increasingly realized that the global public health landscape was changing dramatically and that more understanding (and action) was required to address the determinants of health if the health of the population was to be promoted. Unforeseen opportunities and chal- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S17 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ lenges surfaced, such as the negative effects of climate change on population, geopolitical changes, debt in developing countries, and of course globalization of people, money, products and services [1], which had very important implications on wider public health as well as the way health promotion should position itself. It was in this context that the Sixth Global Conference on Health Promotion in Bangkok in 2005 identified actions, commitments and pledges required to address the determinants of health in a globalized world through health promotion [8]. The conference was structured around 4 themes: the new context, health- friendly globalization, partners, and sustain- ability, and resulted in the second health promotion charter, which identified 4 key commitments to promote health (central to the global development agenda; a core responsi- bility for the whole of the government; a key focus of communities and civil society; and a requirement for good corporate practice) and 5 key action areas (advocate for health based on human rights and solidarity; invest in sustainable policies, actions and infrastructure to address the determinants of health; build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy; regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people; and part- ner and build alliances with public, private, nongovernmental and international organiza- tions and civil society to create sustainable ac- tions). The 4 key commitments and the 5 key action areas build on the previous key action areas put forward by the Ottawa Charter and articulate a renewed vision on health promo- tion, tackling the inequities and inequalities in health through addressing the determinants of health. However, some of the terms commonly used in the public health community, e.g. dis- ease prevention, health education, wellness, quality of life, and health promotion, have at times led to confusion in their understanding. It is therefore, important that the concepts of health promotion, prevention and protection are discussed so as to effectively understand the difference between these public health disciplines. Prevention, promotion, protection and education in health: similar or different entities? As mentioned above, a clear understand- ing of the terms (and their application) is essential for public health practitioners to understand: • Are these more or less the same terms, and applied in a similar fashion? • If different, can they be applied togeth- er? • If the same, why are different terms used in public health practice? This paper does not aim to generate a theoretical debate on these questions but to try to argue (based on the published lit- erature) for a more rational approach in the meaning and application of these terms. Prevention Prevention in health calls for action in ad- vance, based on knowledge of natural his- tory, in order to make it improbable that the disease will progress subsequently. Preven- tive actions are defined as interventions di- rected to averting the emergence of specific diseases and reducing their incidence and prevalence in populations. The discourse of prevention is based on modern epide- miological knowledge. It aims to control the transmission of infectious diseases and reduce the risk of degenerative diseases or S18 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ other specific ailments. Health prevention and education projects are structured by circulation of scientific knowledge and nor- mative recommendations to change habits. To promote means “to further the devel- opment, progress, or establishment of (a thing); encourage, help forward, or sup- port actively (a cause, process, etc.)” (New Shorter Oxford English Dictionary, Ox- ford University Press, 1997). Traditionally, health promotion is defined more broadly than prevention, since it relates to measures that “are not directed to a given disease or disorder, but serve to increase overall health and well-being” [9]. Promotion strategies emphasize changing people’s living and working conditions, which underlie health problems, calling for an intersectoral ap- proach [10]. Although this undeniably constitutes progress, this positive concept entailed a new problem at both the theoretical and practical levels. By considering health in its full sense, we are dealing with something as broad as the notion of life itself [11]. Promotion Health promotion reaffirms considering not only how to avoid being sick, a negative concept, but also how to expand the poten- tial for living, a positive view: “The main difference between health promotion and disease prevention is the premise of health promotion regarding health as a resource of everyday life” [12]. Without doubt, most people want life to include being able to move about freely, enjoying food, feeling good, remembering things, and having fam- ily and friends. This is clearly beyond disease preven- tion, and illustrates the importance of con- sidering the nature of health promotion [11]. There are other dimensions differentiat- ing health promotion from disease preven- tion which are embedded in the definition of health itself (WHO 1986): health balance and health potential [2]. Health balance is essentially the Hippocratic notion of dynamic equilibrium between the human organism and its environment, a basically stable relationship of a person with the world outside. On the other hand health potential consists of reserves, an individual capacity to cope with environmental influ- ences that jeopardizes health balance. This concept goes beyond the idea of immunity to harmful biological agents: it includes the ability to withstand the adverse effects of causes leading to ill-health, the loss of a loved one or myriad other injurious circum- stances of daily life [13–15]. Health is a phenomenon of the individual just as disease is: each person has a certain degree of health that may be expressed as a place in a spectrum. From that perspective, promoting health must focus on enhancing people’s capacities for living. This means shifting them toward the healthier end of the spectrum, just as prevention is aimed at avoiding the conditions that can push them toward the opposite end. Of course, many of the actions, e.g. obtaining adequate exercise and appropriate nutrition, aimed at health promotion also achieve specific dis- ease prevention. When such measures are directed against a particular disease, such as cessation of smoking to minimize the risk of lung cancer, they may be regarded as dis- ease prevention; when the same measures are aimed at improving health generally, for example, preserving optimum respiratory and cardiovascular systems, they may be regarded as health promotion [16]. Health promotion is seen as a human right (as laid down in the constitution of WHO). This is a positive concept emphasiz- ing social and personal resources as well as physical capacities. The responsibility of health promotion actions extends far beyond Eastern Mediterranean Health Journal, Vol. 14, Special Issue S19 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ the health sector and health behaviour to well-being and quality of life. It is a human- istic approach having the human being and human rights in focus again. The individual becomes an active and participating subject. The role of professionals is to support and provide options, enabling people to make sound choices; to point out the key determi- nants of health; and to make people aware of them and able to use them [17]. Protection Health protection offers equality of op- portunity for people to enjoy the highest attainable level of health, and is achieved through the development and implementa- tion of legislation, policies and programmes in the areas of environmental health protec- tion and community care facilities. Health protection in the modern public health age focuses mainly on: • preventing and controlling infectious diseases • protecting against radiation, chemical and environmental hazards. In summarizing these disciplines based on the recent public health discussion, the available literature shows that the health protection perspective means that the inter- ventions limit the risk of disease. The efforts and interventions are population-based and passive. Health protection aims at reducing the likelihood that people will encounter environmental hazards or behave in unsafe or unhealthy ways. The interventions are aimed at preventing people from falling into sickness or illness by building protective mechanisms. The preventive perspective utilizes active interventions characterized by an empowering attitude where people are actively involved. The rationale is to reduce the negative effects and risks, thus maintaining the health of the public. The interventions are both population-directed (protective) and individual-based (preven- tive) [18]. Education Health education has a long tradition in public health practice. Originally, it was a question of the professionals informing people of health risks and giving advice on how people should live healthy lives. Today it is based on a dialogue, involving people in their own lives and making their own decisions supported by public health knowledge. People are, in general, more ac- tively involved than in the previous stages. The interventions are directed towards both individuals and groups and one of the key outcomes is improved health literacy [19]. Discussion Distinctions between health protection, health promotion and disease prevention are discussed in the literature in many ways. Health protection and disease prevention are considered to be consistent with the dis- ease perspective. The dominant approach to “health” in the literature is health promo- tion, which focuses attention on facilitating health to promote wholeness, integration and harmony [5]. It is based on health philo- sophy, and utilizes health protection as well as promotion strategies to promote the health of individuals, families and com- munities. A clear-cut demarcation between these public health disciplines, however, would always be difficult to achieve. This dif- ficulty arises partly in the way modern-day public health is defined. One issue is that public health defines itself as responsible for promoting health, while its practices are organized around disease concepts. Another is that these practices tend not to consider the distance between the concept of dis- S20 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ ease (a mental construct) and falling ill (an experience endured), at times substituting one for the other [11]. It is precisely here that the radical, and at the same time very small, difference between prevention and promotion in health stands out. It is radical because it entails far-reaching change in the way knowledge is interlinked and used in formulating and operationalizing health practices, and this can only truly occur by way of a transformed world view, as discussed above. It is very small because, just like those of prevention, the practices of promotion use scientific knowledge. Health promotion projects also rely on the classic concepts (disease, transmis- sion, risk) that guide the production of specific knowledge in health and whose rationality is the same as that of preven- tion discourse. This can lead to confusion and a lack of differentiation between the practices, mainly because the radical dif- ference between prevention and promotion is not always clearly affirmed or exercised. The idea of promotion involves strengthen- ing individual and collective capacity to deal with the multiplicity of factors that influence health. Promotion goes beyond applying techniques and norms. It is not enough to know how diseases function and to find mechanisms to control them: it has to do with strengthening health by building a capacity for choice, using knowledge to discern differences between events. In comparison with other established fields such as medicine, psychology, or sociology, the field of health promotion has only recently evolved. Health promotion has its roots in many different disciplines. As the field has developed, more and more components have become incorporated. Many of these components existed be- forehand in their own isolated and limited sphere of influence: health education in schools or primary health care settings; public health programmes such as immu- nizations or screenings; and occupational health measures aimed at preventing dis- ease or accidents at the workplace. These activities involve education, prevention, protection and legislation, and all relate to the concepts of positive health, well-being and lifestyle [20]. The health promotion model developed by Downie, Fyfe and Tannahill demonstrates the wide range of possibilities for health promotion by incor- porating prevention, health education and health protection in overlapping spheres [21]. According to this model, Prevention focuses on services such as immuniza- tion, cervical screening, hypertension case- finding, the use of nicotine-containing chewing gum to aid smoking cessation, etc; health education is aimed at influencing behaviour on positive health grounds and seeks to help individuals, groups or whole communities to develop positive health attributes which are central to the enhance- ment of true well-being; and health protec- tion deals with regulations and policies such as the implementation of a workplace smoking policy in the interests of providing clean air, or the commitment of public funds to the provision of accessible leisure facili- ties in order to promote positive health. Health promotion not only incorporates all the domains described above, but also the overlapping areas. Preventive health education includes educational efforts to in- fluence lifestyle in the interests of prevent- ing ill-health, as well as efforts to encourage the uptake of preventive services. Preven- tive health protection addresses policies and regulations of a preventive nature such as fluoridation of water supplies to prevent dental caries. Health education aimed at health protection involves raising aware- ness of, and securing support for, positive health protection measures in the public and in policy-makers [20]. All 3 dimensions Eastern Mediterranean Health Journal, Vol. 14, Special Issue S21 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ come together as health education, preven- tion and protection overlap in efforts to stimulate a social environment conducive to the success of preventive health protection measures, e.g. intensive lobbying for seat- belt legislation. These categories, however, are not rig- idly separate compartments in practice but are in reality often combined. For example, most health promotion measures are of a preventive nature and aimed at empower- ing individuals to adopt healthy lifestyles. Further, the discussion also underlines the necessity to include other disciplines such as psychology, sociology, public admin- istration, business and economics, com- munications and politics. This indicates that health promotion comprises efforts to en- hance positive health and prevent ill-health through the overlapping spheres of health education, prevention, and protection. References 1. Catford J. Ottawa 1986: the fulcrum of global health development. Promotion and education, 2007, (Suppl. Hors-série, Edición especial 2):3. 2. The Ottawa Charter for Health Promo- tion. Geneva, World Health Organization, 1986. 3. Alma-Ata Declaration: primary health care. Geneva, World Health Organization 1978. 4. Primary health care. Geneva, World Health Organization, 1977. 5. Leddy SK. Integrative health promotion— conceptual bases for nursing practice, 2nd ed. Sudbury, Massachusetts, Jones and Bartlett, 2006. 6. Concepts and principles of health promo- tion. Geneva, World Health Organization, 1984. 7. Fifth Global Conference on Health Promo- tion: bridging the equity gap, 5–9 June 2000, Mexico City. Geneva, World Health Organization, 2000 (http://www.who.int/ healthpromotion/conferences/previous/ mexico/en/index.html, accessed 12 Au- gust 2008). 8. The Bangkok Charter for health promo- tion in a globalized world. Geneva, World Health Organization, 2005. 9. Leavell S, Clark EG. Medicina preventive, trans. São Paulo, McGraw-Hill, 1976. 10. Terris M. Public health policy for the 1990s. Annual review of public health, 1990, 11:39–51. 11. Czeresnia D. The concept of health and the difference between prevention and promotion. Cadernos de saúde pública, 1999, 15(4):701–9. 12. Breslow M. From disease prevention to health promotion. Journal of the American Medical Association, 1999, 281(11):1030– 3. 13. Abelin T, Brzezinski, ZJ, Carstairs VDL, eds. Measurement in health promotion and protection. Copenhagen, World Health Organization Regional Office for Europe, 1997 (Regional Publications Eu- ropean series No. 22). 14. Khayat H. The evolution of health promo- tion in the EMR. Presentation given at the inter-country meeting on national plans of action based on health promotion strat- egy, Cairo, 26–28 June 2006. 15. Noack H. Concepts of health promotion. In: Abelin T, Brzezinski ZJ, Carstairs VDL, eds. Measurement in health promotion in protection. Copenhagen, World Health Organization Regional Office for Europe and International Epidemiological As- sociation, 1987 (Regional Publications European series No. 22). S22 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 16. Breslow L. Health status measurement in the evaluation of health promotion. Medi- cal care, 1989, 27(3 Suppl.):S205–16. 17. Lindstrom B, Eriksson M. Contextualizing salutogenesis and Antonovsky in public health development. Health promotion international, 2006, 21:238–44. 18. Eriksson M, Lindstrom B. A salutogenic in- terpretation of the Ottawa Charter. Health promotion international, 2008, 23(2):190– 9. 19. Nutbeam D. Health literacy as a public health goal: a challenge for contempo- rary health education and communication strategies in the 21st century. Health pro- motion international, 2000, 15:259–67. 20. Wolf K. Health promotion—an interna- tional phenomenon. Washington DC, Na- tional Center for Health Fitness, American University (http://www.american.edu/ac- ademic.depts/cas/health/iihp/archives/ pubsiihpchinawolf2.html, accessed 25 July 2008). 21. Downie RS, Fyfe C, Tannahill A. Health promotion models and values. Oxford, Oxford University Press, 1990. To deal with some of the underlying determinants of health, a global framework for a health promotion strategy is needed. This is a respon- sibility of all government ministries at all levels, as well as communi- ties and corporate and civil society. Source: Engaging for Health. Eleventh General Programme of Work 2006–2015. A Global Health Agenda Eastern Mediterranean Health Journal, Vol. 14, Special Issue S23 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Aspiring to build health services and systems led by primary health care in the Eastern Mediterranean Region Ahmed Ali Abdullatif 1 1World Health Organization Representative Egypt and Former Coordinator, Health Systems Development, Division of Health Systems and Services Development, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Ahmed Ali Abdullatif: alatifa@egy.emro.who.int). Introduction In celebrating the 30th anniversary of pri- mary health care (PHC) and the declaration of Alma Ata in 1978, it is useful to remind ourselves that PHC was identified as the means or strategy to achieve health for all. In other words PHC was considered a com- prehensive health developmental approach. Such an approach includes several features and each word in the phrase “primary health care approach” represents an essential con- stituent. Thus the “Primary” element means that it involves what is essential from the perspec- tive of burden of disease, epidemiology, morbidity, mortality and cost–effectiveness, as well as what is acceptable. The “Health” element means complete health as defined by the World Health Organization (WHO), i.e. a state of complete physical, mental and social well-being and not merely the ab- sence of disease or infirmity. Health is also seen in the context of overall development and encompasses the social determinants of health. Related sectors and the community usually contribute more to the “H” of PHC than the Ministry of Health which focuses on services or rather the PC of PHC. The “Care” element (which is broader than cure) includes preventative, curative and reha- bilitation-related care. It also covers per- sonal and public aspects. The “Approach” element indicates that PHC is dynamic, health system-oriented and is the means to achieve health for all. As the health system orientation covers health services and non- health services, such as nutrition, water and sanitation, primary care (PC) is sometimes used interchangeably with PHC. There is, however, a clear difference. PC can be considered the essential or basic service provided by the health authorities and is the most widely addressed component of PHC as a whole worldwide. PC provides promo- tive (mainly health education), preventive and curative care. PHC values and principles PHC is a global public health movement based on ethical values and principles. De- spite the faltering implementation of the PHC approach, the world has come to see that its values and principles are time-tested and as much needed now as they were in 1978. The principles of PHC include: eq- S24 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ uity, universal coverage, involvement of the people, comprehensiveness, integration, human rights based, person/user centred- ness. Equity is a fundamental principle of PHC and is congruent with the vision of health for all. It incorporates social inclu- sion and intolerance of health inequality. Health is thus a human right. The PHC approach encompasses social values that put people in the driving seat; health systems are driven to respond to what people need and aspire to. Such people- centred health care delivery requires a health system where: • close-to-client health care networks ex- ist which allow individual, family and community problems to be seen in con- text; • providers and people can build enduring relations of trust that are necessary for care to be comprehensive, integrated, continuous and appropriate; • people have and know their rights, have choices, and can participate in decisions affecting their health; • health strategies are comprehensive and integrated with overall development. Intersectoral action and community in- volvement are essential requirements to ensure comprehensiveness, self-reliance and sustainability of all activities related to PHC. An important PHC principle relates to the way we think of and work for health development. PHC is about thinking deeper and addressing root causes – the determi- A value to people-centred care and the protection of the health of communities requires a response that only PHC-based health systems can provide. nants of health. A consistent theme through- out the PHC approach has been the need to change the way we think about health and healthcare. The existing systems are inherently reactive organizations, designed primarily to cope with poor health, to pick us up when we fall. They are not designed to reduce the likelihood of poor health. Fur- thermore, PHC considers health a strategic element of overall development. Recent economic studies have shown how people can be impoverished because of ill health and catastrophic expenditures (Figure 1). Another principle of PHC is value for money. Within this context, primary care is about provision of essential care, which is most cost-effective. In comparison with specialized care, primary care is associated with a more equitable distribution of health care in the populations of countries which have opted to base their national health systems on PHC. Findings and lessons learnt in EMR The voice of the developing world was loud and clear at Alma Ata in support of PHC and most Eastern Mediterranean Re- gion (EMR) countries accepted and have benefited from the PHC approach. PHC also paved the way for other related ini- tiatives, such as poverty alleviation and the Millennium Development Goals (MDGs), which EMR countries also subscribed to and have benefitted from. All of our countries, rich or poor, are living in two worlds, one for the well off and powerful and one for everyone else. The two worlds are on divergent paths and this is not ethical or acceptable. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S25 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ The health in the Region has improved and continues to do so but more slowly than aimed for (Table 1). Life expectancy and proximity to health services have continued to increase overall, but large parts of the Region have been left behind. Assessment of PHC in EMR indicates that perhaps the main achievements have been in the P and C components of PHC. But even this has been with a variable de- grees of success both between countries and, more importantly, within countries. Using MDG number 4 (under-5 mortality) as a proxy overall indicator, progress is slower than would reasonably be expected (Figure 2), and very variable. High-income countries in EMR with low child, low adult mortality (EMR B countries) have already achieved MDG 4, whereas poor countries with high child, high adult mortality (EMR D countries) are lagging behind. Further- more, the gap between the 2 country groups has widened since 1970 (Figure 2). Progress has not only been uneven in child health. Indicators show that while some countries are on track to meet the health for all goals, others are not keeping up, are stagnating, or are even going into reverse. Table 2 shows the stark inequalities among EMR countries with reference to some selected indicators. As well as wide between-country gaps, exclusion of certain groups and within- country inequalities are evident and have had direct and indirect effects on health. For example, Table 3 shows that Egyptians had, on average, 3.5 outpatient visits per year. In comparison with other low- and middle- income countries, Egyptians are above av- erage users of outpatient services. However, utilization rates vary significantly by region and income. Individuals in urban areas had 4.48 outpatient visits per year compared to 2.75 visits in rural areas. Outpatient visit rates varied with income level. Individuals in the highest income quintile (annual per Figure 1 Household out-of-pocket spending (OOPS) as percentage of total health expenditure (THE) in the Eastern Mediterranean Region, 2005 S26 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Ta bl e 1 Se le ct ed a ch ie v em en ts re la te d to h ea lth in th e Ea st er n M ed ite rr an ea n Re gi on , 1 99 0– 20 06 Co un try Li fe In fa nt Un de r 5 M at er na l Ph ys ic ia ns c N ur si ng & Su st ai na bl e A cc es s to ex pe ct an cy m or ta lit y m o rt al ity m o rt al ity m id w ife ry ac ce ss to im pr o v ed at b irt h ra te a ra te a ra tio b im pr o v ed sa ni ta tio nd (ye ar s) w at er so u rc ed 19 90 20 06 19 90 20 06 19 90 20 06 19 90 20 06 19 90 20 06 19 90 20 06 1 99 0 20 06 19 90 20 06 Af gh an ist an 46 .0 18 2. 0 12 9. 0 25 0. 0 19 1. 0 17 00 .0 16 00 .0 1. 4 2. 00 1. 20 5. 0 20 .0 40 .0 67 .0 Ba hr a in 69 .5 74 .8 20 .0 7. 6 10 .1 60 .0 1. 0 10 .8 27 .6 0 25 .2 0 55 .0 10 0. 0 10 0. 0 D jib ou ti 44 .1 10 2. 0 16 4. 0 12 4. 0 74 0. 0 54 6. 0 2. 0 1. 80 12 .0 0 8. 0 84 .0 85 .0 Eg yp t 62 71 .4 39 .1 20 .5 56 .0 26 .2 17 4. 0 62 .7 24 .3 0 33 .5 94 .0 84 .0 94 .0 Is la m ic R ep ub lic o f I ra n 69 .0 28 .6 36 .0 91 .0 n a 8. 90 14 .1 89 .0 68 .0 Ira q 58 .0 10 7. 9 13 0. 0 11 7. 0 29 4. 0 5. 8 6. 60 7. 00 12 .6 78 .0 61 .0 67 .0 81 .0 Jo rd an 68 71 .5 34 .6 22 39 .0 27 80 .0 41 .0 16 .8 24 .5 0 10 .8 0 33 .0 97 .7 60 .1 Ku w a it 77 .5 8. 2 10 .0 4. 0 18 .0 0 37 .0 1 00 .0 1 00 .0 10 0. 0 10 0. 0 Le ba no n 66 71 .3 44 18 .6 56 .0 19 .2 15 0. 0 88 .0 8. 9 28 .4 0 11 .2 0 13 .2 95 .0 1 00 .0 N A Li by a n A ra b Ja m a hi riy a 66 69 .5 31 25 .0 31 .0 60 .0 40 .0 14 .9 12 .5 0 41 .3 0 48 .0 90 .0 98 .4 94 .8 M or oc co 65 .5 70 .3 54 40 .0 69 .0 47 .0 50 .0 22 7. 0 2. 2 5. 60 9. 00 9. 0 71 .3 76 .0 O m an 74 .3 29 10 .3 34 .0 11 .1 15 0. 0 15 .4 17 .9 0 37 .7 75 .0 89 .0 Pa ki st an 64 .0 91 77 .0 16 2. 0 98 .0 45 0. 0 35 0. 0 5. 3 8. 00 2. 80 3. 0 55 .0 90 .0 21 .0 54 .0 Pa le st in e 72 .5 20 .5 23 .8 90 .0 11 .0 9. 73 16 .0 96 .8 99 .6 Qa ta r 75 .8 12 .9 8. 1 16 .6 10 .7 9. 0 7. 0 14 .8 27 .6 0 73 .8 1 00 .0 1 00 .0 10 0. 0 10 0. 0 Sa ud i A ra bi a 69 73 .6 30 18 .6 34 .0 21 .7 41 .0 12 .0 19 .0 19 .0 0 38 .2 0 35 .0 93 .0 89 .0 86 .0 40 .0 So m al ia 48 N A 12 0. 0 25 2. 0 22 4. 0 16 00 .0 16 00 .0 N A N A 20 .0 50 .0 Su da n 58 .0 70 62 12 3. 0 91 66 0. 0 59 0 2. 90 9. 1 59 .9 59 .7 Sy ria n Ar a b R ep ub lic 66 72 .0 33 18 .0 44 .0 22 .0 14 3. 0 58 .0 14 .8 0 18 .8 88 .0 64 .0 74 .0 Eastern Mediterranean Health Journal, Vol. 14, Special Issue S27 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ capita income > 1700 Egyptian pounds) had the highest number of visits (5.11 visits), compared with those in the lowest income quintile (annual per capita income < 560 Egyptian pounds) with 2.32 visits. For out- patient care the richest had over twice as many visits as the poorest, an indicator of inequity in access to care. The situation in most EMR countries likely follows a similar pattern of inequalities. At the policy level, health leaders in EMR are learning from experience. The dominant pattern of thought in the EMR has assumed that what is required is either more of the same (more hospitals, nurses, doctors, technology) or delivering the same things in a different way (service redesign, community-based care). There is now a general recognition of the need for a com- prehensive approach to health development to ensure better performing health systems. There is therefore a greater readiness to take a fresh look at the potential of PHC and its track record in circumstances where it received adequate support. The evidence shows that, in today’s globalized world, adherence to PHC values is the solution to meet what citizens expect for themselves and their families, and what they aspire for their society. The achievements by countries that ad- hered to PHC principles and strategies, such as Oman, where infant mortality rate was reduced from 118 per 1000 live births in 1970 to 10.25 per 1000 live births in 2008 and the under-5 mortality rate was similarly reduced from 181 per 1000 live births in 1970 to 11 per 1000 live births in 2008, and the Islamic Republic of Iran, where the neonatal mortality rate was reduced from 71 per 1000 live births in1970 to 21 per 1000 live births in 2000 and the mortality rate in children aged 1–59 months was reduced from 150 per 1000 live births in 1970 to 14 per 1000 live births in 2000, prove the Ta bl e 1 Se le ct ed a ch ie v em en ts re la te d to h ea lth in E as te rn M ed ite rr an ea n Re gi on , 1 99 0– 20 06 (c on clu de d) Co un try Li fe In fa nt Un de r 5 M at er na l Ph ys ic ia ns c N ur si ng & Su st ai na bl e A cc es s to ex pe ct an cy m or ta lit y m o rt al ity m o rt al ity m id w ife ry ac ce ss to im pr o v ed at b irt h ra te a ra te a ra tio b im pr o v ed sa ni ta tio nd (ye ar s) w at er so u rc ed 19 90 20 06 19 90 20 06 19 90 20 06 19 90 20 06 19 90 20 06 19 90 20 06 1 99 0 20 06 19 90 20 06 Tu n is ia 73 .4 50 20 .6 30 80 .0 48 .0 9. 50 23 .9 0 31 .4 91 .0 90 Un ite d Ar a b Em ira te s 70 72 .6 11 .4 8. 1 c 14 .9 10 .2 5. 0 1. 0 16 .9 0 35 .6 0 35 .2 98 .0 1 00 .0 95 .0 10 0. 0 Ye m e n 45 62 .9 13 0 75 .0 19 0. 0 10 2. 0 14 00 .0 36 6. 0 2. 5 3. 60 5. 40 5. 7 31 .0 51 .0 23 .0 a Pe r 10 00 li ve b irt hs . b P e r 10 0 00 0 liv e b irt hs . c P e r 10 0 00 p op ul at io n. d % o f p op ul at io n. S28 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ merits of the PHC approach. When there is the will, PHC flourishes. The State has the ultimate responsibility for organizing health systems around the values that drive PHC. Stronger leadership is needed to guide the Ministry of Health in adopting a new role and new style of work- ing. This redefinition of roles is important in all countries but particularly urgent in low-income countries. Experiences indicate the need to strengthen the role of the Min- istry of Health and government and their capabilities in 3 key areas: i) explicit and effective mechanisms for inclusiveness and engagement with a variety of stakeholders; ii) information and knowledge management which includes continuous, real-time evalu- ation as well as projections of future health challenges; and iii) capacity of the leader- ship to combine long-term vision, alliance- building and strategic policy dialogue with national and international stakeholders. The quality of primary care varies from one country to another in EMR and tends to follows the same pattern as the service indicators. Several quality initiatives are under way but are still in their early phases, especially in middle-income countries. Making use of the experiences in devel- oped countries in gatekeeping and efficient use of resources, several countries have embarked on the family physician model; it is expected that about 80% of ailments can be dealt with at this level. Recently some countries have revisited the provision of care especially 2 main as- pects: economic and organizational. Intro- ducing prepayment schemes, such as health insurance schemes, forced national health authorities to consider an economically Figure 2 Under-5 mortality rate in 2 groups of Eastern Mediterranean Region countries, Emr B (high-income countries with low child, low adult mortality) and Emr D (poor countries with high child, high adult mortality),1970–2005 Eastern Mediterranean Health Journal, Vol. 14, Special Issue S29 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ feasible package which will allow realloca- tion of scarce resources to essential care (Afghanistan, Pakistan, Yemen and Iraq). Wealthy countries have also considered a wider package to prepare citizens for a defined package as well as to introduce the gatekeeper concept (Bahrain, Oman, Saudi Arabia, United Arab Emirates, Qatar, Ku- wait). Some lower income countries have also considered packages for improving quality of care (Tunis, Egypt) and provid- ing feasibility and sustainability. Needless to say, these packages, while they mimic primary care’s essential care by incorporat- ing preventive, promotive and curative care, fall short because they are facility-based and reactive rather than proactive; nor do they address the determinants of ill heath. This is not to underestimate the achievements of such schemes but rather to qualify what needs to be developed further on the unfin- ished agenda of PHC in the 21st century. Challenges and the unfinished agenda of PHC in EMR One may wonder why we did not obtain bet- ter results with PHC. The following chal- lenges explain shortfalls in performance and response of the health sector in most EMR countries. Alienation of the health workforce Differences in professional culture and financial disincentives explain why health care providers have been reluctant to inte- grate population-based interventions and health care services. In particular a major challenge is integrating population-based work in the practice of private providers. Fragmentation of care Political and managerial responsibilities (and the corresponding financing mecha- nisms) for population-based services are Table 2 Inequalities in the Eastern Mediterranean Region between the highest- income countries with low child, low adult mortality and lowest-income (countries with high child, high adult mortality Indicator Highest Lowest Population with access to local health services (%) 100 50 Life expectancy at birth (years) 77.5 44.1 Maternal mortality (per 100 000 live births) 1600 1 Physicians (per 10 000 population) 28.4 2 Nurses (per 10 000 population) 55 3.1 Hospital beds (per 10 000 population) 37 4.2 Literacy rate (%) 99 19 Population with access to improved water source (%) 100 20 Population with access to improved sanitation (%) 100 23 Table 3 Annual utilization rate per capita, Egypt, 1995 Category No. of outpatient visits per year Total sample 3.51 Residence Urban 4.48 Rural 2.75 Income quintile Quintile 1 (< LE 560) 2.32 Quintile 5 (LE > 1704) 5.11 Source: Egypt household health utilization and expenditure survey, 1995. LE = Egyptian pounds. S30 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ located in different institutions or different branches of government from those deal- ing with people-centred care. Because of this situation, efforts to decentralize did not work and also there was little input from the people themselves in the decision-making for their health and well-being. Shrinking role of MOH as a normative national institution The global and national policy environ- ments (structural adjustment, decentraliza- tion of the entire public sector, poverty reduction strategies, trade policies, new tax regimes, fiscal policies, withdrawal of the State) have not been sensitive to health issues. Health authorities have failed to anticipate or assess the health impact of these changes. They have shown a poor track record in influencing these policies and have been unable to use the economic weight of the health sector for leverage. Disrupted health systems In some EMR countries, war and humani- tarian crises (Afghanistan, Iraq, Palestine, Somalia, Sudan) have damaged health and impeded health progress, both directly and by disruption of health systems. Erosion of trust in the performance of national health systems There has been chronic under-funding of national health systems, as shown in Fig- ure 3. This has led to under-investment in the infrastructure and human resources for health, which thus has limited the scale of response to people’s needs. There has also been an erosion of trust in the system among the people as a result of wrong choices in investing in health where the share of pri- mary care expenditure in most countries is modest in absolute and relative terms. The health systems of developing countries are thus trapped in a vicious circle of loss of trust and under-performance. Striking examples are high household out-of-pocket expenditure, especially in low- and middle- income countries (Figure 1) and expendi- ture on treatment abroad. For example, in Yemen it is estimated that a third of total health expenditure is for treatment out of the country. Capacity to cope with change Policy choices within the health sector have not kept pace with the challenges of the health transition, both old and new, in- cluding the diseases of poverty, ageing, urbanization and globalization. In addition, the potential of prevention and promotion has been undervalued. Figure 4 shows how Oman has invested judiciously in prima- ry care centres rather than hospitals since 1975. This correct investment policy is also seen in the developed countries, such as the United Kingdom, where primary care is the default health system and the number of hospital beds has steadily decreased since 1928. Policy dilemma Tools, methods and working systems used for policy choices within the health sector have also not kept pace with the demands that have come with globalization, mod- ernization and the amount of information available. The nature of (at times supply- induced) demand is changing. Unlike the market, health leaders have been slow in taking this into account and devising and using new economic, societal, managerial and quality tools. Dilemma of organization of care in a globalized world It has been a challenge to know how best to respond to different forms of trade agreements, patents rights and technology transfer. In national health systems that are Eastern Mediterranean Health Journal, Vol. 14, Special Issue S31 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Figure 3 Total health expenditure (THE) per capita in the Eastern Mediterranean Region, 2005 (THE = US$ 56 billion; average per capita THE = US$ 106; the low income population in the Region is 47% of the total, but THE is only 8% of total) Figure 4 Number of government health institutions in Oman, 1970–2006 S32 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ traditionally fragile and have not been able to cope adequately with healthcare delivery, it is uncertain if they can cope with the ad- ditional more complex politico-economic environment of today and the future. Conflicting messages from international donors and partners History should not repeat itself by sending conflicting messages on revitalization of PHC as happened soon after the Alma Ata conference. An effective safety measure against this is to help national health author- ities take the lead in steering national health programmes and the international support they may receive when revitalizing PHC. Regional aspirations, our strategic axes for action Bearing in mind all the above discussion, there is a need to outline the strategic axes to be taken in the next decades to revitalize the PHC approach in EMR. Despite the deepening economic crisis and increase in food prices globally, the climate for health is not unfavourable for the following reasons. • The world is better armed now to maxi- mize the impact of PHC for health and health equity both technologically be- cause of new technology and informa- tion networks, and also socially because of growing civil society involvement in health and the collective global thinking and solidarity for health. • The awareness of the link between health and poverty makes it possible to establish alliances beyond the health sector. It shows that the responsibility of health leaders is not just for survival and combating diseases, but for health as a capability in society. • Global health is receiving unprecedent- ed attention, with growing interest in integrated action and comprehensive and universal care. EMR countries should therefore seize the opportunities to advance health and “market” PHC values and principles. For example, it is possible for developing coun- tries within the EMR to make substantial gains in reducing the infant mortality rate, as has been done in some countries of the Region, in a shorter period of time than that taken by developed countries in the past: in the United Arab Emirates, the time taken to reduce infant mortality from 100 per 1000 live births to 30 per 1000 live births was 12 years (1965–77); for Oman the time was 15 years (1975–90), for Kuwait 25 years (1955–80), while in England and Wales it was 36 years (1915–51) (Hill & Yazbeck, 1994; Mitchell, 1988). In pursuit of the ultimate strategic goal of health for all, the following axes are proposed. Balancing accountability for health, health care, wellness and illness The fact that many health problems have multiple determinants makes it necessary for PHC population-based interventions to rely on multisectoral approaches, which are challenging to establish and sustain. Furthermore, illness care is only one part if health and PHC should develop to be a vehicle for health promotion, protection and disease control, its core constituents. To maximise these aspects, it is necessary i) for the State to take measures to ensure that population-wide health protection (e.g. iodine supplementation, road safety, etc.) is funded and implemented; and ii) to ensure that, where appropriate, such protection is fully integrated with the development of people-centred services. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S33 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Much more proactive leadership is needed by the State. It needs to: i) survey the current social, political and economic background, to build consensus and explain how PHC can respond to the complex com- bination of challenges, opportunities and aspirations, and to provide communities and other stakeholders with examples of actions they can take now, and in the medium- and long-term, to achieve greater progress in health of the people; ii) improve access by scaling up PHC networks, through strategies that are tailored to the different contexts and circumstances; iii) use financial leverage to improve equity, in particular through targeted strategies to reach the unreached, especially those in the lowest percentiles; (iv) implement initiatives such as institu- tional development of local government and decentralization; (vi) establish the basic structures of accountability within the PHC system. These make effective links between the first level (such as health centres), the districts, and ultimately the Ministry of Health. Strengthening needs assessment and responsiveness One of the core principles of PHC is that health care should be organized and deliv- ered in response to needs in the communi- ties served. The implication of this principle is that the PHC system must have the capac- ity to assess need in order to change services and improve outcomes. The capacity to assess need becomes more important when the health system is facing major epidemiological and de- mographic change (which is the case in developed and developing countries). At present, the capacity for needs assessment in the PHC system in the EMR is limited and needs to be improved, particularly at the district and health facility levels. This requires redeployment of significant re- sources to the districts, in order for them to build the capacity for needs assessment. Making strategic investment decisions in support of PHC infrastructure Primary care is about provision of essen- tial care which is most cost-effective. The evidence from EMR countries shows that primary care in comparison with special- ized care is associated with a more equitable distribution of health care in populations of countries who opted to base their national health systems on PHC. Delivering basic services in primary care requires careful and skillful planning and multiples levels of support – basic is not simple! Strategic investment planning of this sort is arguably the clearest demonstration of any health system’s commitment to PHC. An example of appropriate investment in primary care is provided by Oman (Figure 4). The traditional approach to budget setting in health systems will often work against the implementation of a robust mod- el of PHC. For example, as demand from an ageing population results in increased pres- sure on hospital beds, the temptation is to invest in hospital capacity in response. This would be a traditional and reactive planning model. The alternative is to anticipate those changes well in advance, and to invest in improvements to the PHC infrastructure and reduce the need for hospitalization. In addition to financial investment in PHC, certain policies are needed in relation to: • Guaranteeing universal access to es- sential care through an adequate health system preferably supported by a social security system; • Ensuring a shift from vertical disease- oriented programmes towards a horizon- tal community-oriented approach; • Organizing health systems in an inter- sectoral network, with cross links to S34 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ environment, economy, work and edu- cation at different institutional levels; • Using the bottom-up approach involv- ing civil society. The basic development needs approach (BDN) in EMR is a time-tested approach that can be used in different socioeconomic settings, par- ticularly the deprived ones. Shifting resources to match different communities’ needs The future orientation of the PHC system needs to be towards identifying changing needs in diverse communities, and deploy- ing resources in response to those needs. This will make the PHC system more flex- ible and responsive at the local level. The differences in communities can be seen in age profile, economic status, morbidity patterns, degrees of rurality and also care utilization. Thus each community is differ- ent and unique. The PHC system initially followed a strategy of standardization. However, as needs within communities become more diverse, resources will need to be redirected among communities to deliver a better local match of need and capacity. Ensuring the most effective match should be one of the most important functions of the districts and provinces in the future. This argument also addresses the equity principle. Stratification of communities according to their needs requires close communication with and in- depth knowledge of the community being served. Databases and indicators, such as demographic and health surveys, are thus necessary tools to help achieve this and track progress. Harmonizing the divide between personal and communal care Population-based approaches when adopt- ed have to be rooted in a strong primary care delivery network, even where personal health care delivery does not include the prevention and promotion programmes (as in commercial health care provision). The stratification of the population ac- cording to the spectrum of their health con- ditions is one method to strike the balance between personal and communal care. At one end of the spectrum is the healthy popu- lation whose needs are for promotion and counselling and equipping them with skills to sustain their healthy status. At the other end of the spectrum is the disabled popula- tion with mental or disabling conditions whose particular needs are for rehabilitation and hospice care. In between are those who are at risk, those suffering from acute diseases and those suffering from different grades of chronic disease. Stratification should include everyone and ensure that at any stage of one’s life essential healthcare needs are met. The number of strata must be limited to enable national PHC systems to offer a sensible array of integrated services for each stratum and to make these care services available almost everywhere. This axis is essential for building the credibility of PHC. There is a very large burden of death and suffering from com- municable and noncommunicable diseases. Much of this burden could be averted by im- proved capabilities for their prevention and treatment at the primary care level. Treating tuberculosis is personal care but is also communal care, whereas treating diabetes is personal care. Nonetheless, curbing the magnitude of diabetes in the long term is a communal issue requiring a comprehensive public strategy to address the lifestyle pat- terns of the community. Future efforts to advance PHC should emphasize “compre- hensive” PHC that addresses such problems and, more generally, addresses emergency and other unforeseeable situations which fall more within the personal domain. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S35 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ In a world threatened by emerging dis- eases and pandemics, vigilance of PHC is needed. Any pandemic, such as avian in- fluenza, exposes weak areas in the national health care system, not just in individual care but more importantly in communal care, and not just in standard areas, such as childhood immunization, but more in resources allocation and decision-making. When building PHC capacity, it is resil- ience and experience that will protect both individuals and the community and will hold a system together during a crisis, rather than large-scale financial and infrastructure investment alone. Rethinking the boundaries of primary care Based on the arguments above, primary care should have different first points of contact in response to different needs. With the change in burden of disease and need for continuity of care, primary care has to qualify the first level of contact to meet this. These changing patterns require interven- tions at more than one level of care and, in some countries, by other than the public sector alone. Chronic diseases in particular have different first contact points with the health care delivery system depending on the stage of disease, whether diagnostic, elective or emergency management, or fol- low-up. The orientation of the primary care sys- tem is to deliver care locally wherever possible, and to combine health care with health protection and health promotion in the community. This can, over time, change the orientation and role of some specialties, which are traditionally seen as a part of secondary care, for example paediatrics and obstetrics. In some highly developed health systems, e.g. Oman, these specialties are part of the primary care model, with the specialists operating as members of an extended primary care team at the local level, rather than working predominantly in secondary care settings providing reactive health care. There are growing examples worldwide of new models of care that are rethinking the boundaries of primary care. Some countries are addressing broader health and strategic thinking for healthy nations. They are look- ing to redirect the healthcare system from providing mainly acute and reactive care towards a model which can handle promo- tion and prevention more effectively. Promoting and practising the integration of healthcare Promoting integration involves taking a whole system perspective and actively en- couraging ways of working that blur some of the distinctions between primary, sec- ondary and tertiary care, and link them ef- fectively. There is growing evidence from other systems that suggests that high levels of such integration can produce good results for the population, especially for chronic diseases (Green, 2005). Some practical ex- amples include: • Promoting co-location and co-working. This can mean encouraging special- ists from secondary care to do some of their work in primary care settings, such as health centres, where they operate alongside their primary care colleagues. This has major advantages in developing the skill base within primary care and can help to develop new areas of special interest in the primary care team. It also improves accessibility for patients. • Developing care pathways for speci- fied patient journeys. The pathway will describe the required interventions and contributions to be made by actors, e.g. clinicians in each part of the health sys- tem for that particular patient journey, S36 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ including social care, after-care and re- habilitation. The pathway therefore inte- grates all of the components of the whole care system and clarifies individual re- sponsibilities. The process of developing a new care pathway also gives an ideal opportunity for modifying those con- tributions and improving effectiveness. In line with care pathways, it is also necessary to find a balance between interventions at different levels of care across the disease continuum so as to ensure that the health system includes health promotion, illness prevention, care of the sick and true community de- velopment. This thus redefines the com- prehensiveness of services beyond those considered medically necessary. In the context of health pathways, preventing health problems and responding to them if and when they occur requires a contin- uum of actions at home, in community settings (e.g. places of study, play, work and worship) and in first level and refer- ral levels of health facilities. A range of actors have roles to play in each of these settings, including patients themselves, individuals in daily contact with them (parents and other family members), as well as individuals in regular or oc- casional contact with them (friends, family friends, teachers, sports coaches, religious leaders and health workers). • Using technology to link clinicians across primary, secondary and terti- ary care. The most obvious example is telemedicine, which allows clinicians in primary care settings to have direct access to the skills of their specialist colleagues, in real time, and in relation to particular patients. This promotes co-consulting, and can avoid substantial travelling for the patient. In addition, such technology can help reach isolated and dispersed populations. • Devolving more tasks to the primary care level. New healthcare issues and needs have arisen, such as emerging diseases, healthy living for ageing, debilitating chronic conditions, socially deprivation and injury disability. The question will always be how to strengthen primary care to be able to respond and manage such new health needs. Through devolu- tion, provinces should have the capacity to address integration as a long-term strategy and to support activities, such as the development of new care pathways. This step will also address the present strongly oriented vertical programming. Putting the health workforce at the centre Within the context of comprehensive PHC, health workers have key roles to play in promoting health, preventing health prob- lems and responding to them if and when they arise. They have roles to play both as service providers and as agents of change. As service providers, health workers help well individuals stay well and ill persons to get back to good health. As community change agents, health workers can help in- fluential community members take health seriously. They need to use their credibility and influence to help educators, religious leaders, political leaders and others under- stand the health needs of the community and the importance of working together to meet these needs. Health security, occupational hazards and potential devastating threats, such as avian influenza, demand that primary health care workers play a key role at the front line of epidemic detection and response. In order to retain health workers and ensure their equitable distribution, particu- larly among disadvantaged areas, requires policies and strategies. Globally countries and development partners should address Eastern Mediterranean Health Journal, Vol. 14, Special Issue S37 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ the issues in a more fundamental way and support for incentives for national health workers should be in the context of equity and sustainability. Additionally, unfinished issues related to the health work force should be addressed, such as skills mix, career development, training, distribution, retention and alloca- tion of health workers, job descriptions, and salaries and incentives. Strengthening the steering role of national health authorities and building alliances In its steering role, the State should support the PHC approach through strategic think- ing, coordination, standards setting and quality assurance, and overall assessment of the health of the nation. The leadership of national health authorities for PHC needs to structure and organize an inclusive social debate and clearer set of relationships with key stakeholders. It should identify these stakeholders and show how establishing dialogue and relationships is a long-term endeavour, but one that conditions the suc- cessful reorientation of the health sector. With the understanding of the fundamental PHC values and principles of equity and social justice, there is a rising tide of ex- pectation and mounting public pressure on politicians and other leaders in many coun- tries to re-examine and redefine their com- mitment to such values and to demonstrate more inspired leadership. At present, the main orientation is to the management and delivery of health services. As a result, attention at all levels is focused on health delivery activities, such as number of attendances at health centres and other measures of the “inputs” of health care. This is understandable when the concern is to ensure that all populations have access to health services through the national PHC system. For the future, how- ever, the orientation towards accountability needs to increasingly reflect a concern for health outcomes. This will include linking social determinants of health and intersec- toral action to address the root causes of health and ill health. Alliances should have a purpose in line with PHC principles especially when scal- ing up access to PHC and introducing PHC in areas of massive deprivation, neglected rural areas and post-conflict situations. The State should lead by capitalizing on dis- trict health care approaches and bringing disease-based efforts together in a compre- hensive and coordinated way to strengthen delivery capacity of health systems. The vital alliance is with the community. The principle of community participation is at the heart of the Alma Ata declaration and allows people’s priorities to be considered within the health system, thus increasing their participation and inclusion. It also pro- vides opportunities for expanding delivery of some of the key health interventions. It offers currently the most potential for realigning health care with or integrating it in overall development. Another area for alliance with the com- munity is financial protection as part of the safety net in addtion to empowering the excluded, e.g. the peri-urban poor. An important asset for alliance at the national level is the public–private mix for PHC. In most settings, a wide array of healthcare providers are approached by the people to meet their primary health needs. Evidence from tobacco control in some parts of the industrial private sector in Egypt and tuberculosis programmes shows that public–private mix is a feasible and cost- effective approach to engage diverse care providers so as to support health promotion, strengthen service delivery, improve access to health care and provide financial protec- S38 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ tion to the poor (WHO/EMR, unpublished data, 2008). Developing and using new tools PHC as an approach has to be innovative and dynamic. Additional tools should be continuously developed and used to address new challenges and changes. The tools gen- erated should cater for the following areas. • results-based accountability frameworks to lay out what can be done to make information instrumental to improving outcomes, not only for healthcare, but also for social outcomes, such as the extent to which the system is people- centred, equitable and encourages par- ticipation; • needs assessment and stratification to ensure equity, especially in the margin- alized and deprived areas. In EMR due to the increasing number of displaced people and victims of civil strife, new ways of addressing the needs of such vulnerable groups have to be sought. In these settings models should also be developed to enable primary care to “navigate” patients towards emergency medical service. • partnership of public and private sectors including division of tasks of provision and financing of care, contractual ar- rangements and policy setting. • globalization and its effect at national and local levels, including magnitude of treatment taken abroad and the migra- tion of human resources. • role of PHC in health security especially against pandemics and newly emerging diseases. • policy dialogue and engagement includ- ing evidence-based interventions for policy formulation, and managerial, op- erational and technical activities. • promotion of self care for all the popu- lation to avoid risk factors and, for pa- tients, to encourage compliance with treatment. • cost–effectiveness of the PHC approach to prove its relevance and ability to ad- dress current health needs. • effective decentralization and integra- tion in organizing healthcare and its programmes; • retention, recruitment and career devel- opment of human resources to ensure equity; • effective intersectoral action; • the best practices of participation of peo- ple and civil society organizations; • the strategic use of evidence-based in- formation and communication technolo- gies to advance effective PHC; • health financing in support of PHC and use of financial leverage to promote eq- uity; • effectiveness and distribution of foreign aid in sustaining PHC activities at the national level. Training, followed by continued support and supervision of health professionals, is key to make these tools effective in revital- izing PHC. Promoting global solidarity If we want to move quickly on the above axes we must correct the large financing gap. Hence international solidarity is need- ed, organized so as to bring structural im- provement to the way countries deal with health inequalities. This has implications for reshaping and focusing development aid for health. The predicament of aid-dependent coun- tries shows how countries can build their capacity to put pressure on the global aid Eastern Mediterranean Health Journal, Vol. 14, Special Issue S39 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ environment to bring it more in line with the Paris principles of harmonization and alignment. In this regard the PHC strategy can help countries bring more coherence to global solidarity for health. Concluding key messages “If the determinants of health, as revealed through the PHC approach, are multiple and interactive, then policy-making must have these qualities. We need government ma- chinery which is capable of comprehending the whole system, as a system, rather than its constituent parts…” (Harris & Hast- ings, 2006). In addition to its complexity, health has also become a substantial global economic activity amounting to trillions of dollars. This fact justifies much greater investment in health services research and development and building the capacity of the national health sector to understand and influence the global policies that af- fect progress towards PHC. It is thus of paramount importance to engage senior health sector leadership with other sectors, political leaders and key sector stakeholders in order to: • heighten the profile of health as a politi- cal imperative and social goal; • articulate the values that drive PHC and relate them to other sociopolitical priori- ties; • develop a long-term view of the place of PHC and the whole of the health sector (and not merely its public sector compo- nents) in society; • govern human resources for health with a double objective of re-orienting the system towards PHC and managing the human resources crisis. PHC has demonstrated effectiveness and greater efficiency, drives equity, and has better outcomes and responsiveness in countries where it has been adopted. Thus there is a strong rationale for investing in PHC, and, given the way the world stands today and the challenges of the future, re- vitalization of PHC is more necessary and relevant than ever if we are to achieve the most noble and equitable of goals – health for all. Bibliography 1. Abramson W. Partnerships between the public sector and NGOs: contracting for primary health care services – A State of the Practice Paper. Bethesda, PHR Re- source Center, Abt Associates, 1999. 2. Bennett S, Mills A. Government capacity to contract: health sector experience and lessons. Public administration and devel- opment, 1998, 18(4):307–26. 3. De Silva S. Community-based contract- ing: a review of stakeholder experience. Washington DC, World Bank, 2000. 4. Declaration of Alma Ata. International conference on primary health care, Alma- Ata, USSR, 6–12 September 1978. Ge- neva, World Health Organization, 1978. Calls for real global solidarity Poverty is not an ISSUE for the purpose of health campaigns, it is the CAUSE that should lead our lives of public service. “Global Funds are like stars in the sky, you can see them, appreciate their abundance…..but fail to touch them”. Ministry of Health official, Malawi. Patent rights or patient rights. The choice is clear. S40 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 5. Egypt household health utilization and ex- penditure survey. Cairo, Ministry of Health and Population & El-Zanaty Associates, 1995 6. European Observatory on Health Sys- tems and Policies. Glossary. Copenha- gen, World Health Organization, Regional Office for Europe, 2004. 7. Formulating strategies for Health for All by the year 2000. Geneva, World Health Organization, 1979 (Health for All Series, No. 2). 8. From Alma Ata to the year 2000: re- flections at the midpoint. Geneva, World Health Organization, 1988. 9. Green A. Unpublished report, 2005. 10. Harris A, Hastings N. Working the system: creating a state of well-being. Edinburgh, Scottish Council Foundation, 2006. 11. Hart E, Bond M. Action research for health and social care. Buckingham, Open Uni- versity Press, 1995. 12. High level forum on the health MDGs. Summary of discussions and agreed action points. Geneva, World Health Organization, 2004 (http://www.who.int/ hdp/en/summary.pdf, accessed 23 July 2004). 13. Hill K, Yazbeck A. Trends in under-five mortality, 1960–90: estimates for 84 developing countries. Washington DC, World Bank, 1994. 14. Human rights, health and poverty reduc- tion strategies. Geneva, World Health Organization, 2005. (Heath and Human Rights Publications Series Issue 5). 15. Laverack B. Health promotion and prac- tice: power and empowerment. London, Sage Publications, 2004. 16. Loevnisohn B. Practical issues in con- tracting for primary health care delivery: lessons from two large projects in Bang- ladesh. Washington DC, World Bank, 2002. 17. Martinez J. Assessing quality outcomes and performance management. In: Fer- rinho P, Dal Poz M, eds. Towards a global health workforce strategy. Geneva, World Health Organization. 2003 (Studies in Health Services Organisation and Policy, 21). 18. Mills A. Experiences of contracting: an overview of the literature. Geneva, World Health Organization, 1998 (Macroeco- nomics, Health and Development Series, No. 33). 19. Mitchell BR. British historical statistics. Cambridge, Cambridge University Press, 1988. 20. Paris declaration on aid effectiveness ownership, harmonisation, alignment, results and mutual accountability. 2005 (http://www.gc21.de/ibt/alumni/ibt/docs/ Paris_Declaration_en.pdf, accessed 30 August 2008). 21. Report of the Consultation on Improving Clinical Nursing Practice, Tehran, Islamic Republic of Iran, 27–30 June 1994. Al- exandria, WHO Regional Office for the Eastern Mediterranean, 1994 (WHO-EM/ NUR/303/E/L). 22. Report of the first regional meeting for focal points of paramedical resources development Cairo, Egypt 8–11 June 1996. Cairo, WHO Regional Office for the Eastern Mediterranean, 1996. 23. Report of the WHO Commission Macr- oeconomics and Health. Geneva, World Health Organization, 2002 (A55/5). 24. Report on the Expert Group Meeting on Reform of Health Professions Education in the Eastern Mediterranean Region, 31 March–2 April 2002. Cairo, WHO Region- al Office for the Eastern Mediterranean, 2002 (unpublished document WHO-EM/ HRH/591/E/R). 25. Rifkin SB, Pridmore P. Partners in plan- ning: information, participation and em- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S41 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ powerment. London, Macmillan and TALC, 2001. 26. Role of academia and professional as- sociations in support of HFA. A paper submitted to the WHO/EMR Regional Committee, 44th session, October 1997. Cairo, WHO Regional Office for the East- ern Mediterranean, 1997 27. Ruster J, Yamamoto C, Rogo K. Franchis- ing in health: emerging models, experi- ences, and challenges in primary care. Washington DC, World Bank, 2003 (Pub- lic policy for the private sector, 263). 28. Shadpour K. Primary health care net- works in the Islamic Republic of Iran. Eastern Mediterranean health journal, 2006, 4:822–5. 29. Sheaff R, Uyod A. From competition to co- operation: service agreements in primary care. A handbook for professionals and managers. Manchester, National Primary Care Research and Development Centre, University of Manchester, 1999. 30. Sultanate of Oman second primary health care review mission, 18–24 March 2006. Geneva, World Health Organization, 2006. 31. The work of WHO in the Eastern Medi- terranean Region. Annual report of the Regional Director. World Health Organi- zation Regional Office for the Eastern Mediterranean, 1995 to 2006 (http://www. emro.who.int/rd/AnnualReports.htm, ac- cessed 23 July 2008). 32. Third report on regional evaluation of health for all strategies Cairo, WHO Re- gional Office for the Eastern Mediter- ranean, 1997 (unpublished document EM/RC44/9). 33. Tomorrow’s doctors. Recommendations on undergraduate medical education. London, General Medical Council, 1993. 34. Towards high performing health systems. Paris, Organisation for Economic Coop- eration and Development, 2004. 35. United Nations. Universal declaration of human rights, Preamble 1948 (http://www. un.org/Overview/rights.html, accessed 23 July 2008). 36. World development report 2004: Making services work for poor people. Washing- ton DC, World Bank, 2003. 37. World Health Assembly. WHA Resolution 42.38. Geneva, World Health Organiza- tion, 1989. 38. World Health Organization Regional Of- fice for the Eastern Mediterranean, 1994. The need for national planning for nursing and midwifery in the Eastern Mediterra- nean Region. Resolution EM/RC41/R.10. 39. World health report 2003 – shaping the future. Geneva, World Health Organiza- tion, 2003. 40. World health statistics 2007. Geneva, World Health Organization, 2007. S42 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Primary health care, health policies and planning: lessons for the future Sameen Siddiqi,1 Arnfried Kielmann,2 Susan Watts3 and Belgacem Sabri4 1Regional Adviser, Health Policy and Planning; 3Social Research Scientist; 4Director, Division of Health Systems and Services Development, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Susan Watts: wattss@emro.who.int). 2Visiting Professor, University of Indonesia, SEAMEO TROPMED Regional Centre for Community Nutrition, Jakata, Indonesia. Introduction Choices about forms of health care, includ- ing primary health care (PHC), are fun- damentally political decisions, reflecting global and national power structures and alliances, changing economic conditions, emerging new health problems and health care challenges, and the development of new health technologies. However, these choices also reflect, and are often expressed in terms of, a philosophy or rationale based on ethical theory or political “ideology”, a set of principles that guides decisions. The philosophical perspectives on ethics un- derlying health issues have variously been identified as utilitarianism, liberalism, neo- liberalism, social egalitarianism and com- munitarianism (Box 1) [1,2]. As regimes in many developing countries have changed over time, so has the political ideology, re- sulting in the reinforcement of, indifference to, and sometimes rejection of, the major tenets of PHC. The major tenets of PHC, as they emerge globally and in the Eastern Mediterranean Region (EMR), prior to and following the Alma Ata Declaration of 1978, support universal access to care, health equity and gender equity, community-based activities to link formal health care systems with the communities, and intersectoral action, which are all needed to tackle what we now call the “social determinants of health”. As such, they represent to varying degrees principles of egalitarianism and/or com- munitarianism. This paper traces the evolution of global and regional policies on PHC and its cheq- uered history, which has been marked by a number of phases when conditions were more, or less, favourable for its develop- ment. The paper identifies 3 policy phases: before Alma Ata; Alma Ata – the first 15 years (1978–1993); and the era of health sector reform and the resurgence of PHC (1993–2008). The paper goes on to discuss the regional perspective on PHC and fi- nally closes by recommending a sustainable health system based on PHC. Policy development and planning before Alma Ata Health systems in developing countries in the fifties and sixties In developing countries during the 1950s and 1960s conditions gradually emerged that were favourable to systematic health planning, which extended to the local level and was based on a scientific assessment of what worked. This laid the foundation for the Alma Ata Declaration and the sig- nificant improvement in maternal and child health in the second half of the 20th century. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S43 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Prior to this time, and depending on the country’s political situation, social orien- tation and economic development, health care research and service delivery was frag- mented and, in general, did not respond to actual needs. In former colonial countries health systems were developed primarily to protect the colonizers, and to maintain the economic productivity of the indigenous workforce; as such they were poorly adapted to the health problems and needs of the gen- eral population [3,4]. In India immediately before and following independence, efforts were made to establish an adequate health service infrastructure. However, these ef- forts were largely ineffective, especially in rural areas where 80% of the population lived but only 20% of the health budget was allocated. Health planning restricted itself to developing norms and regulations estab- lished by various committees [5]. In most of Latin America, where as a result of past colonialism and neocolonialism wide gaps prevailed among different social classes with respect to rights and privileges, income, education and land- ownership, as many as 5 different health systems co-existed alongside mostly inef- fective, understaffed and underfinanced regular government health services [6]. Health services provided by missionaries tended to follow the traditional European pattern: treatment-on-demand in stationary facilities. As conversion was frequently considered more important than the deliv- ery of health care, different denominations often duplicated services in one area, while leaving other areas uncovered [4]. In developing countries overall, health services were fragmented and uncoordi- nated. Little was known about the health problems of the general population, and even less about the most vulnerable groups. Most countries failed to develop health in- terventions based on factors acknowledged to have contributed so much to the decline in child mortality in affluent countries in the 19th and early 20th centuries, such as Box 1 Political ideology underpinning health systems worldwide Utilitarianism – humans act to increase their own well-being (Bentham); policies should be judged by their consequences. The greatest good for the greatest number results in, for example, an EPI target to cover 80% of children, without considering the fate of the other 20%. This perspective is closely related to Kantian liberalism, which holds that all individuals have the capacity to make moral choices about their life; hence the modern usage of neoliberalism which seeks to disengage the State from health and social welfare issues that are more appropriately the domain of individual choice in which health is seen as a commodity, not a right. Social egalitarianism – health is seen as a “public good” and the aim is to correct health and social inequalities by promoting a policy which ensures good health on equal terms for the entire population. Communitarianism – based on a belief in the kind of society that is desirable, guided by religion or a sociopolitical philosophy such as socialism or Marxism. Health policy focuses on the provision of universal care and disease prevention in an appropriate social framework, as in the former USSR, Cuba and the Islamic Republic of Iran. • • • S44 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ improved hygiene, housing, nutrition and breastfeeding, and later on immunization and curative programmes. For the implementation of regional or transnational planning, a number of key prerequisites were missing. Most important among these were: a modern concept of public health; qualified public health pro- fessionals; effective communication and exchange of knowledge and experience among health researchers; an epidemiologi- cal database of health indicators for the gen- eral population, especially for vulnerable groups; and the concept of health services planning and the prioritization of health problems and needs, specifying goals and outcome objectives. The “scientific” basis for health planning and policy formulation The period between the mid-1950s and 1970s saw the emergence of modern public health that largely replaced or comple- mented colonial and missionary health care practices and research in the developing world. Investigations into the overall mor- bidity and mortality of the general popula- tion, especially among preschool children, were carried out. Outstanding were the pioneering surveys on health and nutrition of the Haitian population by the United States Department of Health, Education and Welfare [6] and on causes of child deaths in the Americas [7]. In parallel, an ever increasing number of corroborating and complementary findings were made and published by research institutions and indi- vidual researchers the world over, notably the Nutrition Institute of Central America and Panama in Guatemala City in Central America [9–11], ICDDR-B in Bangladesh, [12,13], Narangwal Rural Health Research Centre, Punjab, India (RHRC) and Harvard University in Punjab, India [14,15], other research groups in Africa [16–18] and else- where in the world [19–23]. The nature, precise numbers and causes of child deaths, prevalence and incidence of major morbid- ity states, such as malnutrition, diarrhoeal disease, acute respiratory infections and tuberculosis, were identified and took their rightful place in the hierarchy of health problems. Inter-relationships between vari- ous disease states and their pathological and physiological consequences were re- searched and clarified [24–30]. Relatively simple yet highly effective intervention methods were devised and successfully tested in both urban and rural populations in various centres [31–34]. By the late 1970s enough evidence had accumulated to support worldwide child and maternal health interventions, first for the most vulnerable groups and later for the entire population. Major infectious dis- eases could now be controlled: cholera, diphtheria, measles, neonatal tetanus, polio- myelitis, tuberculous meningitis. The dev- astating disease, smallpox, was eradicated. Preventive as well as curative measures for malnutrition were identified [35]. For the first time selected packages of health interventions could address priority health problems on a worldwide basis [36–38]. At the same time, the causes for and effects of rapid population growth on health, economy and social development were examined and potential solutions advanced [39,40]. The nature and cost of resources needed for these interventions were determined and compared with those available to regular government services [41]. In parallel with these developments and in response to the availability of more evi- dence for successful interventions, compre- hensive health planning in response to the needs of the population now became pos- sible. In the late 1960s, the Pan American Eastern Mediterranean Health Journal, Vol. 14, Special Issue S45 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Box 2 Excerpts from the Declaration of Alma Ata Article I “health…is a fundamental human right and…the attainment of the highest possible level of health is a most important worldwide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector”. Article II “The existing gross inequality in the health status of the people particularly between developed and developing countries, as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.” Article V “Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures.” Article VI “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.” Health Organization (PAHO), in collabora- tion with the Center for Development Stud- ies of the Central University of Venezuela, developed the PAHO–CENDEZ health planning method to prioritize major health problems in order of their effective response to interventions [42]. At about the same time, some public health universities in the US, notably Johns Hopkins University, started to offer courses on national and sub- national health planning [43]. Senior health professionals from virtually all countries of the globe participated and, on return to their own countries, helped to initiate national and regional health plans. The time was now ripe to rally the world to make use of all that had been learned to create more equitable health services that would result in health for all. Evolution of PHC since Alma Ata – the first 15 years (1978– 1993) The Declaration of Alma Ata and its challengers The International Conference in Alma Ata in Kazakhastan in 1978, which was spon- sored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), was a landmark in putting PHC on the global public health agenda. Over 3000 delegates, 134 Member States of WHO and 67 international agencies partici- pated in the conference. The major outcome of the conference was the Declaration of Alma Ata (Box 2) that embraced the goal of S46 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ “Health for All by the Year 2000” using the strategy of comprehensive PHC. In addition to the provision of essential health services, it also envisaged tackling underlying so- cial, economic and political causes of poor health [44]. The idea of comprehensive PHC operated at 2 levels: first, as a level of contact and care within the health system reconfigured to emphasize the basic health needs of the population; and second, as a philosophy of health work, which was part of the overall social and economic develop- ment of the community [45]. Other princi- ples of the PHC philosophy included the use of appropriate technology, a critique of medical elitism and the explicit linkage of health and social development that requires intersectoral collaboration and full commu- nity involvement [46]. The adoption of the Declaration of Alma Ata created a momentum in many develop- ing countries to initiate changes in service delivery. In order to accommodate the new focus on PHC, many developing countries reorganized their ministries of health, in- tegrating some vertical programmes and strengthening district health systems. WHO itself reconfigured its organizational profile to provide the required technical support to countries and to help them to develop necessary capabilities in planning and man- agement using the concept of “managerial process for national health development” [47]. Within a year of the Declaration of Alma Ata, some international health profession- als challenged the comprehensive PHC approach, which gave rise to “selective” PHC. This approach was considered to be more pragmatic, financially palatable and politically less threatening. Rather than trying to strengthen all aspects of the health system and simultaneously transform social and political relations, the proponents of selective PHC maintained that, at least in the short term, efforts should concentrate on a small number of cost-effective inter- ventions aimed at tackling major causes of mortality and morbidity [48]. The UNICEF- led GOBI initiative – Growth monitoring, Oral rehydration therapy, Breastfeeding and Immunization – was the first example of the selective approach. Later, at least on paper, FFF (Family planning, Female education and Food supplementation) was added to GOBI to make it more “comprehensive”. Today, it is clear that the selective approach strengthened what are seen in many countries as established vertical pro- grammes. However, selective PHC was characterized by a top down approach, reduced opportunities for response to local needs and local participation. It also ignored the broader concerns of poverty, develop- ment and equity in favour of short term, possibly unsustainable, improvements that could be easily measured [49]. As such, it could be seen as undermining integrated PHC. In response, efforts were made to push the wider PHC agenda. WHO established an Intersectoral Action for Health Unit, supported by the Rockefeller Foundation [50]. In 1986, Canadian agencies and WHO sponsored the adoption of the Ottawa Char- ter on Health Promotion, which identi- fied 8 key prerequisites for health – peace, shelter, education, food, income, a stable ecosystem, sustainable resources, and social justice and equity [51]. The Rockefeller Foundation supported the “Good Health at Low Cost” initiative to document how some developing countries, such as Cost Rica, Cuba, Sri Lanka and Kerala State in India, had been able to achieve a health status better than expected given their economic resources [52]. According to one analysis, the 5 shared social and political factors that Eastern Mediterranean Health Journal, Vol. 14, Special Issue S47 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ underpinned the success in these countries were: i) historical commitment to health as a social goal; ii) a social welfare orientation to development; iii) community participa- tion in decision-making processes relative to health; iv) universal coverage of health for all social groups; and v) intersectoral linkages for health [53]. By the mid-1980s, moves to sustain PHC were threatened by a prolonged global economic recession and the associated debt crisis in the developing world that pushed many low- and middle-income countries to the brink of economic collapse. These events provided the context within which powerful industrialized governments and international financial institutions, the World Bank and the International Monetary Fund, could intervene directly in the econo- mies of the numerous developing countries, requiring them to reshape their economies according to neoliberal prescriptions in order to qualify for debt rescheduling and continued aid [54]. The health agenda was affected by the broader economic structural adjustment programmes, which required countries to cut spending on health and to undertake health sector reforms (HSR). One of the manifestations of the neo- liberal approach to health was the levying of charges for primary care, which was formalized in the Bamako Initiative of 1987 [55]. This promoted “community financ- ing”, requiring people in poor communities to pay for their own care, compensating for cuts in social expenditures. WHO, which was faced with challenges to PHC and financially weakened by a funding crisis, sought to mobilize financial support to im- plement health for all through PHC. In 1988 it advised Member States to allocate at least 5% of their GDP to achieve this goal [56]. Influence on national health policies and planning The shift from comprehensive to selec- tive PHC has had a major influence on national health policies since the 1980s, with the launch of vertical, unifocal, single purpose disease prevention and control programmes. These currently constitute the major approaches used by national govern- ments to tackle priority public health prob- lems. In many countries, such programmes have been successful and responsible for the control, elimination and eradication of specific diseases. In others, particularly, low-income countries, they have directly contributed to weakening integrated health systems. The neoliberal doctrine has influenced national health policies in two ways: i) the broader structural adjustment programmes, which imposed cuts on social and health sector spending with negative consequences for health and social welfare; and ii) through the health sector reform agenda, which was in itself an extension of the structural ad- justment programmes [2]. The health sector reforms encouraged privatization of health services and decentralization of manage- ment, promoted private insurance and advo- cated or enforced payment for PHC. These cost-cutting measures were undertaken at the expense of equity, and limited the role of government in the provision of health and other social services. The basic premise of the neoliberal vi- sion is that markets freed from government interference are the best and most efficient allocators of resources in production and distribution and thus the most effective mechanism for achieving the common good, including health. This focus on the free operation of the market undermined S48 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ the role of health planning, and exacerbated the decline of the already weak capacity of ministries of health for health planning. The era of health sector reform and the resurgence of PHC (1993–2008) PHC and health sector reform strategies The publication of the 1993 World Bank World Development Report: investing in health marked the next phase in the see- saw between PHC and HSR [57]. By that time it was clear that the deteriorating mac- roeconomic situation and the effects of the structural adjustment programmes had undermined the health systems in poor countries and the health status of their populations. The report proposed a three- pronged approach to government policies for improving health: i) foster an environ- ment that enables households to improve health; ii) improve government spending on health; and iii) promote diversity and com- petition. The report also defined and costed a basic benefit package of essential public health and clinical interventions estimated at US$ 12 per capita that governments should ensure reached all the population. The introduction of the concept of disability adjusted life years as a measure of health was intended as a tool to monitor the impact of disease control programmes [49]. This report strengthened the notion of selective PHC and proposed further struc- tural reforms in the health sector, which were contrary to the spirit of comprehensive PHC (Table 1) [58]. By the late 1990s the initial optimism about HSR in developing countries was giving away to concern. In 2000 Berman and Bossert [59] recognized that the more sweeping reforms, such as the establishment of nationwide health insur- ance systems, were hard to implement and were rarely successful, while the apparently more modest and seemingly less demanding reforms, such as hospital autonomy, also had mixed results. At the same time, some commentators stressed the need to remedy the neglect of equity in HSR [60]. During this period, WHO sent mixed signals about PHC. In its 1998 annual re- port, WHO reinterpreted and reinvigorated the health for all strategy under the banner of Health for all in the 21st century. The revitalization of health for all included a re- Table 1 Contrasts between the approaches of primary health care and health sector reform Attributes Primary health care Health sector reform (Declaration of Alma Ata) Ideology promoted Social egalitarianism Utilitarianism Overall approach Comprehensive Selective – essential package of services Role of the government Greater public sector Restricted role of involvement the government Focus Equity and social justice Efficiency and competition Champions Social scientists Economists Type of reforms Programmatic Structural Basis Rights-based Reform-based Eastern Mediterranean Health Journal, Vol. 14, Special Issue S49 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ newed effort to promote intersectoral action as a key component of public health strate- gies [61]. However, the WHO’s millennium World Health Report 2000 did not follow up on these messages [62]. Nevertheless, as this report was devoted to improving health systems, it did succeed in bringing WHO back to the centre of the debate on health systems. The year 2000 also marked the launch of the Millennium Development Goals (MDGs), many of which are health related. To many, the MDGs were seen as a vindica- tion of the comprehensive PHC philosophy. Overall goals are “comprehensive” in that they represent commitments to reduce pov- erty and hunger, gender inequality, lack of education, lack of access to clean water and environmental degradation. However, the health goals are “selective” in that they target specific health problems [63]. Equity and social justice were not, at first, explic- itly addressed in the MDGs. In the same year the growing corpus of human rights laws was strengthened with additions to the landmark 1976 International Covenant on Economic, Social and Cultural Rights, which obligated health policy-makers and practitioners to ensure the right of equitable access to health care and health facilities [64]. This clearly demonstrated the im- perative to recognize human rights in the delivery of care and the implementation of public health programmes [65]. In 2005, WHO launched the Global Commission on Social Determinants of Health. The Commission, which will de- liver its final report in mid-2008, drew attention to the social determinants of health that are known to be among the most impor- tant causes of poor health and inequalities between and within countries. These de- terminants include gender inequity, unem- ployment, unsafe workplaces, urban slums, globalization and lack of access to health services [66]. To complement these positive develop- ments in PHC and health equity, WHO has taken upon itself the revival of PHC, making it the subject of the upcoming 2008 World Health Report. WHO is well placed to support PHC as it is among the most decentralized of all United Nations organizations, with 6 regional offices with direct access to Member States. During the PHC–HSR phase, many regional offices remained steadfast to the PHC approach to health systems: among them the Eastern Mediterranean [67], European [68] and Pan American Offices [69]. Influence of the PHC–HSR discord on health policy and planning in countries There is no question that organized global movements influence global, regional and national policies, especially the swings in health policy between PHC and HSR. For example, in the 1990s many ministries of health, which boasted of directorates, de- partments or units of PHC became truncated or were replaced by HSR units. In some cases, ministries of health have found ways to work with vertical units, elsewhere the relationship has been marked by dishar- mony. The relationship has also been com- plicated by the increasing number of global players since 2000, bringing unprecedented opportunities to access external assistance, primarily directed towards specific diseases rather than integrated PHC [70]. Over the past several years there has been a greater effort, particularly in the Eastern Mediterranean Region, to establish health policy analysis and reform units within ministries of health in order to strengthen health systems based on PHC. The capacity for strategic planning in health in most developing countries has been and remains weak. However, the policy swings between more centralized planning and S50 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ greater reliance on free market approaches have created tension and confusion in the minds of health policy-makers in develop- ing countries. Because HSR is in general a macro-reform, which has little to offer in terms of how health services can actu- ally be delivered on the ground, they have distracted attention from service delivery, the district health system based approach and district health planning, which are so critical to effective programme implemen- tation in most poor countries. These reforms also continued to ignore the importance of planning health services according to the health problems and needs of communities, and in harmony with their sociocultural and economic ecosystem. By doing so, service effectiveness and ultimately efficiency will once again be jeopardized as it was in the era of structural adjustment programmes and selective PHC. Eastern Mediterranean Region’s commitment to PHC Despite the ebb and flow of PHC, the Re- gional Office for the Eastern Mediterranean (EMRO) has remained steadfast in its com- mitment to the PHC approach, as seen in the report of the activities of the Regional Office during its first 40 years, 1949–1989, and in the number and nature of resolutions endorsed by its Regional Committee over the past decade [71–77]. This commitment has also been reflected in the community- based initiatives programme, especially in the basic development needs (BDN) component, initiated in Somalia in 1988. During scaling up, BDN has evolved from meeting minimum needs to comprehensive development centred on health, focusing on tackling social determinants of health. This regional initiative is currently supported by WHO in 12 countries of the Region [78]. District Team Problem Solving (DTPS), a district planning and management tool to strengthen the district health system, was developed to identify and solve priority health problems using community resourc- es. The DTPS manual developed for this purpose has been translated into national languages of the Region and training has been provided [79]. At the country level, a number of EMR Member States have taken pioneering steps in PHC. The commitment of Oman to strengthen the welayat (governorate) health system, using the DTPS approach, has received global recognition. The PHC programmes based on the training of male and female community health workers, behvarz, in the Islamic Republic of Iran and the training of 100 000 lady health workers in Pakistan financed and organized by the government have had a considerable impact on health outcomes in both countries and are considered to be the largest community- based health initiatives in the Region, along with the EMRO community-based initia- tives programme [80,81]. Finally, the more recent policy of contracting out PHC serv- ices to nongovernmental organizations to provide health services in the war disrupted health system in Afghanistan has shown some encouraging results. What remains to be seen is whether this can be sustained in the long term and whether there is a greater role for the public sector in future [82]. In countries in which PHC became more widely institutionalized, changes in medical education were needed to more closely align curricula with the objectives of PHC. To foster this approach, WHO and PAHO have promoted community-oriented educational institutions for health sciences [83]. The Islamic Republic of Iran underwent a major change in 1985 when all health-related schools and institutions were moved from the Ministry of Higher Education and inte- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S51 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ grated into the new Ministry of Health and Medical Education [84]. Until today, this is considered to be one of the most important initiatives in the country’s commitment to, and the success of, its PHC programmes. Lessons for a sustainable PHC strategy in the future The ups and downs in the short life of PHC since it was formally recognized as a strategy for health for all is not a matter of coincidence and provides several lessons for national health policy-makers, planners and programmers as well as development partners. • Health for all through PHC as a philoso- phy and approach has stood the test of time and remains relevant to all Member States, rich or poor. However, PHC can- not be a “one size fits all” strategy and has to be adapted to the needs of each country. Among the areas that need to be considered are: the set of health services to be provided, the skill mix required, the mechanisms for monitoring, the cost and financing of these services, and, most important, the non-health determi- nants to be addressed. • The MDGs, the growing corpus of human rights instruments, and the re- emphasis on tackling social determi- nants of health can serve as a sound foundation for the revitalization of the comprehensive PHC approach. There is thus a great need to align with and build on existing global initiatives, rather than to launch a new PHC project. • The evidence generated during the pre- Alma Ata years on priority public health problems provided the scientific basis for formulating health policies and plans and for the interventions that became an integral part of the PHC approach. There can be no compromise on the need for sound evidence. However, today evi- dence is needed on how to make health systems functional and able to tackle the wider health determinants, as well as on disease control. • Improved efficiency and competition are desirable but under no circumstance should these override the collective value of equity and social justice embedded in health for all, which should continue to underpin the development of the health system in any country, rich or poor. • Increased involvement of communities through better governance, effective decentralization and greater responsive- ness of health systems is essential. This requires a high level of political commit- ment, respect for the citizenry, retraining and patience among professionals, and the development of strategies that en- gage literate and illiterate communities. • Reforming ministries to become stew- ards of health instead of health care is essential to forward a comprehensive PHC agenda. This entails strengthen- ing ministries of health to engage in a serious dialogue on health with national and international development partners, to lead the effort on intersectoral action for health, and to advocate for greater investment in health for the social and economic development of the country. • The role of a vibrant civil society is es- sential for the purpose of health advoca- cy, capacity building, applied research, service delivery, and as a watchdog to ensure that the values of PHC are not compromised in health development. • During the 1980s and 1990s the promo- tion of different ideological perspectives by development partners confused and often damaged national health systems. In addition, the recent addition of new S52 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ and powerful global health players also poses new challenges. These develop- ments call for better global health gov- ernance through greater harmonization among development partners. The Paris Declaration for greater aid effectiveness is a step in the right direction. WHO will have to play its catalytic role in better coordination among the players and im- proving aid effectiveness [85]. • The success of PHC rests heavily on the strengthening of the public sector, civil society and academic and research institutions and building a critical mass of individual leaders who can guide these institutions in developing coun- tries. Over-reliance on institutions of in- dustrialized countries would be a recipe for failure. • WHO will have to prepare itself to ful- fil its ambitious agenda to revitalize PHC. This means visionary leadership, strengthening its position among global and national partners, providing techni- cal advice based on sound evidence, developing appropriate tools and instru- ments from policy to community levels and strong capacity in country offices. Most importantly, this time there can be no wavering from the commitment to PHC for at least another 30 years. References 1. Roberts MJ, Reich MR. Ethical anal- ysis in public health. Lancet, 2002, 359(9311):1055–9. 2. World Health Organization. Action on the Social Determinants of Health: Learning from Previous Experiences. A background paper prepared for the Commission on Social Determinants of Health. Geneva, 2005 (http://www.who.int/social_determi- nants/resources/action_sd.pdf, accessed 17 July 2008). 3. Trankell IB, Ovesen J. French colonial medicine in Cambodia: reflections of gov- ernmentality. Anthropology & medicine, 2004, 11(1):91–105. 4. Musisi S, Musisi N. 2008. The legacies of colonialism in African medicine (http:// www.who.int/global_health_histories/ seminars/nairobi02.pdf, accessed 17 July 2008). 5. National Institute of Health and Family Welfare, National Documentation Center, Committees and Commissions (Bhore Committee 1946, Mudaliar Committee 1962, Mukherjee Committee 1966) (http:// www.nihfw.org/ndc-nihfw/html/Commit- teAndCommunications.htm, accessed 16 June 2008). 6. Sebrell WH et al. Appraisal of nutrition in Haiti. American journal of clinical nutrition, 1959, 7:538–84. 7. Puffer, RR, Serrano CV. Patterns of mor- tality in childhood. Washington DC, Pan American Health Organization, 1973 (PAHO Scientific Publication, No. 262). 8. Behar M et al. An investigation into the causes of deaths in children in four communities in Guatemala. Bulletin of the World Health Organization, 1958, 19:1093–102. 9. Bruch HA et al. Studies of diarrheal dis- ease in central America. V. Environmental factors in the origin and transmission of acute diarrheal disease in four Guatema- lan villages. American journal of tropical medicine and hygiene, 1963, 12:567–79. 10. Scrimshaw NS et al. Nutrition and infec- tion field study in Guatemalan villages, 1959–1964. IX. An evaluation of medical, social and rural health benefits with sug- gestions for future field study. Archives of environmental health, 1969, 18:51–8. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S53 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ nutrition in Haiti]. Paris, Presses Universi- taires de France, 1970. 22. Mata LJ, Urrutia, JJ. Lechtig A. Infection and nutrition of children of a low socioeco- nomic rural community. American journal of clinical nutrition, 1971, 24:249–59. 23. Graham GG. Environmental factors affect- ing the growth of children. American jour- nal of clinical nutrition, 1972, 25:1184–8. 24. Wills VG, Waterlow JC. The death rate in the age group 1–4 years as an index of malnutrition. Journal of tropical paediat- rics, 1958, 3(4):167–70. 25. Scrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. Geneva, World Health Organization, 1968 (WHO Monograph, No. 57). 26. Kass EH. Infectious diseases and social change (presidential address, Infectious Disease Society of America). Journal of infectious diseases, 1971, 123:110–4. 27. Lechtig A et al. Influencia de la nutrición materna sobre el crecimiento fetal en poblaciones rurales de Guatemala. II. Suplementacion alimentaria [Influence of maternal nutrition on fetal growth in rural populations of Guatemala. II. Nutrition supplement]. Archivos latinoamericanos de nutrición, 1972, 22:117–31. 28. Buckley RH. Iron deficiency anemia: its relationship to infection, susceptibility and host defences. Pediatrics, 1975, 86:993– 5. 29. Kielmann AA, McCord C. Weight-for-age as an index of risk of death in children. Lancet, 1978, 1(8076):1247–50. 30. Kielmann AA et al. The effect of nutritional status on immune capacity and immune responses in preschool children in a rural community in India. Bulletin of the World Health Organization, 1976, 54:477–84. 31. King M. Medical care in developing coun- tries. Nairobi, Oxford University Press, 1966. 11. Bengoa JN. The problem of malnutrition. WHO chronicle, 1974, 28:3–7. 12. Cash RA et al. Rapid correction of acido- sis and dehydration of cholera with oral electrolyte and glucose solution. Lancet, 1970, 2(7672):549–50. 13. Nalin DR, Cash RA, Rahman M. Oral (or nasogastric) maintenance therapy for cholera patients in all age-groups. Bulletin of the World Health Organization, 1970, 43(3):361–3. 14. Wyon JB, Gordon JE. The Khanna Study: population problems in rural Punjab. Cam- bridge, Harvard University Press, 1971. 15. Kielmann AA et al. Child and maternal health services in rural India. The Narang- wal Experiment, Vol. 1. Integrated nutri- tion and health care. Baltimore, Johns Hopkins University Press, 1983. 16. McLaren DS. A Study of the factors under- lying the special incidence of keratomala- cia in Oriya children in the Phulbani and Ganjam districts of Orissa, India. Journal of tropical paediatrics, 1956, 2(3):135– 40. 17. Morley D. The public health problem created by measles in the developing countries. Archiv für die gesamte Virus- forschung, 1965, 16:19–26. 18. Burgess HJL, Burgess AP. The arm circumference as a public health index of protein calorie malnutrition in early childhood. Journal of tropical paediatrics, 1969, 15:189–92. 19. Jelliffe DB. The assessment of the nutri- tional status of the community. Geneva, World Health Organization, 1966 (WHO Monograph, No. 53). 20. Cravioto J et al. The ecology of infant weight gain in a pre-industrial society. Acta paediatrica Scandinavica, 1967, 56:71–84. 21. Beghin I, Fougere W, King K. L’alimen- tation et la nutrition en Haiti [Food and S54 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 32. Comstock GW, Edwards PA. An Ameri- can view of BCG vaccination illustrated by results of a controlled trial in Puerto Rico. Scandinavian journal of respiratory disease, 1972, 53:207–17. 33. Berggren WL. Administration and evalu- ation of rural health services. I. A tetanus control program in Haiti. American journal of tropical medicine and hygiene, 1974, 23:936–49. 34. McCord C, Kielmann AA. A successful programme for medical auxiliaries treat- ing childhood diarrhoea and pneumonia. Tropical doctor, 1978, 8:220–5. 35. Morley D, Woodland M. See how they grow. New York, Oxford University Press, 1979. 36. Gopalan C. Health problems in pre- school children. III. Worldwide experi- ence, special problems and preventive programmes. Indian journal of tropical paediatrics, 1968, 14:228–32. 37. Morley D. Paediatric priorities in the de- veloping world. London, Butterworths, 1973. 38. Arole M, Arole R. The comprehensive rural health project in Jamkhed, India. In: Newell JN, ed. Health by the people. Ge- neva, World Health Organization, 1975. 39. The determinants and consequences of population trends. New York, United Na- tions, 1953 (rev. 1973) (Report # ST/SOA/ Ser. A/17) 40. Taylor CE, Newman JS, Kelly NU. The child survival hypothesis. Population stud- ies, 1976, 30:263–78. 41. Parker RL et al. The Narangwal experi- ment on interactions of nutrition and in- fection. III. Measurement of services and costs and their relation to outcome. In- dian journal of medical research, 1978, 68(Suppl.):42–54. 42. Gutiérrez JL. Health planning in Latin America. American journal of public health, 1975; 65(10):1047–9. 43. Reinke WA. Health planning for effective management. New York, Oxford Univer- sity Press, 1988. 44. World Health Organization/United Nations Children’s Fund. Declaration of Alma Ata 1978 (http://www.who.int/hpr/NPH/docs/ declaration_almaata.pdf, accessed 16 June 2008). 45. Werner D, Sanders D. Questioning the solution: the politics of primary health care and child survival. Palo Alto, Health- wrights, 1997. 46. Cueto M. The origins of primary health care and selective primary health care. American journal of public health, 2004, 94(11):1864–74. 47. Managerial process for national health development: guiding principles for use in support of strategies for health for all by the year 2000. Geneva, World Health Organization, 1981 (Health for All Series, No. 5). 48. Walsh J, Warren K. Selective prima- ry health care, an interim strategy for disease control in developing countries. New England journal of medicine, 1979, 301:18:967–74. 49. Italian Global Health Watch. From Alma Ata to the Global Fund: the history of in- ternational health policy. Social medicine, 2008, 3(1):36–48 (http://journals.sfu.ca/ socialmedicine/index.php/socialmedicine, accessed 11 May 2008). 50. World Health Organization and Rocke- feller Foundation. Intersectoral action for health: the way ahead. Report of the WHO/Rockefeller Foundation meeting 3–6 March 1986. New York, Rockefeller Foundation, 1986. 51. World Health Organization. Ottawa Char- ter for Health Promotion (http://www.who. int/healthpromotion/conferences/previ- ous/ottawa/en/, accessed 16 June 2008) Eastern Mediterranean Health Journal, Vol. 14, Special Issue S55 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 52. Halstead S, Walsh J, Warren K, eds. Good health at low cost. New York, Rocke- feller Foundation, 1985. 53. Saenz L. Health changes during decade: The Costa Rica case. In: Halstead S, Walsh J, Warren K, eds. Good health at low cost. New York, Rockefeller Founda- tion, 1985. 54. Gershman J, Irwin A. Getting a grip on global economy. In: Kim J et al., eds. Dy- ing for growth: global inequality and the health of the poor. Monroe, Maine, Com- mon Courage, 2000. 55. McPake B, Hanson K, Mills A. Community financing of health care in Africa: an eval- uation of the Bamako initiative. Social sci- ence & medicine, 1993, 36(11):1383–95. 56. Savedoff W. How much should countries spend on health? Geneva, World Health Organization, 2003:10 (Discussion Paper Number 2, EIP/FER/DP.03.2). 57. World Bank. World Development Report 1993: Investing in health. New York, Ox- ford University Press, 1993. 58. Laurell AC, Arellano OL. Market com- modities and poor relief: the World Bank proposal for health. International journal of health services, 1996, 26(1):1–18. 59. Berman PA, Bossert TJ. A decade of health sector reform in developing coun- tries: what have we learned? Cambridge, Harvard School of Public Health, 2000 (DDM Report No. 81) (http://www.hsph. harvard.edu/ihsg/publications/pdf/clo- seout.PDF, accessed 18 June 2008). 60. Gwatkin DR. The need for equity-oriented health sector reforms. International jour- nal of epidemiology, 2001; 30:720–23. 61. Health for all in the 21st century. Geneva, World Health Organization, 1998. 62. The World Health Report 2000. Health systems: improving performance. Ge- neva, World Health Organization, 2000 (http://www.who.int/whr/2000/en/index. html, accessed 17 July 2008). 63. United Nations. UN Millennium Develop- ment Goals (http://www.un.org/millen- niumgoals/index.html, accessed 30 June 2008). 64. Office of the United Nations High Com- missioner for Human Rights, United Na- tions Economic and Social Council. The right to the highest attainable standard of health. General Comment No. 14, 2000 (E/C.12/2000/4, 11 August 2000) (http:// www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C. 12.2000.4.En?OpenDocument, accessed 30 June 2008). 65. Hunt P. Right to the highest attain- able standard of health. Lancet, 2007, 370(9585):369–71. 66. World Health Organization. Commission on Social Determinants of Health [web- site] (http://www.who.int/social_determi- nants/en/, accessed 16 June 2008). 67. Primary Health Care: 25 years after Alma Ata. Technical paper presented at the 50th Session of the World Health Organi- zation Regional Committee for the East- ern Mediterranean, 2003 (http://www. emro.who.int/RC50/documents/DOC8. doc, accessed 16 June 2008 ) 68. World Health Organization Regional Office for Europe. The Ljubljana Char- ter on Reforming Health Care, 1996 (http://www.euro.who.int/AboutWHO/ Policy/20010927_5, accessed 16 June 2008). 69. Renewing primary health care in the Amer- icas. A position paper of the Pan Ameri- can Health Organization/World Health Organization (PAHO/WHO). Washington DC, Pan American Health Organization, 2007. 70. Garrett L. The challenge of global health. Foreign affairs, January/Febru- ary 2007 (http://www.foreignaffairs. org/20070101faessay86103-p0/laurie- garrett/the-challenge-of-global-health. html, accessed 30 June 2008). S56 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 71. World Health Organization Regional Of- fice for the Eastern Mediterranean, 2006. Role of governments in health develop- ment. Resolution EM/RC53/R.8 (http:// www.emro.who.int/rc53/media/pdf/EM- RC53RTech1.pdf, accessed 16 June 2006). 72. World Health Organization Regional Of- fice for the Eastern Mediterranean, 2004. Health system priorities in the EMR: Chal- lenges and strategic directions. Resolu- tion EM/RC51/R.7 (http://www.emro.who. int/governance/PDF/RC51_Resolutions. pdf, accessed 16 June 2008). 73. World Health Organization Regional Of- fice for the Eastern Mediterranean, 2003. Primary health care: 25 years after Alma Ata. Resolution EM/RC50/R.12 (http:// intranet.emro.who.int/RC55/RC50final- report.pdf, accessed 16 June 2008). 74. World Health Organization Regional Of- fice for the Eastern Mediterranean, 2001. Health system development. Resolution EM/RC48/R.3 (http://www.emro.who.int/ governance/PDF/RC48_Resolutions.pdf, accessed 16 June 2008). 75. World Health Organization Regional Office for the Eastern Mediterranean, 2000. Quality assurance and improve- ment in health systems with special ref- erence to primary health care: a shared responsibility. Resolution EM/RC/47/R.8 (http://www.emro.who.int/governance/ PDF/RC47_Resolutions.pdf, accessed 16 June 2008). 76. World Health Organization Regional Of- fice for the Eastern Mediterranean, 1999. Regional health for all policy and strat- egy for the 21st century. Resolution EM/ RC46/R.4. 77. EMRO: Partners in health in the Eastern Mediterranean, 1948–1988. Alexandria, World Health Organization, Regional Of- fice for the Eastern Mediterranean, 1991. 78. Assai M, Siddiqi S, Watts SJ. Tackling social determinant of health through com- munity-based initiatives. British medical journal, 2006, 333:854–6. 79. The Work of WHO in the Eastern Mediter- ranean Region. Annual Report of the Re- gional Director 1 January–31 December 1999. Executive Summary (www.emro. who.int/Rd/AnnualReports/1999/Exec- utiveSummary.htm, accessed 16 June 2008). 80. The Eastern Mediterranean: pioneer in primary health care. In: EMRO: partner in health in the Eastern Mediterranean, 1949–1989. Alexandria, WHO Regional Office for the Eastern Mediterranean, 1991. 81. Lady health worker programme: external evaluation of the National Programme for Family Planning and Primary Health Car, Final Report. Oxford, Oxford Policy Man- agement, March 2002. 82. Sabri B et al. Towards sustainable de- livery of health services in Afghanistan: options for the future. Bulletin of the World Health Organization, 2007, 85:712–18. 83. Network of community-oriented educa- tional institutions for health sciences; a short description of aims and activities. Maastricht, The Netherlands, University of Limburg, 1996. 84. Marandi A. Integrating medical education and health services: the Iranian experi- ence. Medical education, 1996, 30:4–8. 85. Lorenz N. Effectiveness of global health partnerships: will the past repeat itself? Bulletin of the World Health Organization, 2007, 85(7):567–8. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S57 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Community ownership and intersectoral action for health as key principles for achieving “Health for All” Mohammad Assai Ardakani1 and Humayun Rizwan2 1Regional Adviser, Community-Based Initiatives, Community and Sustainable Development, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Mohammad Assai Ardakani: assaim@emro.who.int). 2World Health Organization Representative’s Office, Somalia. Introduction The Alma Ata Declaration of 1978 ex- pressed the need for urgent and unified actions by all governments, health workers and communities to protect and promote the health of all people. The declaration emphasized: equity in access to health serv- ices, economic and social development, the community’s right and duty to participate in health, access to primary health care (PHC) and intersectoral collaboration for health development [1]. During the past few decades, the health sector has confirmed its catalytic role for health promotion, devising appropriate initiatives for improving health and quality of life of the community. This effort has been promoted in the Eastern Mediter- ranean Region (EMR) of the World Health Organization (WHO) since 1988 through Community-Based Initiatives (CBI), which have provided opportunities to integrate health interventions in local development processes. The CBI approach addresses the major determinants of health within a broad per- spective of development, and creates access to essential social services for optimum level of equity at the grass roots level through the active involvement of the community and intersectoral collaboration [2]. The initia- tive adheres to the recommendations of the Alma Ata Declaration, and provides an excellent, replicable model of community ownership for health development. Current- ly, CBI covers a population of 18 054 316 in 17 countries of the Region. The major strength of CBI remains the empowered and organized communities who gained the knowledge and capacity to change in order to attain better social and economic status. This has created a move among the communities to achieve self-reliance, self- sufficiency and solidarity. The success of the programme has resulted in improve- ments in health and other socioeconomic indicators in the implementing sites. This paper presents experiences from countries in the WHO/EMR, with a focus on community ownership, intersectoral actions and building partnerships for health devel- opment. It was prepared on the occasion of the 60th anniversary of WHO, the 30th an- niversary of the Alma Ata Declaration and the 20th anniversary of CBI implementation in the Region. S58 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Community-Based Initiatives The CBI is an integrated, bottom-up, socio- economic development concept, which is based on full community involvement, sup- ported through intersectoral collaboration [3]. It is a self-sustained, people-oriented strategy that addresses the diverse basic needs of the community and recognizes health as a social cohesion factor. CBI of- fers the added value of overcoming ineq- uity, which has positive implications for health. The most salient aspects of this ap- proach are the organization, mobilization and enhancement of community capabilities and involvement in micro-development through social and income generating schemes [4]. The ultimate objective of the programme is to reach the goal of the Alma Ata declara- tion, “Health for All”. The EMR countries are implementing different programmes under the umbrella of CBI: Healthy Villages, Healthy Cit- ies, Basic Development Needs (BDN) and Gender in Health and Development. The CBI was launched in Somalia in 1988, and has subsequently been extended to support community development in other countries of the Region. The programme focuses on fostering community action in poor areas and ad- dressing inequities in health. The major strategies of the CBI programme are: • empowering community and intersecto- ral collaboration; • addressing the needs of women, children and youth; • strengthening health, nutrition and envi- ronmental conditions; • improving economic status to reach self- sufficiency at the local level; • targeting poor and underprivileged com- munities; • encouraging networking; • partnership with nongovernmental or- ganizations, universities and potential donors; • linking various health-related pro- grammes. Intersectoral coordination is an integral part of the CBI concept; it encourages gov- ernment line departments to work together, and mobilizes communities and involves them in the development process. Inter- vention sites are identified in response to requests by local residents [5]. For needs assessment and implementation, each site is divided into clusters of 25–40 households. Each cluster elects 1 representative. The cluster representatives nominate a commu- nity/village development committee. The CBI intersectoral team provides training and support to the cluster representatives and the development committee to enable them to conduct a baseline survey assessing the socioeconomic needs of the commu- nity. The final interventions/development projects are decided on, implemented and managed by the community, which ensures the programme’s sustainability [6]. Community-designed projects include: rehabilitating health facilities, training community health workers and volunteers, using the community to accelerate the Expanded Programme on Immunization, raising awareness on reproductive health and nutrition, implementing the directly observed treatment, short course (DOTS) strategy for treating tuberculosis (TB), com- munity-based water and sanitation projects, organizing literacy classes and vocational training centres for women, establishing community-based information centres, sup- porting agriculture and livestock projects, and tree planting. The CBI brings into reality commu- nity ownership and intersectoral action for health, which are the 2 main principles of Eastern Mediterranean Health Journal, Vol. 14, Special Issue S59 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ PHC strategy. The CBI experiences are used as a successful model to encourage policy-makers and key stakeholders and seek their support in expanding PHC based on active community involvement. Community ownership and political commitment Community involvement in pre- and post-conflict situations in Afghanistan The BDN programme in Afghanistan, im- plemented for more than a decade, covers a population of nearly 120 000. The pro- gramme endured all the challenges of war and political instability, and continued under the protection of the community even in the absence of a government. In BDN villages, the community convinced the authorities to reopen girls’ schools while many schools in the rest of the country remained closed. At the beginning of the post-conflict era in 2002, the government included the BDN programme in the national health policy as a priority and established a special unit in the Ministry of Health to run the programme. The community’s active participation in TB-DOTS and Roll Back Malaria initia- tives are successful examples of linkages between BDN and PHC services. Villagers living on the Kabul River continuously suffered from waterborne dis- eases until the community prioritized the construction of a deep well and the resulting clean drinking water supply alleviated one of their long-standing health problems. Similarly, the establishment of female vil- lage development committees motivated the women to utilize the available health serv- ices. Currently, 56% of economic projects target women. An informal assessment in BDN sites showed that social and income-generating interventions have made a significant dif- ference to the health, social status and live- lihoods of families (Afghanistan office assessment, unpublished report, 2007). The programme has created confidence in the community to strive for ownership, self help and self reliance. Table 1 shows changes in some of the key indicators that occurred as a result of BDN intervention between 2003 and 2007. Particularly notable are the greatly increased access to safe drinking water and the proportion of births attended by trained individuals. Community health workers and women health volunteers in the Islamic Republic of Iran [7] Selection and training of the community health workers (behvarz) in the Islamic Republic of Iran started in the 1970s, in- troducing new front-line health workers. Behvarz are native, literate, young females and males with intermediate qualifications, selected by the community and trained by the government for 2 years. They are re- sponsible for providing PHC services to a defined population of around 1500. The be- hvarz are stationed at health houses, which Table 1 Changes in some key health and social indicators between 2003 and 2007 as a result of interventions in Basic Development Needs sites in Afghanistan Indicator 2003 2007 % % Births assisted by trained personnel 29 82 Enrolment of eligible children in school 53 82 Access to safe drinking-water 12 66 EPI full coverage for children aged < 1 year 40 77 EPI = Expanded Programme on Immunization. S60 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ is the most peripheral unit of the national health system. In the mid 1980s the district PHC network expanded throughout the country with the behvarz being the first line of contact between the community and the health system. Currently more than 25 000 behvarz provide the bulk of good qual- ity PHC services in rural areas all over the country. In addition, health houses collect and report vital events using a unique health planning tool called the Vital Horoscope. This is a simple tool that the community health worker can use to register the vital events in his/her catchment area. A number of health indicators can be extracted from the Vital Horoscope, which is now a source of demographic and health information in rural areas of the country. Another example of community involve- ment in health development is the use of women health volunteers who are active in urban areas, building bridges between fami- lies and the urban health centres. Women health volunteers are trained on priority lo- cal health problems and participate in health education, promotion and prevention activi- ties on a voluntary basis. Commitment toward development in Morocco [8] The BDN programme in Morocco covers a population of more than 200 000 in 17 provinces. The programme evolved during the past decade, supported by tools such as a territorial approach; institutionalization of local development committees; participa- tive community diagnosis; and community- based health insurance. Apart from the posi- tive impact on quality of life, the programme resulted in improved incomes for poor fami- lies through small loans. In addition, BDN played an important role in mobilizing the community towards local development and the fight against illiteracy. In 2005, His Majesty King Mohamed VI endorsed the National Initiative for Hu- man Development (NIHD), providing a holistic perspective for Morocco’s national development goals. This was an opportunity for reforms and structural projects that were launched to promote development and the rights of women and children and to im- prove the conditions of vulnerable groups. In this context, CBI joined NIDH and used high level political commitment to move the programme forward. As a partner of the BDN programme, the Ministry of Interior assesses and facilitates intersectoral action and ensures submission of community- based projects to NIHD authorities. NIDH provides not only an opportunity to extend the CBI programme, but also a platform to institutionalize intersectoral actions in an integrated development process with a strong focus on equity. Political commitment for expanding the Healthy City Programme in Oman CBI started in Oman in 2002. Over the years, community support group volunteers have established themselves as an important part of the PHC network. The Healthy City Programme currently covers a population of 219 274. Oman is going through a rapid epide- miologic and demographic transition, and health promotion has been identified as the main strategic choice, focusing on key risk factors such as diet (including breastfeed- ing), physical activity, tobacco and safety. The establishment of the department for CBI within the Ministry of Health has fa- cilitated the consolidation and expansion of CBI and demonstrates Ministry of Health commitment to encouraging community participation and intersectoral action to tackle major health problems. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S61 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Lady Health Workers in Pakistan With the aim of achieving universal health coverage, the Government of Pakistan, in collaboration with WHO, successfully launched the National Programme for Fam- ily Planning and Primary Health Care in 1994. The programme aimed to deliver basic health services to the doorstep in rural com- munities through training and deployment of Lady Health Workers. The programme is currently implemented in almost all districts of the country, with 100 000 Lady Health Workers providing PHC services to nearly 80% of the population. The Lady Health Workers are trained to provide preventive, promotive and ba- sic curative care, including vaccination, antenatal and postnatal care, and family planning services. They also manage minor health problems, advise families on referral, and keep records of vital events in their catchment areas. An international third party evaluation highlighted the important role played by Lady Health Workers in the provision of a comprehensive package of PHC services and in serving as a vital bridge between health facilities and the community (unpublished report, Agha Khan University, Pakistan, 2008). The programme has be- come an indispensable part of the national health system, and contributes significantly to overall human resource development and poverty reduction. Community-based information centres in Sudan [9] The BDN programme, introduced into Su- dan in the 1980s, currently covers a popula- tion of 250 000. Community information centres, where the data to be used for plan- ning and decision-making is collected and analysed, have been established in 27 of 72 BDN areas. The required information is collected through a baseline household sur- vey, allotting a number to each family; this helps in project planning, implementation and management. The village development committee and BDN team members super- vise the survey process to ensure quality and reliability. Cluster representatives are trained to collect data on key health indica- tors on a monthly basis and record it in the community information centre based at the nearest health facility. The information is presented in a simple format and is acces- sible to communities. It is valuable to health personnel in identifying target groups and to the community at large for priority-setting, developing village profiles, monitoring in- terventions and evaluating results. BDN bridging access to deliver PHC services in complex emergencies, Somalia The BDN initiative in Somalia closely integrated its activities with other PHC programmes, notably the Expanded Pro- gramme on Immunization, malaria control and basic hygiene and sanitation. As a re- sult, communities in BDN villages actively participated in the implementation of these programmes, which led to improved access, coverage and quality of services. For exam- ple, the coverage rate for a measles catch-up immunization campaign in 3 visited BDN villages in Hargeisa was more than 95%. An assessment in 8 BDN villages in 2005 con- cluded that “the general health situation is better (than other villages) and there are no children affected by measles after the mea- sles catch-up immunization campaign”. Moreover, the initiative was instru- mental in expanding integrated malaria control activities, including distribution of insecticide treated nets; introduction of larvivorous fish to open, shallow irrigation wells; provision of antimalarial drugs and supplies; training of health staff; and rais- ing community awareness for prevention and control measures. These interventions S62 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ helped contain frequent outbreaks of malar- ia in BDN villages. Likewise, the initiative contributed to improved antenatal, delivery and postnatal services in BDN villages through the provision of supplies, training, and supervision. Intersectoral action for health and partnership development Political commitment and partnership for BDN in Djibouti The Minister of Health in Djibouti launched the national strategy and plan of action for expansion of BDN in 2006. The strategy was developed in collaboration with Min- istries of Labour, Agriculture, Women’s Development and Tourism after consulting with key stakeholders and members of the community. The strategy demonstrated the government’s high commitment towards making BDN a tool for reducing poverty. The strategy addressed partnership and set up an organizational structure for BDN management and expansion. A presidential decree was issued in 2007 to establish an institutional framework for promoting health and involving community in poverty-reduction [10]. The decree was an important step in institutionalizing the BDN programme and achieving the mil- lennium development goals (MDGs) in Djibouti. As a result, 5 regional committees have been established for health promotion and poverty reduction. The Health and Local Development Committee, which is involved in activities related to HIV/AIDS, tuberculosis and malaria, has now been extended to the BDN-implementing sites. Jordan’s experience of building partnerships for the Healthy Village Programme [9] The Jordanian Ministry of Health, with support from WHO, introduced the Healthy Village Programme in 1996 with the objec- tive of creating a supportive environment for improving the health and quality of life of the people. The programme implemented CBI and adopted other measures to respond to the needs of the area, particularly those related to health, environment and educa- tion. By mid-2005, the programme covered 30 villages in all governorates. The Ministry of Health established a Healthy Village Programme directorate in 2005, and the programme was later ex- panded to cover 36 villages. Around 400 income-generating loans were distributed amounting to more than US$ 283 000. The project targeted improvement of socio- economic status of beneficiaries, of which 70% were women. Over 84% of the projects were sustained, with 92% recovery rate. The programme succeeded in creating the first national network of women volunteers who actively participate in designing local interventions and strategies for health pro- tection, environmental health and adoption of healthy lifestyles. Effective, result-based partnership in Basic Development Needs, Pakistan The BDN programme is currently imple- mented in 9 districts of Pakistan, covering a population of 4 million. The government of North West Frontier Province has pro- vided funds to replicate the programme in 5 additional districts. The programme has established an effective partnership with Khushhali Bank, the United Nations Development Programme, the World Food Programme (WFP), the United Nations Population Fund and local nongovernmen- tal organizations. In addition, a US$ 2.7 million grant has been approved by Round III of the Global Fund to Fight AIDS, Tuber- culosis and Malaria to support communities in the fight against these diseases in 9 BDN districts [11]. In an effort to achieve health equity, the Ministry of Health, in collabora- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S63 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ tion with district governments and WHO, has taken important steps to institutionalize the programme and involve civil society. The Healthy City Programme in Saudi Arabia The Healthy City Programme, implemented in Saudi Arabia since 1998, currently cov- ers a population of nearly 8 million in 23 districts. The programme is supported by the government and is a priority programme under the Director-General of Preventive Health at the Ministry of Health. There is active community participation in all as- pects of the programme, including health and environment, with a strong focus on the promotion of women in planning and implementation. Support from princes and governors ensures sustainability, and inter- sectoral collaboration is one of the corner- stones of the programme. City health profiles are being developed and poverty reduction initiatives are under- taken supporting finance schemes for the underprivileged and poor segments of the community. Health promotion activities are imparted in schools, and children are provided with free supplementary meals. In addition, a project on rehabilitation of disa- bled people is being implemented through this programme. Integrated community recovery and development; United Nations joint programme in Sudan In Sudan, The United Nations Children’s Fund (UNICEF), WHO, WFP, the Food and Agriculture Organization and the United Na- tions Development Programme have joined hands in a collaborative project for poverty reduction and achieving the MDGs in 15 vil- lages. The project attempts to fulfil the basic social and economic needs of vulnerable communities in South Kordofan through the introduction of BDN. This programme is a model for the joint programming under the United Nations Development Assistance Framework 2009–2011 [12]. Partnership with local nongovernmental organizations in the Syrian Arab Republic to increase access of the poor to social services and improve economic status The Syrian Ministry of Health adopted the Healthy Village Programme in 1996, with the main focus on health development. The programme, implemented in 615 villages, covers a population of 1.27 million. It has been successful in strengthening health facilities and PHC services, including Inte- grated Management of Childhood Illness, Mother and Child Health, the Expanded Programme on Immunization, promotion of healthy lifestyles, healthy school initia- tives and no-smoking campaigns. UNICEF and WHO are working together in sup- porting the community school programme, early childhood development, child friendly homes and community initiatives. In 2001, Mrs Asmaa al-Assad, wife of President Bashar al-Assad, visited Healthy Village Programme sites and, acknowledging the concept, supported the establishment of the nongovernmental Fund for Integrated Rural Development to provide assistance to underprivileged communities. WHO, the Fund for Integrated Rural Development, the Agha Khan Development Network and other partners have provided loans to com- munities for micro-credit schemes amount- ing to more than US$ 11 million for Healthy Village Programme activities. These loans created 11 039 job opportunities and the reimbursement rate was close to 100%. The external evaluation of the Healthy Village Programme in 2005 showed that, in areas where the programme had reached a certain level of maturity, the adult lit- eracy rate improved from 70% to 93%, S64 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ access to safe drinking-water from 76% to 98%, and the population with adequate sewage disposal facilities from 65% to 92% [13]. The immunization of children under 1 year old improved from 79% to 100%, and tetanus-toxoid vaccination of mothers increased from 58% to 92%. There was also a significant reduction in the incidences of respiratory infection, diarrhoeal disease and leishmaniasis [13]. Healthy and safe school environment project, Yemen [14] The healthy and safe school environment for children project was launched by the WHO Regional Centre for Environmental Health Activities in Yemen in 2005 to raise awareness, through community participa- tion and intersectoral action, about the im- pact of the physical environment in schools on children’s health. The school committees assessed the environmental health status of 65 schools in the BDN areas and prepared and imple- mented action plans to improve the environ- mental health status. WHO is assisting the Ministry of Public Health and Population and the Ministry of Education in promot- ing the project and to generate resources through building partnerships with the World Bank’s Social Development Fund, UNICEF, WFP and other partners. Intersectoral collaboration to improve female literacy in Basic Development Needs sites of Egypt The recent project launched in BDN sites in Egypt was the result of a combined effort and partnership between the Ministry of Communication and Information Technol- ogy, community members, the United Na- tions Development Programme and WHO. The idea was to enhance the effectiveness of literacy classes by providing a new learning tool called “literacy CD”. Class instructors from BDN areas were given the opportunity to develop their skills through training on these CDs. The training was conducted by the Ministry of Communication and Infor- mation Technology, and the community contributed by paying their transportation costs. By the end of the training sessions, literacy instructors were able to go back to their respective communities and teach their students using this new method. The BDN communities were provided with the neces- sary teaching aids and equipment to com- mence this endeavour, and the communities have shown great interest and enthusiasm in learning through this new method. The project also generated community-wide in- terest in learning basic computer skills. Challenges, lessons learned and future directions A major challenge for the CBI programme is the issue of sustainability for existing projects and scaling up at the sub-national and national level so that WHO can redirect its support to expansion in new sites. War and civil strife have prevented the govern- ments in Afghanistan, Iraq and Somalia from providing effective support to the CBI programme. Government support for CBI creates opportunities for programme expansion and obtaining external support. Involvement of civil society organizations can also enhance sustainability, when they assume the re- sponsibility of managing local projects. The WHO country offices need addi- tional technical assistance to monitor and supervise implementation of the community- based development plans. More emphasis needs to be placed on linkages between MDGs, CBI, poverty reduction strategy, sector-wide approaches and making CBI an integral part of national development and health policies. Partnerships need to be built between CBI, public health institutes Eastern Mediterranean Health Journal, Vol. 14, Special Issue S65 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ and universities at the country level, making these centres a technical resource for train- ing and research in health and development. Improvements in the health component of CBI through integration of various health interventions/programmes will remain at the top of our priorities. In an effort to assist countries in achiev- ing the CBI objectives, a greater emphasis will be placed on developing and reviewing national MDG strategies and plans of ac- tion. This will be done in consensus with all major stakeholders and donors, with the aim of making Poverty Reduction Strategy Papers and Country Cooperation Strate- gies documents MDG-oriented. Efforts will be placed on strengthening coordina- tion between intersectoral health-related programmes. CBI will continue to develop advocacy materials and to encourage Member States to create their own kits in the local language for exchange of experiences, evidence build- ing for programme expansion and resource mobilization. The experience of CBI in countries of the EMR provides a useful model for other regions in implementing grass roots level interventions that address social determi- nants of health. CBI is particularly effective in overcoming gender discrimination and in providing a social environment that sup- ports women’s development. The WHO Regional Office for the East- ern Mediterranean is committed to follow- ing up and providing technical support to Member States through [15]: • institutionalizing CBI within the na- tional health policy and plan; • building the capacity of communities to become partners in health planning and provision of PHC services, with special focus on poor and underprivileged areas; • intrasectoral coordination for improv- ing access, demand and quality of PHC services; • implementing local development projects through community ownership and partnership development; • scaling up CBI expansion, promoting partnerships and linking CBI with ongo- ing development activities like MDGs, Poverty Reduction Strategy Papers, etc; • streamlining programme management and the monitoring, reporting and evalu- ation system; • integrating disaster preparedness, re- sponse and management components in CBI-implementing areas; • obtaining government support for CBI; • involvement of civil society organiza- tions. Acknowledgements Thanks go the following people, who have contributed in the preparation of this docu- ment: Randa Ahmed, TO, CBI, WRO Egypt; Dr Abeer Alagabany, TO, WRO Sudan; Dr Sumaia Alfadil, National Programme Officer, WRO Sudan; Dr Jihane Tawila, WR Oman; Mr Falah Al-Mazrou, Direc- tor-General of Preventive Health, Ministry of Health, Saudi Arabia; Mr Khan Aqa Aseel, STC/BDN, WRO Yemen; Dr Nazar Elfaki, MO, WRO Syria; Ms Tatyana El- Kour, National Programme Officer, WRO Jordan; Samira Jabal, TO, WRO Morocco; Khoshhal Khan, NPO, WRO Pakistan; Dr Safiullah Nadeeb, National Officer, BDN, WRO Afghanistan; Mrs Ruth Mabry, TO, WRO Oman; Mrs Shady Sirous, TO, WRO Islamic Republic of Iran; Mrs Rachida Sou- issi, MO, WRO Djibouti. S66 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ References 1. Declaration of Alma-Ata. International conference on primary health care, Alma- Ata, USSR, 6–12 September 1978. Ge- neva, World Health Organization, 1978. 2. Assai M, Siddiqi S, Watts S. Tackling so- cial determinants of health through com- munity-based initiatives. British medical journal, 2006, 333(7573):854–6. 3. Guidelines and tools for management of basic development needs. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2000 (http:// www.emro.who.int/CBI/PDF/BDN/BDN_ Guidelines.pdf, accessed 29 May 2007). 4. Assai M. Community-based initiatives and their relation to poverty reduction and health development in the EMR. East- ern Mediterranean health journal, 2007, 13(6):1242–9. 5. Sheikh MR. CBI—lessons learnt and way forward. Paper presented at the 22nd Annual Meeting of the Regional Director with WHO Country Representatives and Regional Office Staff, Cairo, Egypt, Feb- ruary 2007. 6. Bile MK. The basic development needs concept “community solutions to commu- nity problems”. Healthy cities, healthy vil- lages quarterly journal (Ministry of Health and Medical Education, Islamic Republic of Iran), 2001, 3:4–8. 7. Assai M. Community-Based Initiatives as a tool for poverty reduction and health development in countries of the Eastern Mediterranean Region. Brief given to the WHO South East Asia Regional Meeting on “Revisiting community-based health workers and community health volun- teers”, 3–5 October 2007, Chiang Mai, Thailand. 8. H.M. King Mohamed VI’s commitment to the National Initiative for Human Develop- ment. CBI newsletter, 2005, 1(3):8. (http:// www.emro.who.int/cbi/PDF/Newsletter/ CBI/Newsletter-issue3.pdf, accessed 29 May 2008). 9. Implementation of poverty reduction strat- egy in the EMR. Report of an intercountry meeting Cairo, Egypt, 14–16 November 2005. Cairo, World Health Organization Regional Office for the Eastern Medi- terranean, 2006 (WHO-EM/CBI/052/ E) (http://www.emro.who.int/cbi/PDF/ PoveryReduction-Egy-11-05.pdf, ac- cessed 29 June 2008). 10. Presidential decree on the establishment of an institutional framework of health promotion and community participation for the poverty reduction. Djibouti, 2007 (Presidential Decree No 2007/0139 PRW/ MS 23 June 2007). 11. PC-I proforma of the strengthening of the basic development needs programme in Sindh, July 2005–June 2008, Karachi, Pakistan. Karachi, Department of Health, Government of Sindh, 2006. 12. Report of WHO Country Office, Sudan, November 2007. Khartoum, World Health Organization Regional Office for the East- ern Mediterranean, 2007. 13. Evaluation of the Healthy Village Pro- gramme in the Syrian Arab Republic. Cairo. World Health Organization Region- al Office for the Eastern Mediterranean, 2007 (WHO-EM/CBI/049/E). 14. A healthy and safe school environment for children in Yemen. CBI newsletter, 2005, 1(4):10 (http://www.emro.who. int/cbi/PDF/Newsletter/CBI/Newsletter- issue4.pdf, accessed 29 May 2008). 15. Community-based initiatives future di- rections. CBI newsletter, 2006, 2(1):12 (http://www.emro.who.int/cbi/PDF/News- letter/CBI/Newsletter-Vol2_Issue1.pdf, accessed 29 May 2008). Eastern Mediterranean Health Journal, Vol. 14, Special Issue S67 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Health research in the Word Health Organization Regional Office for the Eastern Mediterranean Mohammad Afzal1 1Acting Regional Adviser, Research Policy and Cooperation, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Mohammad Afzal: afzalmo@emro.who.int). Introduction Research has been an integral part of World Health Organization (WHO) collaborative programmes with Member States since the inception of the Organization in 1948. Arti- cle 2(n) of the WHO Constitution states that WHO is “to promote and conduct research in the field of health” [1]. The principles governing the research functions of WHO were endorsed by the Second World Health Assembly in 1949. In the early life of WHO, most research was managed by the technical units of WHO headquarters. An Advisory Committee on Medical Research was estab- lished in 1959 [2] to provide the Director- General with the necessary scientific advice in relation to WHO’s research programme. With time, the regional offices of WHO assumed a greater role in managing health research among their Member States, and regional advisory committees were created. Institutionalization of health research in EMRO WHO’s Regional Office for the Eastern Mediterranean (EMRO) had been involved in medical research since 1966, by assisting and promoting medical and health research in the Region, as deemed appropriate and feasible. However, these collaborative ac- tivities were intensified in 1976 with the establishment of the Eastern Mediterranean Advisory Committee on Biomedical Re- search [3] as a result of a proposal by the WHO Committee on Medical Research, supported by resolutions of the World Health Assembly and the Executive Board (WHA27.61 and RB55.R35), for greater in- volvement of the regional offices in research activities in their respective regions. The name of the committee was later changed to the Eastern Mediterranean Advisory Com- mittee on Health Research (EM ACHR), as was done in the WHO headquarters and other regions, in order to reflect a broader scope and remit [4]. It comprises senior and outstanding researchers from the Region and represents a balanced disciplinary and geographical distribution. EM ACHR functions to advise the Regional Director on all issues related to health research and development in the Region. Among its aims is to strengthen the informational, scientific and ethical founda- tions of health research systems. Since its inception, numerous activities have been undertaken by the Regional Office covering almost all aspects of the research needs of the Region. Another milestone for health research promotion in the Region was the establish- ment of a Research Promotion and Develop- ment unit in the Regional Office in 1978 [5], subsequently renamed Research Policy and S68 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Cooperation (RPC) unit. RPC maintains close contacts with its counterparts at WHO headquarters and in the regions as well as with national focal points for research or medical research councils and major health research institutions in the Region. RPC works in close collaboration with other technical units of the Regional Office and other national and international partners. Research promotion and development in Member States The Regional Office has been involved in many activities to promote research in the Region, including: assessment of the health research potential and research priorities of Member States; determination of areas of collaboration; designation of collaborating centres; training in research methodology; research management and scientific writ- ing, funding of research within the Region; and assisting Member States with strength- ening their capacity and setting their pri- orities to undertake health research with a view to strengthening their health research systems. The establishment of the Health services journal in 1986 and its replacement, the Eastern Mediterranean health journal, in 1995 facilitated the publication of results of research by scientists in the Region [6]. Support to health research Since the establishment of regional mecha- nisms for promotion and development of research in the late 1970s, EMRO has fund- ed a small number of research proposals received from within the Region. However, until 1992 the proposals were supported on an ad hoc basis and dealt with a wide range of topics. A scheme of small grants was es- tablished in 1992 in collaboration with the Tropical Disease Research (TDR) unit in WHO headquarters. A similar scheme oper- ates under the UNDP/UNFPA/WHO/World Bank Special Programme of Research, De- velopment and Research Training in Human Reproduction. The scheme aims to support researchers from the Eastern Mediterranean Region to address local problems in disease control and to raise the research capacity of regional researchers in operational re- search. The research topics were initially limited to problems such as malaria, schis- tosomiasis, tuberculosis, leishmaniasis and lymphatic filariasis. In 2002, the scope of the small grants scheme was expanded to include other communicable diseases such as HIV and sexually transmitted infections, vaccine-preventable diseases, haemorrhagic fevers, brucellosis, meningitis and echinoc- occosis. More than 340 proposals have been funded in 17 countries of the Region under this scheme since 1992. In 2002, a new grant for research was established by EMRO, the Eastern Medi- terranean Regional Office Special Grant for Research in Priority Areas of Public Health. The aim of this grant is to address local problems and issues of public health importance, with special emphasis on health systems research. So far 140 proposals have been funded under this scheme. The Regional Office, in partnership with the Standing Committee for Science and Technology of the Organization of Islamic Countries, established a special grant for re- search in applied biotechnology and genom- ics in 2004 to promote research, encourage networking, generate new knowledge and stimulate the application of biotechnology and genomic driven interventions in health care [7]. Thus far, 35 proposals have been supported in 2 rounds of research funded through this grant. The third call for propos- als is in process. The Regional Office also catalysed the establishment of an Eastern Mediterranean Health Genomics and Biotechnology Net- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S69 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ work in 2004, with its secretariat hosted at the Pasteur Institute of the Islamic Republic of Iran [8]. Capacity building in health research The Regional Office has long been advis- ing and assisting Member States to develop their capacity to undertake health research. It has supported efforts for capacity- building in health research, especially in research methodology, clinical research, re- search proposal and scientific paper writing, community-based research for health and user-driven research. So far more than 500 health researchers have been trained from almost all countries of the Region. Human resources development in health research is among the key strategies emphasized in the Renewed Policy for Health Research and Development in the Region. With a view to developing innovative and effective strategies for strengthening national health research systems in the Region, in 2002 and 2003 the Regional Office and TDR supported a detailed and systematic situation analysis of health re- search in 5 countries, namely Egypt, Islamic Republic of Iran, Morocco, Pakistan and Sudan. More recently, the Regional Office in collaboration with the Council on Health Research for Development and Gulf Coop- eration Council (GCC) States conducted a survey of health research in 7 GCC states and in Jordan, Lebanon and Tunisia. The situation analysis highlighted the absence or inadequate development of in- tegrated, well designed and functioning national health research systems. How- ever, from the information collected it ap- pears that a well developed infrastructure for health research exists in most of the countries and some useful research is car- ried out both in specialized centres and in academic institutions. Nonetheless, there is a great need to strengthen the existing systems to improve the quantity and quality of demand-oriented research for health and for developing mechanisms for translating research results into policy. A database on the regional institutional capacity in genomics and biotechnology was made available on the Internet by the Regional Office in 2005 [9]. Further de- velopment of the database on institutional capacity for conducting research in the Region is continuing by extending the infor- mation to several other aspects of research for health, such as health researchers of the Region, their highest qualifications, affiliations, current projects, research areas of interest, latest publications. Eastern Mediterranean health research strategies and policies At the close of the last century several of the international agencies involved in funding health research, including WHO, tried to se- riously examine the role of health research as an important contributor to sustainable human development. They also attempted to assess how governance of research at national, regional and global levels could be made more effective and efficient. As a result of these deliberations a landmark conference, the International Conference on Health Research for Development, was held in Bangkok, Thailand, in October 2000 and was attended by over 700 participants. It was recognized at the conference that the research efforts in many countries were fragmented, with much duplication of work, and were not focused on national needs and priorities. This led to the emergence of a vision of a systems approach to health research, driven by equity, focused on na- tional goals and priorities, and operating within an interactive regional and global framework. S70 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ During 2000–2001 the Regional Office undertook a review and restructuring of the regional policy for health research through intensive debate and dialogue within the Office and with Member States. This had become necessary with the realization that health research, a key to promotion of equi- table health care, had largely been ignored in the Region (and indeed in most developing countries). The outcome of the review was the Renewed Policy for Health Research and Development in the Eastern Mediterranean Region, which was endorsed in a resolution at the 48th session of the Regional Com- mittee in 2001 [10]. The regional policy on health research emphasizes the necessity to promote equitable health care in the Region through the development of sustainable health research systems that promote the use of research for providing evidence for decision-making, policy formulation and actions. The Regional Committee agreed to allocate 2% of the Joint Programme Review and Planning Mission funds (the regular biennial budget allocated to countries of the WHO/EMRO) in support of regional health research. In addition, Member States were requested to consider allocating 2%–3% of their budget for activities related to health research in their countries. The Regional Office in collaboration with WHO headquarters held a regional consultation for health research and devel- opment in 2004 in Cairo, Egypt [11]. The objectives were to identify critical issues facing the development of health research in countries of the Region, and to obtain re- gional and country input and perspectives. The Ministerial Summit on Health Re- search was convened by WHO and the Government of Mexico in Mexico City in 2004. The Summit emphasized the need for global cooperation to reduce disparities in health between developing and developed countries. A major theme of the discussion was the need to bridge the gap between what is known about how to improve per- formance of health systems and what is actually done to change policy and practice – the “know–do” gap. The Regional Office held a regional consultation to follow up on the Mexico summit, in Rawalpindi, Pa- kistan, in 2005, to formulate and suggest a strategic direction for health research for the Regional Office and Member States [12]. Recently, the Regional Office has been actively involved in the preparatory ac- tivities for a global ministerial forum on research for health at the regional level. In this regard a ministerial preparatory meet- ing was held in Tehran in collaboration with the Government of the Islamic Republic of Iran in November 2007. This meeting was followed by the ministerial and heads of delegations meeting from which a commu- niqué was issued that proposes a stronger focus on the research priority areas relevant to the disease patterns in each country. This will help advocate the regional perspective at the Global Ministerial Forum on Research for Health, to be held in Bamako, Mali at the end of this year. Effective knowledge transfer and translation of research into policy and practice The Regional Office has recently initiated some measures to promote health systems research. Training programmes are being organized to bring policy-makers and re- searchers together to work to optimize the use of research for policy formulation and implementation of efficient and effective health systems and health services. The aim is to develop a core of “conveners” who can facilitate knowledge translation to bridge the know–do gap. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S71 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Considering the potential of journal- ism for creating public awareness about health research issues, the Regional Office held a workshop in 2007 to improve the technical skills needed by science jour- nalists and health information specialists from countries to cover science and health- related issues and the use of research find- ings. Further workshops will be held in several countries of the Region. The Regional Office has also planned to establish an EMR evidence-informed policy network (EM EVIPNet), which will bring together policy-makers, health sys- tems managers and researchers to develop a continuous and sustainable mechanism to promote the access and use of research evidence (primarily systematic reviews), focusing on emerging needs experienced by local, national and regional health au- thorities and shaped by the local context. In addition, EM EVIPNet will enhance linkages between the producers and users of evidence and will provide training op- portunities that will develop the capacity of decision- and policy-makers to access and apply evidence in low- and middle-income countries of the Region. Research ethics Ethical practice in health care and research is not only needed to ensure equity in health care and research, but also to protect indi- viduals and communities from unnecessary risks and harm. Given the regional social, cultural and religious norms, the Region must have its own set of guidelines and regulations so that Member States can de- fine and draw upon codes of ethical prac- tice. This has been stated explicitly by the Regional Office on several occasions and at the policy level by the Regional Committee, the Regional Consultative Committee and the Eastern Mediterranean Advisory Com- mittee for Health Research. The focus of the WHO drive to strength- en regional bioethics capacities is through advocacy, consultations, meetings, semi- nars, workshops and research through na- tional and regional level activities and in partnership with interested stakeholders. The Regional Office has carried out short- term training programmes within Member States. Currently, EMRO, in partnership with the University of Toronto, is funding a programme to train health care profession- als from Member States for a Masters in bioethics; so far 4 scholars from the Region have been supported. A similar short-term training programme has been initiated in collaboration with the University of Mary- land. The Regional Office has translated 2 WHO publications on ethical issues into Arabic for dissemination in the Region and made them available on the Internet [13,14]. In addition, the Regional Office engages with international organizations such as the Council for International Organization of Medical Sciences, Islamic Organization of Medical Sciences, Islamic Educational, Sci- entific and Cultural Organization, United Nations Educational, Scientific and Cul- tural Organization to organize meetings and seminars on key issues related to bioethics. The Regional Office established an EMR Research Ethics Review Committee in Oc- tober 2007; in future all health research proposals involving human subjects that are conducted or supported by the Regional Of- fice will be reviewed by this Committee. For 2008–2009 the Regional Office has several programmes for enhancing national capacity in ethical review of research for health. S72 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ • Short-term training course in ethics of research for health in collaboration with the University of Maryland • Mapping the infrastructure for ethical review of research in the Region • Provision of technical assistance to Member States to establish national eth- ics review committees • Regional meeting of experts to develop regional guidelines for ethics of embryo research (completed) • First meeting of the forum on bioethics for the Eastern Mediterranean Region of WHO and Arab Region of UNESCO • Second regional meeting for national bioethics committees. Future directions The Regional Office will continue capacity building and supporting research for health in Member States. This support will be aimed at: • Providing health research policy support and advice to Member States • Further strengthening health research capacities in Member States. This will entail: • providing research grants in health systems research and in applied bio- technology • providing training to improve qual- ity of research for health, addressing priorities and improving capacities in research ethics • Building capacities and mechanisms for effective use of the results of health systems research • Undertaking situation analysis of health research systems in more countries of the Region • Engaging stakeholders in regional health research efforts • Developing further collaboration and partnerships with international health research organizations, universities and other partners. Conclusion The activities promoted and supported by the Regional Office over the years have had a positive impact on the development of health research in the Region. Political commitment has grown, national coordinat- ing mechanisms have been established and allocations for research have been made in WHO collaborative programmes. However, there is a need for intensified efforts to en- able Member States to develop their health research systems further and increasingly to make use of research to provide evidence for policy-making and health actions, espe- cially in reducing health inequalities and in addressing the health problems of the poor. References 1. Constitution of the World Health Organi- zation (http://www.who.int/governance/ eb/who_constitution_en.pdf, accessed 4 June 2008). 2. World Health Organization. Twelfth World Health Assembly Geneva, 12–29 May 1959 (http://www.emro.who.int/rpc/pdf/ WHA12-17.pdf, accessed 4 June 2008). 3. Report on the meeting of the Regional Advisory Committee on Biomedical Re- search, Alexandria, 6–8 April, 1976. Al- exandria, WHO Regional Office for the Eastern Mediterranean, 1976 (EM/ADV. COM.BIOMED.RSR/5). 4. Report on the Twelfth Session of Re- gional Advisory Committee on Health Eastern Mediterranean Health Journal, Vol. 14, Special Issue S73 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Research, Lahore, Pakistan, 31 March–2 April, 1987. Alexandria, WHO Regional Office for the Eastern Mediterranean, 1987 (EM/RSR/36-E). 5. Report on the third meeting of the Region- al Advisory Committee on Biomedical Re- search, Alexandria, Egypt, 27–31 March, 1978. Alexandria, WHO Regional Office for the Eastern Mediterranean, 1978 (EM/ RSR/6, EM/#RD.MTG.ACMR/16, EM/ ICP/HMD/ 035/RB). 6. Eastern Mediterranean health journal [website] (http://www.emro.who.int/emhj. htm, accessed 4 June 2008). 7. World Health Organization Regional Office for the Eastern Mediterranean. Development and use of genomics and biotechnology for public health. Resolu- tion EM/RC51/R.11 (http://www.emro. who.int/governance/PDF/RC51_Resolu- tions.pdf). 8. Report on the Eastern Mediterranean consultation for establishing a regional biotechnology network Tehran, Islamic Republic of Iran 31 July–2 August 2004. Cairo, WHO Regional Office for the East- ern Mediterranean, 2004 (WHO-EM/ RPC/016/E). 9. Health related research institutes on ge- nomics and biotechnology in the Eastern Mediterranean Region [website] (http:// www.emro.who.int/rpc/Biotechnology_ Genomics-institutes.htm, accessed 16 June 2008). 10. Forty-eighth session of the Regional Com- mittee for the Eastern Mediterranean, Riyadh, Saudi Arabia, 30 September–3 October 2001. Cairo, Regional Office for the Eastern Mediterranean, 2001 (http:// www.emro.who.int/RC48/index.htm, ac- cessed 16 June 2008). 11. Report on the Eastern Mediterranean re- gional consultation in preparation for the Ministerial Summit on Health Research Cairo, Egypt 4–6 April 2004. Cairo, Re- gional Office for the Eastern Mediterra- nean, 2004 (WHO-EM/RPC/015/E). 12. Summary report of the regional consulta- tion to follow up on the Mexico Ministerial Summit on Health Research, Rawalpindi, Pakistan, 29–30 November 2005. East- ern Mediterranean health journal, 2006, 12(Suppl. 2):S258–61). 13. [International ethical guidelines for biomedical research involving human subjects] (http://www.emro.who.int/rpc/ pdf/InernationalEthicalGuidelines.pdf0 2005, accessed 4 June 2008) [in Arabic]. 14. [Operational guidelines for ethics com- mittees that review biomedical research] (http://www.emro.who.int/rpc/pdf/Guide- lines%202003.pdf, accessed 4 June 2008) [in Arabic]. S74 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Thirty years of essential medicines in primary health care Zafar Mirza1 1Regional Adviser, Essential Medicines & Pharmaceutical Policies, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Zafar Mirza: mirzaz@emro.who.int). 2WHO now uses the term medicines instead of drugs. In this article drugs are sometimes used for historical reference. Introduction The development of the first Model List of Essential Drugs2 [1] and the Declaration of Alma Ata [2], which advocated the adop- tion of primary health care (PHC), were both important milestones in the history of public health. Some elements of both were already in practice in some countries before the late 1970s when the World Health Or- ganization (WHO) adopted and promoted them. They are dependent on each other for their success and they continue to bolster each other. Thirty years of the Alma Ata Declaration is also a history of essential medicines – the concept and its application. It is time to celebrate, reflect and revisit these time-tested concepts in order to face the future challenges for the organization and provision of effective health care serv- ices and health systems. This article first presents the conceptual need for and rationale of essential medi- cines, from its beginnings until now. Essen- tial medicines, as an integral component of the PHC philosophy and system, are explained and developments in the essential medicines approach over the past 30 years are traced. The situation with regard to es- sential medicines in the East Mediterranean Region of the World Health Organization is briefly presented. Finally the existing and future challenges to PHC and essential medicines are defined and their relevance in the changing times and contexts of the 21st century is established. Why essential medicines? The rationale for essential medicines can be explained from both the demand and supply perspectives. From the demand perspective, in a typi- cal low or low-to-middle income country, people from low socioeconomic strata con- tinue to suffer and die from preventable and curable diseases. The most vulnerable – children, women, the elderly – suffer the most. Their medicine needs are served only marginally by the public sector health facilities; they are generally not protected socially for their health care needs. Thus the overwhelming majority has no choice but to take from their pitifully shallow pockets to try and buy their medicines from the packed, thriving and poorly regulated private retail pharmacies. But many of the poor are not able to buy their treatments from the private sector even if they are willing. The rising number of poor in industrialized countries are now also suffering similarly. This is a disturbing paradox of modern health care systems. From the supply perspective, discovery, development and delivery of medicines – an innovation cycle [3] – is primarily market driven. It is not sensitive to public Eastern Mediterranean Health Journal, Vol. 14, Special Issue S75 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ health needs, especially those in developing countries. This wheel of innovation inher- ently ignores the diseases of poverty and the poor. Motivated by return-on-investment, the pharmaceutical industry and private pharmacies fill the shelves with products that can bring more money and focus on those consumers who can buy. Long supply chains are established that involve innumer- able middle-men who make a profit at each step. Science and public health needs are compromised in this enterprise, and what has been created is a proverbial “therapeutic jungle” [4] and a complete lack of essential treatments. These demand and supply situations in the pharmaceutical sector are neither new nor diminishing. Instead, they are inherent and ever growing. Before WHO became involved in the es- sential drug concept, governments had been concerned about the situation for years and some had started to introduce innovative polices and management tools to meet the therapeutic needs of their populations by providing them with the most needed medi- cines. Among developing countries that had started some sort of selection process lead- ing to national drug lists were Sri Lanka, Costa Rica, Peru, Cuba, Egypt, Papua New Guinea, Mozambique and Tanzania. In the more developed world, Scandinavian countries, Canada and Australia had such selection processes in place. Inspired by these national initiatives and concerned about the pharmaceuti- cal situation, especially in poor settings, WHO gradually became involved in these issues. In May 1975, Dr Halfdan Mahler, Director-General of WHO at the time, strongly advocated before the Member States at the World Health Assembly for the development of national pharmaceutical policies based on the affordability, quality and availability of drugs [5]. A resolution was passed which urged the Secretariat of WHO to help Member States to formulate national pharmaceutical policies that meet the actual health needs of the people [6]. Rapidly, the concepts of “essential drugs” and “national drug policy” entered the vo- cabulary of global public health [7]. After the compilation of national practices based on lists of basic drugs in 1976, the first meeting of the Expert Committee on Selec- tion of Essential Drugs was held [8] and in 1977 WHO adopted the first Model List of Essential Drugs [1]. Since then it has been reviewed and updated every 2 years and the current WHO Model List is its 15th edi- tion. Whereas in 1977 only around a dozen countries had what could be considered a national essential medicines list (NEML), today 4 out of 5 countries have one, i.e. 156 countries out of 193 Member States of WHO. The basic idea behind the essential medicines concept is that while there are many medicines registered and available on the market, it is important to be selec- tive, bearing in mind the medical needs of the majority of the population, and to ensure the efficacy, safety and cost– effectiveness of the medicines. By follow- ing this strategy most needed medicines can be supplied to a maximum number of people. The approach is fair, efficient and above all based on common sense. This is also a way of overcoming imperfections and failures of the pharmaceutical market. The concept is not only applicable in the public sector where it is most used but also in the private sector, especially in health insurance systems. It contributes to achieving health objectives and is based on sound economics and ethics. S76 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Essential medicines and PHC Chronologically, the development of the first model list of essential medicines in 1977 coincided with the Health for All strategy [9], both of which preceded the Alma Ata Declaration that brought PHC into being in 1978. The PHC advocated in the Declaration of Alma Ata was based on 8 fundamental elements, one of which was the “provision of essential drugs”. When the first WHO Expert Commit- tee on the Use of Drugs produced the first edition of WHO Model List of Essential Medicines in 1977 [1], it also recommended the “compilation of a separate list of drugs appropriate for use in primary health care”. Thus the second report of the expert com- mittee [10] produced a separate list of 23 medicines taken from the main list as a model list to be adopted at the national level (Table 1). The report fully adopted the ethos of the Declaration of Alma Ata on PHC in terms of explaining the establish- ment of PHC systems, respecting the local context, the traditional and existing patterns of health care and the use of these medicines by health workers. Most of the NEMLs today list the medi- cines that must be available at the PHC level and aim to make these available in recom- mended dosage forms all the time. It is also important to mention that PHC requires a proper referral system to secondary and tertiary health care. Together these 3 levels constitute the “basic health care system” in a country. The WHO Model List of Essen- tial Medicines covers all these levels. The creation of the WHO Drug Action Programme [11] was a significant develop- ment between 1979 and 1981 and led to the creation of essential drugs programmes in certain low-income countries. These programmes were established within the context of the national health systems and PHC programmes and began with Tanza- nia. Some other countries in Asia, Africa and Latin America also established such programmes. Later came the “selective PHC” ap- proach promoted by agencies like the United Nations Children’s Fund (UNICEF) and United States Agency for International Development (USAID). This gave birth to Table 1 Model List of Essential Drugs for primary health care from the 2nd Report of the WHO Expert Committee Drug 1 Acetylsalicylic acid 2 Activated charcoal 3 An antacid 4 An antihaemorrhoidal drug 5 Atropine (antispasmodic) 6 Benzoic acid + salicylic acid 7 Benzyl benzoate 8 Calamine lotion 9 Chlorhexidine solution 10 Chloroquine 11 Chlorphenamine 12 Ephedrine (asthma) 13 Ergometrine (postpartum haemorrhage) 14 Gentian violet 15 Iodine 16 Ipecacuanha 17 Iron/folic acid (nutritional supplement during pregnancy) 18 Lindane 19 Mebendazole 20 Oral rehydration salts 21 Paracetamol 22 Piperazine 23 Tetracycline eye ointment Source: [9] Eastern Mediterranean Health Journal, Vol. 14, Special Issue S77 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ vertical disease programmes. Along with this there was an ideological change that gradually converted health care as a hu- man right and primary responsibility of the State to a commodity that must be bought by individuals, whether through the public or private sectors. The harbinger of this paradigm shift was the World Bank [12]. These policy shifts fractured the compre- hensiveness of PHC and negatively affected community involvement in and ownership of these programmes. Despite these fundamental changes in health care provision, countries have con- tinued to develop and implement NEMLs. In 1988 WHO came out with guidelines for developing national drug policies [13] (NDPs) which were widely embraced by Member States and country after country began to develop their own NDPs. The con- cept of essential medicines was a basic tenet of these NDPs. Today more than 100 coun- tries have NDPs based upon this concept. Like WHO itself, most countries review their NEMLs, typically every 2 years, in order to add, delete or change medicines. PHC, as a first level of health care, if not the comprehensive approach promoted by the Declaration of Alma Ata, continues to use the essential medicine concept in the public sector. But in most low and low-to- middle income countries the situation in the private sector remains disturbing. The first level of health care in the private sector is still provided by private general practition- ers and other allied health professionals, not to mention unqualified practitioners. These, as well as suppliers and sellers of medicines in private pharmacies, are generally not well informed about the concept of essential medicines and they freely prescribe all medicines available in the market. Irrational prescription, adverse drug reactions and high household spending on medicines are all testament to this. However, the emer- gence of health insurance systems, managed by autonomous institutions or by the private sector, has led to the use of limited lists of medicines, which is actually an applica- tion of the essential medicines concept but without the name. Evolution of the concept of essential medicines The concept of essential medicines has kept pace with the changing times in terms of evolving public health needs and advance- ment in medical treatment. It remains as relevant today as it was 30 years ago. What started as a list of 208 medicines in 1977 has been reviewed 15 times since then. Every 2 years a systematic review is conducted by the WHO Expert Committee on Selection of Medicines. Many medicines have been added to the list, some have been removed and others have been replaced with better alternatives. The 15th edition of WHO Model List of Essential Medicines (2007) consists of 340 medicines, an addi- tion of 132 medicines over 30 years. In 2007 when the Expert Committee met to review the 14th edition of the list its criteria were “due regard to disease prevalence, evidence on efficacy and safety, and comparative cost–effectiveness.” A major difference in criteria used in the selection of essential medicines has taken place over the years especially from 2002 onwards. The 2nd report of the WHO Expert Committee while laying down the criteria of selection mentioned, “The choice of such drugs depends on many factors, such as pattern of prevalent diseases; the treatment facilities; the training and experi- ence of available personnel; the financial resources; the genetic, demographic and en- vironmental factors.” From 2002 onwards, however, affordability changed from a con- S78 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ dition to a consequence of selection. Before 2002, expensive medicines were often not included on the Model List because their inclusion was seen as unrealistic. Under the new definition, a cost-effective medicine can be selected even if the price is high, and the fact that it is considered essential then implies that it has to become available and affordable. The first examples of this new approach were the first-line antiretroviral medicines, which were added to the Model List in 2002 when they were still priced at over US$ 1000 per patient per year; in 2007 they can cost less than US$ 100 per patient per year. Essential medicines are intended to be available within the context of functioning health systems at all times, in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford. The implementation of the concept of es- sential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility [14]. Another important change from 1977 is that now there are a number of associ- ated complementary activities related to essential medicines and based around the Model List of Essential Medicines (Figure 1). The List has been incorporated into the web-based WHO Essential Medicines Library [15], which provides direct links to relevant WHO clinical guidelines, sup- porting evidence, model formulary text, price information, quality standards and nomenclature. In 2008 a new WHO Model List of Essential Medicines for Children was pub- lished for the first time [16]. Figure 1 World Health Organization (WHO) Essential Medicines Library: EMP = Essential Medicines Programme; BNF = British National Formulary; EMP = Essential Medicines and Pharmaceutical Policies; ATC = anatomical and therapeutic chemical classification. DDD = defined daily dose; CCs = collaborating centres; MSH = management sciences for health; UNICEF = United Nations Children’s Fund; MSF = Médecins Sans Frontières; EC = European Community; BMJ = British Medical journal Eastern Mediterranean Health Journal, Vol. 14, Special Issue S79 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Situation in the Eastern Mediterranean Region Out of 22 countries in the Eastern Medi- terranean Region of the WHO, 15 have NEMLs: Afghanistan, Djibouti, Egypt, Is- lamic Republic of Iran, Iraq, Jordan, Mo- rocco, Oman, Pakistan, Palestine, Somalia, Sudan, Syrian Arab Republic, Tunisia and Yemen. Not surprisingly all the above- mentioned countries that have NEMLs also have national medicines policies in place which are explicitly based on the essential medicines concept. The 7 countries that do not have NEMLs (Bahrain, Kuwait, Lebanon, Libyan Arab Jamahiriya, Qatar, Saudi Arabia and United Arab Emirates) include the Gulf States, except Oman, which are high income coun- tries. Somehow the concept of essential medicines has not taken firm root in the Gulf countries. One of the reasons is that they perceive essential medicines as those needed only in poor countries where re- sources are scarce and difficult treatment choices have to be made. This is indeed a misunderstanding. However, as insurance systems are now being established in the Gulf countries, they will presumably reim- burse only those medicines that are included in the list of the insurance agencies. As mentioned before, this is an application of the essential medicines concept and its principles without the terminology. Other countries in the Region that have health insurance systems established by the gov- ernment include Egypt, Islamic Republic of Iran, Jordan, Morocco and Tunisia. The private health insurance sector is in- creasingly establishing itself in middle- and high-income countries in the Region. These private companies also usually have a lim- ited list of fully reimbursable medicines. Challenges in essential medicines WHO estimates that over 10 million deaths per year could be avoided by scaling up certain health interventions, the majority of which depend on essential medicines. Yet today, almost 2 billion people do not have regular access to essential medicines; in some of the lowest income countries in Africa and Asia, more than half of the population has no regular access. There are also challenges in conceptualizing and measuring “access to medicines”. The cur- rent indicators for measurement neither fully capture the situation nor are they easy to measure. The global situation is also reflected in the EMR; universal coverage for basic health care, including provision of essential medicines in some of its poor countries, remains elusive. In fact, 11 medicine price surveys in the Region using standard meth- odology [17] have shown that many impor- tant essential medicines are unavailable in public sector health facilities, their generic forms are relatively less available in the private sector and the prices of both generic and proprietary medicines in the private sector are still unaffordable to the poor; this is especially the case in low-income countries. The essential medicines concept remains limited essentially to the public sector. The private sector, except insurance organiza- tions which are few in low and low-to- middle income countries, has not embraced the concept for the simple reason that it goes against the business interests of suppliers. It is a daunting but necessary challenge to change this situation, particularly in coun- tries where out-of-pocket spending is high. New business models need to be developed S80 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ which can encourage the private sector sup- ply of essential medicines. More and more new essential medicines are needed for existing neglected diseases in developing countries (e.g. trypanosomia- sis, leishmaniasis, hepatitis); for newly emerging diseases (e.g. Ebola virus, SARS, avian influenza); and for diseases which are increasingly not responding to existing treatments (e.g. tuberculosis, malaria, HIV/ AIDS). The research and development pipe- line is not serving these needs, primarily because these problems affect poor people in poor countries who do not represent an attractive market for big pharmaceutical companies. Therefore, even though these companies enjoy unprecedented levels of intellectual property protection, they are not investing in such research. Innovative ways of promoting research and development directed at these problems are needed; for example patent pools, prize funds, research and development treaties. Despite the existence of good practices guidelines in selection, procurement, stor- age and distribution, and use of medicines, supply management of medicines is weak and fragmented in low-income countries be- cause of lack of resources, limited expertise, and minimal accountability and political will. Because of these problems the vertical disease programmes have developed their own supply management systems, and this has resulted in inefficiencies and duplica- tion. Another major problem is that more than half the medicines are prescribed wrongly and half the patients consume medicines irrationally. This can result in a huge wast- age of resources and cause unnecessary suffering through prolonged morbidity and drug injuries. There have been fragmented and ad-hoc efforts to promote rational use of medicines but these have not improved the overall situation in countries and they have not been sustainable. Comprehensive, national and sustained effort is needed to counteract irrational use of medicines. Conclusion The concept of essential medicines has proved itself sound, fair and necessary. However, there remain many challenges, the most important being to improve eq- uitable access to those who still suffer un- necessarily for want of essential health care and medicines. PHC together with essential medicines continues to be the most relevant approach to organize and deliver reliable, sustainable and credible health care services in the 21st century. References 1. The selection of essential drugs: report of a WHO expert committee [meeting held in Geneva from 17 to 21 October 1977]. Geneva, World Health Organization, 1977 (WHO Technical Report Series, No. 615):20–30. 2. Declaration of Alma Ata (http://www.who. int/hpr/NPH/docs/declaration_almaata. pdf, accessed 3 July 2008). 3. Commission on Intellectual Property Rights, Innovation and Public Health. Public health, innovation and intellectual property rights: report of the Commission on Intellectual Property Rights, Innovation and Public Health. Geneva, World Health Organization, 2006. 4. Hardman JG, Limbird LE, eds. Goodman & Gilman’s the pharmacological basis Eastern Mediterranean Health Journal, Vol. 14, Special Issue S81 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ of therapeutics, 10th ed. New York, Mc- Graw–Hill, 2001. 5. WHO Official Records, No. 226, 1975, An- nex 13, pp. 96–110. 6. World Health Assembly. Resolution WHA28.66. Geneva, World Health Orga- nization, 1975. 7. Quick JD et al. Twenty-five years of es- sential medicines. Bulletin of the World Health Organization, 2002, 80(11):913– 4. 8. Helling-Borda M. Memories of the First Expert Committee Meeting and celebrat- ing 25 years later. Essential drugs moni- tor, 2003, 32:14–5. 9. World Health Assembly. Technical Coop- eration. WHA resolution 30.43, 19 May 1977. 10. The use of essential drugs: second report of the WHO expert committee [meeting held in Geneva from 3 from 7 December 1984]. Geneva, World Health Organiza- tion, 1985 (WHO Technical Report Se- ries, No. 722). 11. Mamdani M. Early initiatives in Essential Drugs Policy. In: Kanji N et al., eds. Drugs policy in developing countries. London, Zed Books, 1992:2. 12. Ferranti D. Paying for health services in developing countries: an overview. Wash- ington DC, World Bank, 1985. 13. Guidelines for developing national drug policies. Geneva, World Health Organiza- tion, 1988. 14. The selection and use of essential medi- cines: report of the WHO Expert Commit- tee, 2002 (including the 12th model list of essential medicines). Geneva, World Health Organization, 2003 (WHO Techni- cal Report Series, No. 914). 15. The WHO Essential Medicines Library [website] (http://www.who.int/emlib/, ac- cessed 3 July 2008). 16. The selection and use of essential medi- cines: report of the WHO Expert Commit- tee, October 2007 (including the model list of essential medicines for children). Geneva, World Health Organization (in press). 17. Medicine prices: a new approach to meas- urement. Geneva, World Health Organi- zation, 2003. WHO’s goal in the area of medicines is to help save lives and improve health by ensuring the quality, efficacy, safety and rational use of medicines, including traditional medicines, and by promoting equitable and sustainable access to essential medicines particularly for the poor and disadvantaged. Source: Essential Medicines and Pharmaceutical Policies (http://www.emro.who.int/emp/) S82 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ The progress of Roll Back Malaria in the Eastern Mediterranean Region over the past decade Hoda Atta1 and Ghasem Zamani2 Introduction Malaria has plagued humankind since an- cient times and is still putting nearly 40% of the world’s population at risk. No one is certain how many people contract the disease, but estimates suggest that it afflicts between 350 million and 500 million people every year. The World Health Organization (WHO) estimates that 59% of the world’s clinical malaria cases occur in Africa, 38% in Asia and 3% in the Americas [1]. Malaria in the WHO Eastern Mediterranean Region In total, 54% of the WHO Eastern Mediter- ranean Region (EMR) population resides in areas at various risk of malaria transmission [unpublished annual reports on malaria sur- veillance submitted to WHO by ministries of health, 2004]. The intensity of transmis- sion is generally low in most areas. Compre- hensive review of the community surveys conducted in malaria-endemic countries of the Region during 1985–2007 showed that in 87% of the surveys, falciparum malaria prevalence was below 10%, indicating that malaria is hypo-endemic [3]. Geographical diversity in the Region determines malaria variability in terms of endemicity, intensity of transmission and type of malaria. All age groups are at risk in endemic countries where transmission is seasonal and unstable, while pregnant women and children of young age are at higher risk in areas of stable malaria trans- mission, which exist in the south zone of Somalia and south Sudan. In Saudi Arabia, Yemen and the sub-Saharan countries of the Region (Djibouti, Somalia and Sudan), Plasmodium falciparum is the dominant species, while in Afghanistan, the Islamic Republic of Iran and Pakistan, both P. falci- parum and P. vivax are transmitted, with P. vivax as the dominant species. According to the malaria situation, countries of the Region are categorized into 3 groups. Group 1 (13 countries: Bahrain, Egypt, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Pales- tine, Qatar, Syrian Arab Republic, Tunisia and the United Arab Emirates) have elimi- nated local malaria transmission or have very residual foci. Group 2, (3 countries, the Islamic Republic of Iran, Iraq and Saudi Arabia) retain malaria endemicity in a few localized areas and are implementing elimi- nation strategies. More than 95% of the malaria cases in the Region occur in group 3 (6 countries, Afghanistan, Djibouti, Paki- stan, Somalia, Sudan and Yemen); Sudan alone accounts for almost 50% of the total Regional burden [4]. The Roll Back Malaria initiative The Roll Back Malaria (RBM) initiative was launched in 1998 by WHO, the United 1Regional Adviser; 2Medical Officer, Roll Back Malaria, Division of Communicable Diseases Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Hoda Atta: attah@emro.who.int). Eastern Mediterranean Health Journal, Vol. 14, Special Issue S83 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank in response to the unacceptably huge malaria burden on health and economies. The initiative renewed the global focus on malaria and revitalized the neglected malaria control programme, developed after the loss of as- piration for global eradication in 1969. It has been clearly stated that malaria eradication is not the objective of the new initiative: it is aimed at halving malaria-associated mortal- ity and morbidity by 2010, and it is empha- sized that this can only be achieved through strengthened local health systems [5]. The new approach created new opportu- nities for partnership between the public and private sectors. RBM now has a very wide range of partners, including malaria-endemic countries, their bilateral and multilateral development partners, the private sector, nongovernmental and community-based organizations, foundations, and research and academic institutions. Voting members of the RBM Partnership Board are: malaria- endemic countries (8), donor countries (3), UNICEF, WHO, UNDP, World Bank, re- search and academia (1 each), non-govern- mental organizations (2), private sector (2), foundations (1). The board also includes 2 non-voting ex officio members [6]. Roll Back Malaria in the Eastern Mediterranean Region Before the initiation of RBM, the Region had a malaria control programme. The RBM initiative in the EMR was launched in 1999. The wide spectrum of malaria eco-epidemiology and burden, from ma- laria-free status to the meso-hyperendemic situation, resulted in the adoption (at that time) of different objectives for 4 different groups of countries: high-burden countries and/or those with non-functional health sys- tems, low to moderate endemicity countries with functional health systems, countries with some residual foci of transmission, and malaria-free countries. In 2002–03 this programme was evaluated by external bodies, and proved to be a successful initia- tive, with significant impact on the malaria burden [7,8]. Achievements of Roll Back Malaria in the Eastern Mediterranean Region Impact on malaria burden Reported malaria cases gradually decreased from 6.1 million in 2000 to 3.6 million in 2006 [unpublished annual reports on malar- ia surveillance submitted to WHO by min- istries of health]. However, these reported figures represent only a fraction of the true incidence owing to the weakness of the health information system. It is estimated that there were about 10.5 million cases in 2005 (compared to an estimated 15 million in 2000). About 59 000 malaria-related deaths occur every year in the Region [9]. Since the RBM initiative, 3 countries have been freed from malaria (Oman, Mo- rocco, Syrian Arab Republic). Iraq is imple- menting a malaria elimination programme and is very close to victory in the fight against the disease (only 2 local cases in 2007). There has also been significant de- crease in the malaria burden in Saudi Arabia and the falciparum burden in the Islamic Republic of Iran. Commitment and partnerships Success in malaria control and elimination requires long-term, high-level commitment from governments, partners and donors, and the amount of resources allocated is an indicator of this commitment. Resources allocated to malaria control increased tremendously from both internal and external sources. All countries have in- creased their national allocation for malaria control and elimination. Based on the 2006 S84 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ country reports, the total annual budget al- located for malaria control in the Region is over US$ 84 million, 60% of this was from national resources. This expansion in finan- cial expenditure is indicative of a significant increase in political commitment to malaria control at national and international levels. Both the Regional Office and the coun- tries have been very successful in estab- lishing partnerships, particularly in those countries with a high malaria burden. Nongovernmental organizations have been active in promoting insecticide-treated nets (ITNs) in Afghanistan and Pakistan, and community mobilization in the northern and southern states of Sudan and in Yemen. Collaboration established the Malaria At- las Project to conduct malaria operation research in Somalia and other countries that will guide implementation of relevant interventions. Resource mobilization The total expenditure on malaria through joint programmes between WHO and the countries increased from almost US$ 3 million in 1998/99, the first year of RBM, to just over US$ 13 million in 2006/2007. The planned budget for 2008–09 is more than US$ 19 million. RBM/EMR also sup- ported countries in the Region in applying for funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). By round 7 of GFATM, all eligible malaria- endemic countries that applied for a Global Fund grant were successful in being award- ed at least one grant. The total approved lifetime budget for 7 countries from rounds 2 to 7 is more than US$ 382 959 000. By March 2008, the countries had already re- ceived US$ 81 853 111 [10]. The Arab Fund for Social and Economic Development and the International Islamic Relief Organization are regional organiza- tions that have provided financial support for malaria-endemic countries. Individual countries have provided support for pro- grammes in Afghanistan and Yemen. Af- ghanistan has received US$ 1 300 000 from the United States Agency for International Development (USAID), which has been used mainly for providing technical support and rehabilitation of the National Institute for Malaria and Leishmaniasis in Kabul. Collaboration with the Islamic Development Bank is ongoing and will support expansion of the Khartoum and Gezira malaria-free programme to 2 other states. Planning and management After RBM started, with technical support from the Regional Office, malaria-endemic countries developed multi-year strategic plans, regularly updating them to conform with WHO guidelines. The strategic plans have been the foundation of resource raising activities from national and donor agencies. By 2007, all malaria-endemic countries had updated their national strategic plan till 2010. Now, national malaria management teams have a strong capacity for revising and updating their national control strategy. In Afghanistan, the first national malaria control strategy was fully developed by in- ternational partners, but in 2008 the national teams took the lead in updating it. Human resource development and institutional support Human resource development and institu- tional support are key supportive strategies for RBM, and from the beginning it was realized that national capacity was weak in many poor, malaria-endemic countries, where the need was greatest. Health staff had left the malaria service or become de- moralized because of low salaries, poor working conditions and the absence of es- sential supplies. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S85 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ The Regional Office has supported in- stitutional assessment for development/ upgrading of Regional training centres. Currently 3 centres are available for Re- gional training courses: • Bandar Abbas (Islamic Republic of Iran), which is a field station of the Tehran School of Public Health. It was established in 1997 for Regional train- ing on planning and management, and upgraded in 2006. • The Blue Nile Research and Training Institute in Wad Medani, Gezira State, Sudan, was established in 1995, and later upgraded to cover Regional train- ing on entomology and vector control. • The central malaria laboratory in Oman was established as a Regional centre of excellence in malaria microscopy and quality assurance in 2007. In addition to general technical support provided by the Regional Office to all EMR countries, technical support for group 3 countries is being provided at the field level by 5 international and 13 national WHO staff. The Regional Office also supported the development and upgrading of the national training/research centres for malaria and other vector-borne diseases. A new na- tional malaria/leishmaniasis centre was established in Kabul in 2006 by WHO with financial support from USAID. The training centre in Jizan, Saudi Arabia was evalu- ated by WHO and upgraded in 2006 from national funds. The malaria headquarters in Yemen was established in Sana’a with resources from GFATM. Training on planning and programme management of malaria control programmes is considered an important aspect of RBM. So far, 10 courses have been conducted in the Regional centre in Bandar Abbas, Islamic Republic of Iran since 1997. The total number of participants trained is 187, including some from the WHO Regional Office for Africa (AFRO) and the WHO Regional Office for Europe (EURO). The Blue Nile Research and Training Institute has hosted 20 different malaria courses since 1997 for about 388 participants, of whom 129 received diplomas in malariol- ogy (9 month course). The trained staff have contributed greatly in improving ma- laria management at the national and sub- national levels in the countries of the EMR. WHO supported the first Regional train- ing course on malaria microscopy in the Regional centre of excellence in Oman in 2007. The curriculum of the Regional one-year masters course in entomology and vector control has been finalized. The first course will be conducted at Gezira Univer- sity in Sudan in late 2008. Several intercountry workshops were held to brief and train national staff on various malaria-related technical topics including: geographic information systems (GIS) for malaria; quality assurance for the laboratory diagnosis of malaria; the de- velopment of integrated vector control and monitoring the therapeutic efficacy of anti- malarial drugs; monitoring and evaluation; burden estimation; and malaria elimination. The regular, annual national programme managers’ meeting has been a place for sharing experiences, providing information on new technical developments, updating Regional malaria surveillance and establish- ing Regional and cross-border coordination among countries. Intersectoral collaboration Several instances of intersectoral collabora- tion and involvement of different sectors for implementation of malaria control and elimination have occurred in the EMR. As a recent example, in Morocco, the ministries of transport, agriculture, communication, S86 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ tourism and travel, and defence and pub- lic works, as well as travel agencies have all been involved in elimination efforts. In Sudan the success of the Malaria Free Initiative in Khartoum was due to strong collaboration between the federal ministries of health, agriculture, education, culture and social affairs, and community organization, along with the private sector. One of the most fruitful collaborations was established between the Malaria Free Initiative and Khartoum Water Corporation: it resulted in the expeditious repair of broken pipes. A disease without borders This is the slogan for the 2008 World Ma- laria Day, which marks 10 years since the launch of RBM. It reminds us that malaria is an ecological disease that cannot be con- fined within political borders. It shows that there are still a number of things that need to be done to strengthen cross-border coor- dination between countries. There are many examples of the invasion of malaria from neighbouring endemic countries: malaria epidemics in the 1940s after the invasion of An. gambiae (most probably Arabiensis) into southern parts of Egypt, the introduc- tion of malaria into the northern part of the Islamic Republic of Iran from Azerbaijan in 1994 and epidemics of malaria in Tajikistan after population movements on the border with Afghanistan in 1993. Cooperation between the WHO offices for Europe and the EMR in malaria con- trol/elimination has strengthened since the RBM initiative. They sponsored 2 meet- ings, in August 1999 and in May–June 2000, in Baku, Azerbaijan between repre- sentatives of neighbouring countries from both Regions. Interregional coordination continued with several further meetings: Dushanbe in 2001, Tashkent 05, Dushanbe 06, Ashgabat 07. The development of a joint plan for elimination of falciparum malaria in Tajikistan and northern areas of Afghanistan is a successful project awaiting donor funding. The Horn of Africa Network for Moni- toring Antimalarial Treatment (HANMAT) is a successful network among Horn of Af- rica countries, even though not yet formally established, which has helped in informa- tion sharing on drug efficacy monitoring and proper decision making for updating drug policy. Saudi Arabia, with focal malaria and better financial resources, and Yemen, with poor resources and a high burden of malaria, set an example of partnership for a joint malaria programme between neighbouring countries. Both are concerned about the high rate of population movement along their long and remote common border. Col- laboration between the 2 countries, in the form of exchange of information and sur- veillance, was assisted by RBM. This inter- country coordination, with WHO support, was further expanded and included other members of the Gulf Cooperation Council; in 2007, the heads of state approved a $ 47.2 million proposal with a vision of malaria elimination in the Arabian Peninsula. Afghanistan, the Islamic Republic of Iran and Pakistan have many common eco-epidemiological and cultural factors that necessitate their continuous and close cooperation in border areas. However, a functional mechanism has not yet been set up. Some recent activities conducted include 2 border meetings; developing a multi-country research project on molecular epidemiology and genetic characterization of the P. vivax populations in each country; and a course for building capacity on ento- mology and vector control in Pakistan and Afghanistan, hosted and supported by the Islamic Republic of Iran. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S87 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Population movement from endemic sub-Saharan African countries to Europe led to an increase in imported cases in countries in the north of Africa, where the migrants often transit. A coordination mechanism is yet to be established. Applied research The Tropical Disease Research (TDR) Small Grants Scheme was established in the Divi- sion of Communicable Diseases at the Re- gional Office in 1992, with support from the Regional Director’s development fund and from the TDR (UNDP/World Bank/WHO) Special Programme for Research and Train- ing in Tropical Diseases. It included malaria as a target disease right from the beginning. The scheme supports research into locally relevant health issues, beginning with prob- lem identification and proposal writing, through the research process to the dissemi- nation of findings. Since the beginning of 2000, RBM has contributed large sums to the TDR Small Grants Scheme: 55 propos- als from 10 countries have been supported by the Scheme and other mechanisms, with Sudan being the highest recipient country (19 proposals) [11]. Yemen received an institutional capacity grant to study the de- terminants of severe malaria. Strengthening monitoring and evaluation and new techniques for data collection and management Reliable and functional malaria surveillance is essential for proper planning and man- agement of malaria control programmes. A Regional workshop on monitoring and eval- uation was conducted by the Regional Of- fice, after which many countries developed their malaria monitoring and evaluation plan as part of their national strategy, and all endemic countries identified focal points. The main product of efforts for strengthen- ing monitoring and evaluation was the first world malaria report, which established the baseline for the accountability and transpar- ency of malaria control programmes. To overcome the problem of the weak malaria surveillance system and the lack of reli- able routine data, a pilot implementation of global malaria data has being initiated in Afghanistan, Yemen and Sudan. RBM/EMR introduced and encouraged countries to use HealthMapper software in their malaria surveillance systems to help them organize their data and to offer the possibility of a spatial view of the informa- tion. Many countries such as Afghanistan, Morocco, Pakistan, Saudi Arabia, Somalia, Sudan and Yemen are using the software as a GIS tool in malaria control and elimina- tion. The Malaria Early Warning Systems (MEWS), based on the weekly reporting of malaria cases in epidemic-prone districts, has been established in Sudan since 2001 and was introduced in Pakistan in 2003. With WHO support, a strategy for detection and control of malaria epidemics was de- veloped in Somalia and epidemic detection and control in the Islamic Republic of Iran was assessed. Malaria elimination and certification of free status The Regional strategy for 2006–10 sup- ports the expansion of malaria-free areas through malaria elimination initiatives at the sub-regional level (North Africa, Ara- bian peninsula); elimination programmes at the national level (Iraq, the Islamic Repub- lic of Iran, Saudi Arabia; the United Arab S88 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Emirates was certified free of malaria by WHO in 2007) and malaria-free projects at the sub-national level such as those outlined below in Socotra and Khartoum. The malaria elimination project was initiated on Socotra Island (a unique po- tential tourism centre) in Yemen in Sep- tember 2000. The impact of the project was a real success story with no local cases reported since 2005. The Khartoum and Gezira malaria-free initiative was launched in 2002, aimed at the elimination of malaria as a public health problem. Khartoum and Gezira were selected due to their political importance as Khartoum is the capital city and a seat of commerce and Gezira is of ag- ricultural importance. The 2 states are home to nearly one-third of the entire Sudanese population. The initiative has resulted in a significant reduction in the malaria burden in Khartoum state, and set an example to be followed by other states. The parasite rate decreased to 0.03% in 2006, compared to 1.5% in 2001. Current sub-national initiatives/projects in high-burden countries could be viewed as starting projects for elimination, sus- tainability and expansion and should be supported. Two guidelines on “elimination of resid- ual foci” and “prevention of reintroduction of malaria” were finalized and published [11,12]. For sharing successful experiences, the story of Morocco in malaria elimination was documented and published [13]. Challenges for Roll Back Malaria in the Eastern Mediterranean Region Malaria-endemic countries are facing a number of challenges, such as: • limited coverage and low quality of laboratory services for diagnosis, partic- ularly in high-burden countries, where only one-quarter of the clinical malaria cases are laboratory confirmed; • weak heath information and malaria surveillance systems, which are unable to provide reliable data on the malaria burden; • limited access to effective treatment and prevention measures; • poor leadership and management skills at national and lower levels; • lack of compliance of the private sector with national policies and guidelines; • weak community involvement and lack of community structures to deliver in- terventions to remote and inaccessible populations. Countries aiming at malaria elimina- tion are confronted with various obstacles, including: • limited expertise in malaria elimination and weak national capacity for imple- menting elimination interventions; • lack of an accurate and up-to-date strati- fication map of malaria transmission; • lack of effective strategies for coordina- tion of cross-border activities; • weak intersectoral coordination. Countries of the Region also face an additional constraint concerning the spread of resistance to drugs and insecticides. The unstable political situation in certain areas due to war or civil unrest and globalization along with rapidly changing dynamics in environment, climate and migration pose formidable challenges. The way forward With the vision of having a malaria-free Region, RBM/WHO Regional Office for the Eastern Mediterranean will continue to provide support to countries to provide Eastern Mediterranean Health Journal, Vol. 14, Special Issue S89 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ universal coverage for malaria control and prevention interventions, and to develop strategic plans for malaria elimination, wherever feasible. WHO will assist countries in their ef- forts to mobilize resources for the malaria programme and to strengthen the health system, as well as in building up national capacity for malaria elimination and in the coordination of cross-border activities. More investment will be given to research to develop innovative strategies to address the challenges facing the programme in all phases and settings, including complex emergency situations. Support will be sustained to consolidate the achievements already made and to pre- vent the re-emergence of malaria. References 1. World malaria report 2005. Geneva, World Health Organization and UNICEF, 2005. 2. Guerra C et al. The limits and intensity of Plasmodium falciparum transmission: implications for malaria control and elimi- nation worldwide. PLoS medicine, 2008, 5(2):e38. 3. Strategic plan for malaria elimination in the WHO Eastern Mediterranean Region 2006–2010. Cairo, World Health Organi- zation Regional Office for the Eastern Mediterranean, 2007. 4. Nabarro DN, Tayler EM. Global health: the “Roll Back Malaria” campaign. Sci- ence, 1998, 280(5372):2067–8. 5. RBM partnership board. Geneva, World Health Organization, UNICEF (http:// www.rbm.who.int/aboutus.html, accessed 5 June 2008). 6. Roll Back Malaria in the Eastern Medi- terranean Region: achievements, chal- lenges and the way forward. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2004. 7. Report on the responsiveness of the RBM programme to country needs in the WHO eastern Mediterranean Region. Cairo, World Health Organization Regional Of- fice for the Eastern Mediterranean, 2004. 8. World health report 2004: changing his- tory. Geneva, World Health Organization, 2004. 9. Global fund grants—progress details: all grants (in USD equivalents). Global Fund To Fight AIDS, Tuberculosis and Ma- laria website, 2008 (March) (http://web. theglobalfund.org/TGFWebReports3/Re- portOutput.jsp?chartId=GrantReport&cur r=USD, accessed 5 June 2008). 10. Operational research in tropical and other communicable disease, SGS final report summaries: Results portfolios 1 (1992– 2000), 2 (2001–2002) and 3 (2003–2004). Cairo, World Health Organization Region- al Office for the Eastern Mediterranean (http://www.emro.who.int/tdr/, accessed 5 June 2008). 11. Guidelines on the elimination of residual foci of malaria transmission. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2007 (Tech- nical Publications Series 33, http://www. emro.who.int/dsaf/dsa742.pdf, accessed 12 August 2008). 12. Guidelines on prevention of the reintro- duction of malaria / WHO Regional Office for the Eastern Mediterranean. Cairo, World Health Organization Regional Of- fice for the Eastern Mediterranean, 2007 (EMRO Technical Publications Series 34, http://www.emro.who.int/dsaf/dsa743. pdf, accessed 12 August 2008). 13. Malaria in Morocco: relentless efforts towards the goal of elimination. Cairo, World Health Organization Regional Of- fice for the Eastern Mediterranean, 2007. S90 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ HIV/AIDS in the last 10 years Abdalla Sidahmed Osman1 1Policy Adviser, UNAIDS, Cairo, Egypt (Correspondence to Abdallah Sidahmed Osman: osmana@emro. who.int). Introduction Now, 28 years after acquired immune de- ficiency syndrome (AIDS) was first recog- nised [1], it has become a global pandemic affecting almost all countries. WHO/UN- AIDS (Joint United Nations Programme on HIV/AIDS) estimate the number of people living with human immunodeficiency virus (HIV) worldwide in 2007 at 33.2 million. Every day 68 000 become infected and over 5700 die from AIDS [2]; 95% of these infections and deaths have occurred in de- veloping countries. The HIV pandemic re- mains the most serious of infectious disease challenges to public health. Sub-Saharan Africa remains the most seriously affected region, with AIDS the leading cause of death there. Although percentage prevalence has stabilized, con- tinuing new infections (even at a reduced Figure 1 Estimated number of people living with HIV globally, 1990–2007, data from UNAIDS [2] rate) contribute to the estimated number of persons living with HIV, 33.2 million (30.6–36.1 million) (Figures 1,2). A defining feature of the pandemic in the current decade is the increasing burden of HIV infection in women, which has additional implications for mother-to-child transmission. In sub-Saharan Africa, almost 61% of adults living with HIV in 2007 were women [2]. The impact of HIV mortality is greatest on people in their 20s and 30s; this severely distorts the shape of the population pyramid in affected societies. Globally, the number of children living with HIV increased from 1.5 million in 2001 to 2.5 million in 2007, 90% of them in sub-Saharan Africa [2]. HIV/AIDS also poses a threat to eco- nomic growth in many countries already in distress. According to the World Bank Eastern Mediterranean Health Journal, Vol. 14, Special Issue S91 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ analysis of 80 developing countries, as the prevalence of HIV infection increases from 15% to 30%, the per capita gross domestic product decreases 1.0%–1.5% per year [3]. The powerful negative impact of AIDS on households, productive enterprises and countries stems partly from the high cost of treatment, which diverts resources from productive investments, but mostly from the fact that AIDS affects people during their economically productive adult years, when they are responsible for the support and care of others. This crisis has necessitated a unique and truly global response to meld the resources, political power, and technical capacity of all UN organizations, developing countries and others in a concerted manner to curb the pandemic. AIDS often engenders stigma, discrimi- nation, and denial, because of its association with marginalized groups, sexual transmis- sion and lethality, hence it requires a more comprehensive and holistic approach. During the past 10 years, many develop- ments have occurred in response to this pandemic. WHO has played an important role in this response. This article reviews the major developments in treatment and prevention and the role of WHO in response to these developments. Treatment of HIV During the first decade of the AIDS epi- demic, the outcome for nearly every person infected with HIV around the world was virtually the same: most of those who be- came infected with HIV eventually died as a result of AIDS. This began to change, how- ever, in 1996 with the advent of protease inhibitors and highly active antiretroviral therapy. Antiretroviral therapy was a real break- through, changing HIV infection from an almost uniformly fatal infection into a chronic disease. At the XI International Conference on AIDS in 1996, results of studies in high income countries confirmed the effectiveness of combination antiretro- viral regimens in preventing AIDS-related illness and death [4]. It was clear that this would make a tremendous change in rich countries, but treatment would remain be- Figure 2 Estimated adult (15–49 years) HIV prevalence (%) globally and in sub-Saharan Africa, 1990–2007, data from UNAIDS [2] S92 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ yond the reach of people living with HIV in low- and middle-income countries. Hence the human toll from the epidemic will con- tinue to erase decades of public health gains in sub-Saharan Africa. Voices rejecting this situation increased, including those of people living with HIV, and leaders in governments, religion, in- dustry and civil society. Between 1998 and 2000, WHO and UNAIDS started to exert pressure on company leaders towards dif- ferential pricing for anti-retrovirals. There was also international pressure to end the so-called treatment apartheid. Due to these efforts, the Accelerating Access Initiative was launched in May 2000; this included the pharmaceutical companies and UNAIDS, WHO, the World Bank, UNICEF and the UN Population Fund. This agreement was followed by a Declaration of Commitment on HIV/AIDS, endorsed by the UN General Assembly in 2001, embracing equitable ac- cess to care and treatment as a fundamental component of a comprehensive and effec- tive global response [5]. In late 2001 and early 2002, a number of factors converged to increase the mo- mentum for treatment access. WHO took the first steps in developing guidance on a public-health approach, including simplified treatment regimens and clinical monitoring, and added 10 antiretroviral drugs to its list of essential medicines. The first edition of the WHO treatment guidelines for resource- limited settings was published in March, 2002 (it included the first mention by WHO of the 3 by 5 target) [6]. These guidelines included simplified schemes for treatment and clinical diagnosis, including reduced laboratory support. These approaches fa- cilitated wider access to large populations in need of treatment in the poorest countries. In September 2003, in the follow-up meeting to the UN General Assembly Special Session in New York, Richard Feachem, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Ma- laria, UNAIDS and WHO declared the gap between those who do and those who do not have access to treatment a “global health emergency” [7]. By December of that year, WHO had launched its plan for achieving 3 by 5, and UNAIDS allocated additional resources for its support [8]. The 3 by 5 initiative The 3 by 5 initiative committed all compo- nents of the UNAIDS family and a broad array of partners to a highly ambitious target: to provide 3 million people living with HIV/AIDS in low- and middle-income countries with antiretroviral treatment by the end of 2005. In fact there were good results. In a recent survey, 36 out of 39 of the 3 by 5 focus countries had developed national anti- retroviral therapy guidelines with at least one WHO first-line treatment regimen [9]. From a baseline of approximately 400 000 people receiving antiretroviral therapy in low- and middle-income countries in December 2003, more than 1.3 million people were receiving treatment by December 2005. Antiretroviral therapy coverage in low- and middle-income countries increased from 7% at the end of 2003 to 12% by the end of 2004 and 20% at the end of 2005. Over the past year, the number of people receiving treatment increased by about 300 000 every 6 months. The scale-up in sub-Saharan Africa was most dramatic, from 100 000 at the end of 2003 to 310 000 at the end of 2004 and 810 000 at the end of 2005. More than half of all people receiving treatment in low- and middle-income countries are now living in this region compared with a quarter 2 years ago. By the end of 2005, data reported from 18 countries indicated that they had met the 3 by 5 target of providing treatment to at least half of those who need it [10]. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S93 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ In sub-Saharan Africa, the number of people receiving treatment increased more than 8-fold over the 2-year reporting period, and has more than doubled in the past year. Coverage increased from 2% in 2003 to 17% at the end of 2005. About 1 in 6 of the 4.7 million people in need of antiretroviral therapy in this region now receives it [10]. Worldwide, it is estimated that between 250 000 and 350 000 deaths were averted in 2004–2005 as a result of increased treat- ment access [11]. The 3 by 5 initiative highlighted the value of target-setting in driving important public health initiatives and will continue to influence the public health landscape as we move towards universal access by 2010. Funding Despite these many achievements, as of December 2005 at least 80% of those in clinical need of antiretroviral drugs were not receiving them. On the funding front, many international organizations have been set up to assist in funding and implementing HIV prevention and care programmes and related health ini- tiatives worldwide. These include the Presi- dent’s Emergency Plan for AIDS Relief; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Rollback Malaria, the Global Alliance for Vaccines and Immunization; the Global Health Council; Médecins Sans Frontières; the Bill and Melinda Gates Foundation; the World Bank Multicountry HIV/AIDS Programme; the Accelerating Access Initiative and the William J. Clinton Presidential Foundation. These organizations contribute increas- ing amounts of money to confront AIDS and other pressing global health issues. UNAIDS reports that in 1996, approxi- mately US$ 330 million was available for HIV/AIDS initiatives worldwide [12], a figure which had risen to US$ 4.7 billion by 2003. Although this represents a huge in- crease in funding, it is still less than half the US$ 12 billion that is now required, and this demand is expected to rise to US$ 20 billion by 2007 [12]. The relative availability of funds encouraged the international commu- nity to plan for more-accessible services. At the June 2006 United Nations General As- sembly High-Level Meeting on HIV/AIDS in New York, Member States agreed to work towards the goal of “universal access to comprehensive prevention programmes, treatment, care and support” by 2010. This goal calls for the international com- munity to further build on the progress made in the global response to HIV/AIDS in recent years through, for example, the WHO/UNAIDS 3 by 5 initiative and the increased resources made available to coun- tries by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, the President’s Emergency Plan for AIDS Relief and other bilateral efforts, as well as those made available by private foundations and nongovernmental organizations. Prevention In the absence of curative therapy, control of the HIV/AIDS epidemic requires broad implementation of effective and sustainable prevention measures. In the past 20 years, substantial advances have been made in the field of HIV prevention. Prevention of infection must be based on strategies that interrupt sexual, blood-borne, and perinatal transmission of the virus. A number of preventive interventions have been tested and proved to reduce HIV- associated risk behaviours across a variety of populations [13]. Strategies for the pre- vention of sexual transmission have focused on reducing unsafe sexual behaviour (by promoting sexual abstinence or decreasing S94 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ the number of partners), encouraging con- dom use, and treating sexually transmitted infections. In addition, effective prevention strategies have been developed to reduce mother-to-child transmission of HIV-1 in- fection and to reduce blood product trans- mission of HIV through use of sensitive and reliable screening methods [13]. At country, regional and global lev- els, there continue to be concerns about the unmet need for comprehensive HIV- prevention programming within the current state of AIDS response. While coverage of some key preven- tion programmes such as the prevention of mother-to-child transmission increased markedly over the year, still only 17 of 108 low- and middle-income countries are on track to meet the United Nations General Assembly Special Session on HIV/AIDS, 25–27 June 2001 target of a 50% reduc- tion in infection among infants. Even the most basic building block of successful HIV prevention programmes—knowing how HIV is transmitted—is far from being achieved: in only 10 out of 78 low- and middle-income countries do a majority of young people (15–24 years) have com- prehensive AIDS knowledge. In view of this prevention challenge, WHO advocated dramatic scale-up of HIV testing and coun- selling and provided support for dissemina- tion and implementation of guidance on provider-initiated testing and counselling. Comprehensive integration of Prevention of Mother to Child Transmission of HIV with maternal and newborn child health continued to be a priority for WHO. Guid- ance was developed on key prevention and care programmes for people living with HIV [14]. Male circumcision Three recent randomized, controlled clini- cal trials have demonstrated the efficacy of adult male circumcision in reducing female- to-male transmission of HIV by approxi- mately 50%–60% [14–16]. These results have heightened interest in male circumci- sion as an HIV prevention intervention and have led to an increased demand for male circumcision services. In response to the findings of the trials, WHO, UNAIDS and their partners held an international consultation in early March 2007 with the goal of defining specific policy and programme recommendations for expanding and/or promoting male cir- cumcision for HIV prevention. In addi- tion to this practice being recognized as an important intervention to reduce the risk of HIV infection, experts at the consultation emphasized that, particularly in countries with high HIV prevalence as a result of het- erosexual transmission and with low male circumcision rates, male circumcision could have a major impact on the HIV epidemic. It was recommended that these countries urgently consider expanding access to safe male circumcision services. Operational tools for male circumcision, including for training on surgical procedures, quality as- surance, situation analysis, and monitoring and evaluation, were developed [14]. Future challenges Despite the progress to date, some persistent challenges continue to hamper the scaling up of antiretroviral therapy and HIV pre- vention. These include critical weaknesses in health systems, difficulty in ensuring eq- uitable access and lack of standardized sys- tems for the management of programmes and for monitoring progress. There is still the challenge of making the money work by harmonizing the efforts of partners. The World Health Report (2004) states that “the 3 by 5 initiative cannot be imple- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S95 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ mented in isolation from a regeneration of health systems” [17]. Several studies sup- port this statement, reflecting the unfavour- able conditions in the health care systems of developing regions [12,18]. Concerted efforts are needed to address the challenge to health systems, including effective fund- ing efforts. However, certain social and biological complexities profoundly affect the transmission, progression and mortality of the disease; these lie beyond the scope of health services. To sum up, the HIV pandemic has con- tinued to pose great challenges to public health. During the last 10 years different players have confronted the pandemic. WHO has played an important role in pro- viding technical support to countries in prevention and in leading the initiatives in treatment. References 1. Centers for Disease Control. Pneumo- cystis pneumonia—Los Angeles. Mor- bidity & mortality weekly report, 1981, 30:250–2. 2. Aids epidemic update 2007. Geneva, World Health Organization/UNAIDS, 2007 (http://data.unaids.org/pub/EPIS- lides/2007/2007_epiupdate_en.pdf, ac- cessed 29 June 2008). 3. HIV and human development: the devas- tating impact of AIDS. Geneva, UNAIDS & World Bank, 1999. 4. Report on the global AIDS epidemic. Ge- neva, UNAIDS, 2006. 5. Keeping the promise: summary of the Declaration of Commitment on HIV / AIDS, United Nations General Assem- bly, special session on HIV/AIDS, 25–27 June 2001, New York. Geneva, UNAIDS, 2002. 6. Scaling up antiretroviral therapy in re- source-limited settings: guidelines for a public health approach, 1st ed. Geneva, World Health Organization, 2002. 7. World Health Organization says failure to deliver AIDS medicines is a global health emergency. Geneva, World Health Or- ganization, 2003 (http://www.who.int/me- diacentre/news/releases/2003/pr67/en/, accessed 29 June 2008). 8. Schwartländer B, Grubb I, Perriëns J. The 10-year struggle to provide antiret- roviral treatment to people with HIV in the developing world. Lancet, 2006, 368(9534):541–6. 9. Beck EJ et al. National adult antiretroviral therapy guidelines in South Africa: con- cordance with 2003 WHO guidelines? AIDS, 2007, 20(11):1497–1502. 10. Progress on global access to HIV antiret- roviral therapy: a report on 3 by 5 and be- yond. Geneva, World Health Organization & UNAIDS, 2006. 11. AIDS epidemic update 2005. Geneva, World Health Organization/UNAIDS, 2005 (http://www.unaids.org/epi/2005/doc/re- port_pdf.asp, accessed 29 June 2008). 12. Coovadia HM, Hadingham J. HIV/AIDS: global trends, global funds and delivery bottlenecks. Globalization and health, 2005, 1(1):13. 13. Del Rio C. AIDS: the second wave. Archives of medical research, 2005, 36(6):682–8. 14. Gray RH et al. Male circumcision for HIV prevention in men in Rakai, Ugan- da: a randomised trial. Lancet, 2007, 369(9562):657–66. 15. Auvert B et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS medicine, 2005, 2(11): e298. S96 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 16. Bailey RC et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lan- cet, 2007, 369(9562):643–56. 17. World health report 2004 – changing his- tory. Geneva, World Health Organization, 2004. 18. Travis P et al. Overcoming health sys- tems constraints to achieve the millen- nium development goals. Lancet, 2004, 364(9437):900–6. The estimated number of people living with HIV in the Region by end 2007 was 530 000 with HIV prevalence estimated between 0.1% and 0.3 % of the adult population aged 15-49 years. There are concentrated epidemics among injecting drug users in four countries with another at high risk of such an epidemic. Overall, countries succeeded in providing ART to 79% of people living with HIV known to the health system. However, this relates to only 6% of the estimated number in need of ART. Source: The Work of WHO in the Eastern Mediterranean Region. Annual Report of the Regional Director1 January–31 December 2007 Eastern Mediterranean Health Journal, Vol. 14, Special Issue S97 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Improving maternal health to achieve the Millennium Development Goals in the Eastern Mediterranean Region: a youth lens Ramez Mahaini1 1Coordinator, Family and Community Health, Division of Health Protection and Promotion, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Ramez Mahaini: mahainir@emro. who.int). Introduction The fifth Millennium Development Goal (MDG) aims to improve maternal health. The 2 targets set for this goal are to “reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio” and “achieve, by 2015, universal access to reproductive health”. Six indicators have been selected to help track progress towards these tar- gets: maternal mortality ratio; proportion of births attended by skilled health personnel; contraceptive prevalence rate; adolescent birth rate; antenatal care coverage (at least 1 visit and at least 4 visits); and unmet need for family planning [1]. This paper briefly outlines the general situation in relation to maternal health in the Eastern Mediterranean Region of the World Health Organization (WHO) and goes on to focus on the perspective of adolescent pregnancy and reproductive health. General regional and sub- regional trends of the goal Improving maternal health has been en- dorsed as a key development target by Member States. It has been included in con- sensus documents arising from international conferences, including the World Summit for Children in 1990, the International Con- ference on Population and Development in 1994, the Fourth World Conference on Women in 1995, the Millennium Summit in 2000 and the United Nations General Assembly Special Session on Children in 2002 [2]. Despite the international efforts and commitment to the Safe Motherhood Initiative since its inception at the Nai- robi Conference in 1987, progress towards reducing maternal mortality globally has been slow. According to the WHO/United Nations Children’s Fund (UNICEF)/United Nations Population Fund (UNFPA), global estimates on maternal mortality in 2005 in- dicated that 536 000 women continue to die every year as a result of pregnancy-related complications [3]; around 53 000 of these women die in the WHO Eastern Mediter- ranean Region [4]. Over 95% of the burden of maternal death in the Region is shared by 7 countries, namely Afghanistan, Iraq, Mo- rocco, Pakistan, Somalia, Sudan and Yemen (Figure 1) [4]. In 2005, the mean maternal mortality ratio (MMR) in the Eastern Mediterranean Region was estimated at 377 per 100 000 live births, compared to 465 per 100 000 live births in 1990, a reduction of only 18.9% in maternal death in the Region in the period from 1990 to 2005. If the current S98 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ trend in reducing maternal death continues in the years to come, MMR is expected to be around 300 per 100 000 live births in the year 2015, while the target for MMR set by the MDG in the Region is 116 per 100 000 live births (75% lower than its level in 1990) (Table 1) [4]. It is worth mentioning here that the reduction in MMR has not yet exceeded 30% in 6 countries in the Region (Figure 2). These are: Afghanistan, Djibouti, Iraq, Pa- kistan, Somalia and Sudan. These countries contribute to over 90% of maternal deaths in the Region (Figure 1) [4]. However, there are great variations in maternal death levels among countries of the Region, ranging from 0 in Bahrain to 1600 per 100 000 live births in Afghanistan and Somalia (Table 1). In other words, countries of the Region can be classified in the 4 following groups. • MMR is less than 100 per 100 000 live births: this group contains 14 countries, namely: Bahrain, Egypt, Islamic Re- public of Iran, Jordan, Kuwait, Leba- non, Libyan Arab Jamahiriya, Oman, Palestine, Qatar, Saudi Arabia, Syrian Arab Republic, Tunisia and United Arab Emirates. • MMR ranges from 200 to 400 per 100 000 live births: this group contains Morocco, Iraq, Pakistan and Yemen. • MMR ranges from 500 to 600 per 100 000 live births: this group contains Sudan and Djibouti. • MMR is around 1600 per 100 000 live births: this group contains Afghanistan and Somalia. Regional trends of teenage marriage and pregnancy in relation to the MDG5 Adolescent pregnancy is commonplace in many countries. An estimated 14 mil- lion women aged from 15 to 19 years give birth each year to around 10% of all births worldwide. More than 90% (12.8 millions) of these female adolescents live in develop- ing countries [5]. More than half the women in sub-Saharan Africa and about a third in Latin America and the Caribbean give birth Figure 1 Maternal health: current situation: contribution of maternal deaths by country, 2005. Source: MPS indicators for countries of the Eastern Mediterranean, WHO/EMRO: 2005 Eastern Mediterranean Health Journal, Vol. 14, Special Issue S99 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ before the age of 20 years [6]. The regional average rate of births per 1000 women aged 15–19 years is 143 in sub-Saharan Africa and 78 in Latin America and the Caribbean compared to the world average of 65 [7]. Meanwhile, in the 28 countries of the Or- ganization for Economic Cooperation and Development, the percentage of women who give birth before age 20 years ranges from 2% in Japan to 13% in the United Kingdom and 22% in the United States [8]. For example, in the Arab world families are experiencing major changes as new patterns of marriage and family forma- tion emerge across the Region. Universal early marriage is no longer the standard it once was in Arab countries [9] (Table 2). The average age at marriage for both men and women is generally rising, and more Arab women are staying single longer or not marrying at all. While these trends are part of a general global phenomenon, they are also introducing new issues into Arab societies, issues that can confront deeply- rooted cultural values and present legal and policy challenges. Changing demographic patterns of marriage in the Arab world re- flect broader social and economic changes taking place throughout the Region. Arab economies have increasingly moved away from an agrarian system, which supported both early marriage and an extended family structure [9] (Table 3). Situation analysis of youth reproductive health in the Region WHO, in its contribution to meeting the MDGs, is according priority attention to issues pertaining to the management of adolescent pregnancy. Three of the aims of the MDGs, the empowerment of wom- en, the promotion of maternal health and the reduction of child mortality, embody key priorities of WHO and its overarching policy framework of poverty reduction. The UN Special Session on Children in particular focused on some of the key rights issues affecting adolescents, including early Table 1 Progress made in achieving the fifth Millennium Development Goal in the Eastern Mediterranean Region (maternal mortality ratio by country and year) Country Maternal mortality ratio (per 100 000 live births) 1990 2000 2005 2015 Afghanistan 1700 1600 1600 425 Bahrain 60 20 0 15 Djibouti 740 546 546 185 Egypt 174 68 63 44 Islamic Republic of Iran 91 37 37 23 Iraq 117 294 294 29 Jordan 80 41 41 20 Kuwait 11 7 4 3 Lebanon 150 104 88 38 Libyan Arab Jamahiriya 60 40 40 15 Morocco 500 228 227 125 Oman 190 38 15 48 Pakistan 450 350 350 113 Palestine 90 21 11 23 Qatar 9 0 22 2 Saudi Arabia 41 18 12 10 Somalia 1600 1600 1600 400 Sudan 660 509 509 165 Syrian Arab Republic 143 65 58 36 Tunisia 80 45 45 20 United Arab Emirates 5 0 1 1 Yemen 1400 366 366 350 Region 465 395 377 116 S100 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ marriage, access to sexual and reproduc- tive health services, and care for pregnant adolescents. Adolescent girls face considerable health risks during pregnancy and childbirth, ac- counting for 15% of the Global Burden of Disease for maternal conditions and 13% of all maternal death [10]. Adolescents Table 3 Age at first marriage in selected Arab states Country Year Age at first marriage (years) Males Females Algeria 2002 31.9 29.1 Lebanon 2004 32.8 28.8 Morocco 2004 31.0 26.9 Syrian Arab Republic 2001 29.4 25.6 Tunisia 2001 32.9 29.9 Yemen 2003 25.5 22.3 Source: Pan Arab Project for Family Health (www. papfam.org, accessed 8 July 2008). Figure 2 Percentage change in maternal mortality ratio by country WHO/EMRO, 2005. Source: Making Pregnancy Safer indicators for countries of the Eastern Mediterranean, 2005 Table 2 Decline in teenage marriage among women in selected Arab countries Country Year Women married at 15–19 years (%) Egypt 1976 22 2003 10 Tunisia 1975 11 2001 1 Libyan Arab 1973 40 Jamahiriya 1995 1 Kuwait 1970 38 1996 5 Palestine 1967 17 2004 14 United Arab 1975 57 Emirates 1995 8 Source: United Nations, World Fertility Report 2003, Tables II.9 and II.11; Pan Arab Project for Family Health (Tunisia 2001); Gulf Family Health Survey (United Arab Emirates 1995 and Kuwait 1996); and for Demographic and health survey Jordan 2002, Egypt 2003 and Palestine 2004. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S101 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ aged 15–19 years are twice as likely to die during childbirth and those under age 15 are 5 times as likely to die during childbirth as women in their twenties [8]. Unsafe abortion (defined by WHO as a procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking minimal medi- cal standards or both), pregnancy-induced hypertensive diseases [11] and severe anae- mia [12] contribute to a large extent to high maternal mortality among adolescents (Figure 3). Infant and child mortality is also higher among children born to adolescent mothers [13]. Adolescents suffer a significant and disproportionate share of death and dis- ability from unsafe abortion practices [14]. The number of abortions globally among adolescents ranges from 2.2 to 4 million annually [15]. Recent estimates reveal that 14% of all unsafe abortions in developing countries are performed on adolescents aged 15–19 years. Of these unsafe abortions in developing countries, Africa accounts for 25% while Latin America and the Carib- bean account for 14% [16]. Pregnant adolescents vary greatly in their circumstances, their behaviour and consequently their needs. Lack of informa- tion about the needs of pregnant adoles- cents means that service providers are ill equipped to deal with them. Failure on the part of communities to acknowledge and address the issues related to and stem- ming from the problem further complicates the situation. There are major barriers that preclude adolescents’ access to maternal health care services. Failure to address these barriers and needs seriously threatens the healthy outcomes of the young mother and newborn child and further contribute to the already high maternal mortality ratio and pregnancy-related morbidities. A major challenge to adequately meeting the educational, informational and clinical needs of adolescent women in developing nations is the eradication of existing social and cultural biases against adolescent wom- en. Youth-friendly services are reported among the best strategies to overcome such a challenge. Therefore, the needs of preg- nant adolescents must be approached from a holistic standpoint, rather than a solely biomedical perspective (Figure 3). There are 3 generally identified delays in accessing and receiving care that con- tribute to maternal and infant mortality [17] (Figure 4): 1. Delay in deciding to seek care on the part of the individual, family or both. Factors that shape the decision to seek care include actors involved in decision-making (individual, partner, family, community); this also includes knowledge about pregnancy, labour and symptoms and signs of complications (perception of need), status of women, costs, and cultural factors. 2. Delay in reaching an adequate health care facility. Causes include an inabil- ity to access health facilities because of underdeveloped transportation infra- structures, nonexistent communications networks, prohibitive costs of transpor- tation and other financial constraints. 3. Delay in receiving adequate care at an existing facility. Causes include inef- ficient triage systems, inadequate care- giver skills, inadequate numbers of caregivers, inadequate equipment and supplies and lack of a referral system. Although these delays are largely sys- temic, and thus affect health care for most pregnant women in developing countries, their presence poses particular challenges for the care of pregnant adolescents because S102 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ of an adolescent’s physical and psychologi- cal immaturity and limited autonomy. Un- less appropriate actions to eliminate these delays and evidence-based practices and procedures are implemented, it will be un- realistic to reduce maternal mortality ratios, especially among adolescents (Figure 5). Policy recommendations pertaining to overall and youth- specific attainment of MDG5 at the regional level with a focus on gender issues and concerns The evidence cautions that the situation of pregnant adolescents varies tremendously by age, marital status, whether the preg- nancy is wanted or unwanted, social class, educational attainment, urban or rural resi- dence, region and cultural context; this therefore calls for interventions that are flexible and responsive to these disparate needs. Policies must address the underlying social, cultural and economic factors that Figure 3 Health consequences of adolescent pregnancy contribute to pregnancy and childbearing among adolescents. They must improve the status of adolescent girls and expand their opportunities through the following actions. • Opportunities for formal education should be provided and reproductive health education introduced into the curricula at school. Special efforts are needed to overcome barriers that pre- clude young girls from attending school. Greater political commitment and re- sources are required to improve the overall status of girls. • Pregnant and parenting girls need to be able to continue their schooling. Tradi- tionally, pregnant schoolgirls have been forced to leave school. Policies designed to keep girls in school will allow them to acquire education and develop skills that will enhance their ability to care for themselves and their families, and to take advantage of worthwhile employ- ment opportunities. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S103 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Figure 4 Barriers to accessing health care for pregnant adolescents S104 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Figure 5 Determinants of pregnant adolescents seeking health care Eastern Mediterranean Health Journal, Vol. 14, Special Issue S105 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ • Existing laws on minimum age of mar- riage should be publicized and enforced towards establishing statutory marriage law applicable to all marriages. Experi- ence in many countries suggests that it is difficult for policy-makers to influ- ence age at marriage and childbearing directly. In spite of the legal age limit at marriage being 16 or 18 years, many women marry before reaching this age. • Reproductive health information and youth-friendly services for married and unmarried, non-pregnant and pregnant adolescents should be legally available and widely accessible. • Health providers should be trained par- ticularly in counselling and interperson- al communication skills to better work with adolescents. Adolescents should particularly be given adequate social support during pregnancy, labour, deliv- ery and postpartum period. • Safe motherhood programmes need to be particularly vigilant, sensitive and responsive to physical abuse of adoles- cents during pregnancy and the postpar- tum period. • Maternal health care for adolescents should be provided early and include pregnancy test, counselling, early detec- tion and management of complications, psychological support, and nutrition- al, iron and vitamin supplementation. Treatment and management of malaria and other communicable diseases in endemic areas should be a component of antenatal care provided to adolescents. • In light of the higher incidence of pre- mature delivery in adolescents, planning for the birth should be undertaken, in- cluding the place of birth, availability of transportation and costs involved. • Postpartum care should be provided as it is particularly important for adolescents in order to promote and support breast- feeding and provide the contraceptive method of choice. • Individuals, families and communities, including social and religious leaders and other key decision-makers, should be targeted to increase their knowledge on the health and social burden associ- ated with adolescent pregnancy. This intervention should help ensure provi- sion of the required support to pregnant adolescents. References 1. United Nations Population Fund. About the Millennium Development Goals (http:// www.unfpa.org/icpd/about.htm, accessed 7 July 2008). 2. Making Pregnancy Safer: WHO’s flag- ship programme to improve the lives of women and their newborns. Geneva, World Health Organization, 2003. 3. Maternal mortality in 2005: estimates de- veloped by WHO, UNICEF and UNFPA. Geneva, World Health Organization, 2007 (http://www.who.int/reproductive-health/ publications/maternal_mortality_2005/, accessed 7 July 2008). 4. MPS indicators for countries of the East- ern Mediterranean. Cairo, WHO Regional Office for the Eastern Mediterranean, 2005 (http://www.emro.who.int/rhrn/sta- tistics.htm, accessed 7 July 2008). 5. World Population Monitoring 2002 – re- productive rights and reproductive health: selected aspects. New York, United Na- tions, 2004 (ST/ESA/SER.A/215). 6. Into a new world: young women’s sexual and reproductive lives. New York, Alan Guttmacher Institute, 1998. 7. The progress of nations 1998. New York, United Nations Children’s Fund, 1998. S106 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 8. A league table of teenage births on rich nations. Florence, UNICEF Innocenti Re- search Centre, 2001 (Innocenti Report Cards, No. 3). 9. Rashad H, Osman M, Roudi-Fahimi F. Marriage in the Arab world. Washington DC, Population Reference Bureau, 2005. 10. World Health Organization, Global Pro- gramme on Evidence, 2000. 11. Granja A et al. Adolescent maternal mor- tality in Mozambique. Journal of adoles- cent health, 2001, 28:303–6. 12. Brabin B, Hakimi N, Pelletier D. An analy- sis of anemia and pregnancy related ma- ternal mortality. Journal of nutrition, 2001, 131:604S–614S. 13. World Population Profile: 1996. Washing- ton DC, US Bureau of the Census, 1996. 14. Singh S. Adolescent childbearing in de- veloping countries: a global review. Stud- ies in family planning, 1998, 29:117–36. 15. Olukoya A et al. Unsafe abortion in ado- lescents. International journal of gynecol- ogy and obstetrics, 2001, 75:137–47. 16. Shah I, Ahman E. Age patterns of un- safe abortion in developing country re- gions. Reproductive health matters, 2004, 12(Suppl.):9–17. 17. Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Social sci- ence & medicine, 1994, 38:1091–110. The majority of the countries in the Region are on track to achieve the Millennium Development Goals, however, in seven countries, the relevant goals are unlikely to be achieved unless major efforts are made. The adoption of the Making Pregnancy Safer (MPS) strategy and its implementation in countries where maternal and neonatal deaths are still high will strengthen the efforts being made. Specific attention is being given to: strengthening health systems; improving knowledge and skills of health workers about early detection and management of complications in pregnancy, delivery and childhood; and raising the awareness of individuals, families and communities about emergency preparedness and life-saving practices. Source: The Work of WHO in the Eastern Mediterranean Region. Annual Report of the Regional Director1 January–31 December 2007 Eastern Mediterranean Health Journal, Vol. 14, Special Issue S107 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Nutrition in the Eastern Mediterranean Region of the World Health Organization Kunal Bagchi1 1Regional Adviser, Nutrition for Health and Development, World Health Organization Regional Office for South-East Asia, New Delhi, India, and former Regional Adviser, Nutrition, Division of Health Promotion and Protection, World Health Organization Regional Office for the Eastern Mediterranean, Cairo Egypt (Correspondence to Kunal Bagchi: bagchik@searo.who.int). Background A complex combination of dietary practices and environmental, social and economic factors in countries of the World Health Or- ganization (WHO) Eastern Mediterranean Region (EMR) has resulted in the persist- ence of what is described as the double burden of malnutrition, where undernutri- tion among young children and women of childbearing age co-exists with nutrition of excess, demonstrated by increasing rates of overweight, obesity and chronic disease. Based on a combination of nutrition and health indicators and risk factors, the countries of the Region can be divided into 4 categories [1]. In the first category are countries that are characterized by high prevalence of overweight and obesity along with a moderate level of undernutrition among children under the age of 5 years and micronutrient deficiencies in popula- tion sub-groups (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emir- ates). The major risk factors that may be attributed to the role of government are lack of clear food and nutrition policies and strategies; unclear lines of coordination and collaboration between the national authori- ties concerned; lack of consumer education and protection laws; and overall inadequate food safety and nutrition education among the general population. At the consumer and individual levels, risk factors are very high intake of energy-dense foods (fats, sugar/ refined carbohydrates) and low vegetable/ fruit consumption combined with a sedentary lifestyle with minimum physical activity, all existing within an overall environment of aggressive commercial marketing of fast foods and breast-milk substitutes. In the second category are countries where moderate levels of overweight/obesity co-exist with moderate levels of undernutri- tion in specific population pockets and age groups alongside widespread micronutrient deficiencies (Egypt, Islamic Republic of Iran, Jordan, Lebanon, Libyan Arab Jama- hiriya, Morocco, Syrian Arab Republic and Tunisia). The major risk factors that may be attributed to the role of government are again lack of clear food and nutrition policies and strategies; unclear lines of coordination and collaboration between the national authori- ties concerned; lack of consumer education and protection laws, and inadequate food safety and nutrition education among the general population. The risk factors present at the consumer and population levels are increased dietary intake of fats and re- fined sugar and inadequate energy, fruit and vegetable consumption combined with a sedentary lifestyle with minimum physical activity, occurring within an environment S108 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ of aggressive commercial marketing of fast foods, breast-milk substitutes and persist- ence of poverty pockets, particularly in peri-urban settings and among remote rural population groups. In the third category are those countries with significant undernutrition consisting of acute and chronic child and maternal malnutrition, widespread micronutrient de- ficiencies and emerging overweight/obesity and nutrition of indulgence in population sub-groups (Pakistan and occupied Pales- tinian territory). Prevailing risk factors that may be attributed to the role of government are weak social and economic infrastructure in certain geographical areas; the ad hoc nature of nutrition programmes; lack of a coherent nutrition policy; lack of con- sumer education and protection laws and inadequate institutional capacity and trained human resources for food safety control; and inadequate and insufficient intake of food by a major portion of the popula- tion. Widespread poverty and insufficient income; inadequate access to a safe water supply and poor sanitation; and pockets of low literacy are the environmental compo- nents that contribute to the perpetuation of this situation. The fourth category relates to countries experiencing humanitarian crisis with high prevalence of severe child and maternal un- dernutrition and widespread micronutrient deficiencies (Afghanistan, Djibouti, Iraq, Somalia, Sudan and Yemen). In these coun- tries, the national development programmes have been disrupted, including food safety and food control mechanisms, along with a lack of institutional capacity and trained human resources to monitor food security, food aid and food safety. Prevalence of undernutrition Over the years, significant progress has been made in improving the health and nutrition status of the population of the EMR [2]. Six countries in this Region (Djibouti, Jordan, occupied Palestinian territory, Oman, Syr- ian Arab Republic and Tunisia) are on track to meet the Millennium Development Goals (MDGs) targeting a reduction in the propor- tion of children under 5 years of age who are underweight [3]. Furthermore, 12 coun- tries have underweight prevalence rates of 10% among the under-5s. The overall proportion of underweight children under 5 years of age has, however, increased in the EMR from 14% in 1990 to 17% in 2004 (i.e. 8 million children still suf- fer from underweight). Regional statistics have been dragged down by 3 heavily popu- lated countries: Iraq, Sudan and Yemen. In Iraq, the proportion of underweight children under 5 years of age is still higher than it was in 1990, standing at 16%. In Yemen the situation has also deteriorated, with 46% of all under-5s being currently underweight compared with 30% in 1991–92. It is esti- mated that 53% of under-5s in Yemen are stunted, and 32% of babies are born with low birth weight. In Sudan, where civil war has influenced children’s nutritional status, 41% of under-5s are underweight and 31% of babies are born with low birth weight. Sudan is afflicted with the highest propor- tion of wasted children (16%) in the Region [WHO-EMRO unpublished data, Personal communications, 3]. The assumption that economic growth and development will improve undernutri- tion is not always accurate. For instance, Kuwait, Saudi Arabia, and the United Arab Emirates have high per capita gross national incomes but have the same or even higher rates of wasting as low-income Yemen [WHO-EMRO unpublished data, 2003, 3]. Underweight is also reported among adults in the Region. The prevalence of underweight [body mass index (BMI) < 18.5 kg/m2] in the Islamic Republic of Iran, Morocco, Saudi Arabia and Tunisia Eastern Mediterranean Health Journal, Vol. 14, Special Issue S109 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ is in the range of 5%–7% [4,5]. A lower prevalence of adult underweight is noted in Kuwait (2.5%) but with a strikingly higher prevalence in the adolescent population group aged 13–18 years, 17% of whom were found to be underweight [5]. Prevalence of micronutrient deficiencies Available data suggest that, for several nutrients including iron, iodine, zinc, cal- cium, vitamin A, vitamin D and folate, the nutritional status of the population of the EMR is suboptimal. Iron deficiency anae- mia is a serious public health problem in all countries of the Region. Iron deficiency and its associated anaemia problems are wide- spread among women, especially those of child-bearing age, and among children. It is estimated that more than one-third of the population is anaemic in the Region [WHO-EMRO, unpublished data]. Anaemia has been estimated at 15% in Saudi Arabia and at 74% in Yemen among preschool children. It ranged from 11% in Egypt to over 40% in the Syrian Arab Republic and Oman among women of childbearing age [6,7]. Data on anaemia rates among preschoolers, pregnant women and women of childbearing age from 1995 to 2001 show no improvement in the overall situation among the Member States of this Region [7,8]. Furthermore, in studies conducted on adolescents in Egypt, Saudi Arabia and Yemen, the prevalence rates for anaemia are high, ranging between 30% and 55% [9–15]. Vitamin A deficiency disorders are con- sidered a public health problem in several countries of the Region. These disorders are observed in large numbers of preschool- ers, school-aged children and women of childbearing age. Available data, based on a serum retinol level of < 20 μg/dL, sug- gest the prevalence of sub-clinical forms of vitamin A deficiency disorder of around 10% in Egypt and the Syrian Arab Repub- lic, 17% in Jordan, 20%–30% in Oman and Pakistan, 40% in Morocco and over 60% in Yemen, but only 2.3% in Tunisia [7,16]. In Sudan, prevalence of vitamin A deficiency is considered a public health problem. This is indicated by 1995 data which showed a prevalence of 8.5% for night blindness in children under 5 years of age. Areas most affected were Southern Darfur and Gezira [8]. In 2002, iodine deficiency was recog- nized as a problem of public health sig- nificance requiring urgent attention in 18 countries of the Region. One-third of the population in the Region is at risk of devel- oping iodine deficiency disorder (IDD). The contributing factors are poor iodine content of soil and limited consumption of food items with adequate iodine content. Uni- versal iodization of salt has been achieved in 8 EMR Member States. At present, IDD is not considered a public health problem in Bahrain and Qatar, and is considered under control in the Islamic Republic of Iran and Tunisia. Prevalence of IDD is considered mild in 8 countries of the Region (Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Oman, occupied Palestinian territory, Syrian Arab Republic and United Arab Emirates), and moderate in 5 others (Egypt, Morocco, Saudi Arabia, Sudan and Yemen). Data on the prevalence of IDD are lacking for Afghanistan, Djibouti, Iraq, Pakistan and Somalia [7]. Vitamin D deficiency has been docu- mented among children under the age of 5 in Yemen, Morocco and the Islamic Repub- lic of Iran, and studies conducted on adults and adolescents show that the prevalence of suboptimal serum 25-hydroxyvitamin D concentrations varies between 46% and S110 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 83% in the countries of the Region [17–25]. Severe forms of hypovitaminosis D have been particularly reported among veiled women, with prevalence levels ranging between 50% and 62% [17,21–24,26]. Other micronutrient deficiencies have also been documented in some countries of the Region. There are reports on beri beri (thiamine deficiency) and pellagra (niacin deficiency) in Sudan (Darfur), scurvy (vi- tamin C deficiency) in Afghanistan (Herat province) [Personal communication], folate and vitamin B12 deficiencies in women of childbearing age and zinc deficiency in children under 5 years in Lebanon [25,27]. Prevalence of overweight and obesity Overweight and obesity in adults present a dramatically increasing trend in the Re- gion. Based on data compiled by WHO for adults aged 15 years and above from 16 countries of the Region [28], it can be shown that the highest levels of overweight (BMI 25 kg/m2) are observed in Kuwait, Egypt, United Arab Emirates, Saudi Arabia, Jordan and Bahrain, where the incidence of overweight/obesity ranges between 74% and 86% for women and 69% and 77% for men. These findings have important public health implications since the prevalence of obesity (BMI 30 kg/m2) reaches levels as high as 64.7% in Kuwaiti women and 57% in Egyptian women [28,29]. The low- est prevalence of overweight and obesity are observed in the least developed coun- tries such as Yemen (37.5% in women and 29.7% in men) and Sudan (36.9% in women and 23.4% in men). Overall, available data indicate that a much higher prevalence of obesity is ob- served among adult women compared to men in the Region [28,30]. Prevalence of overweight and obesity increase with age, mainly due to the decline in energy ex- penditure rate and in physical activity level among older people [28,31,32]. Overweight (BMI for age > 85th per- centile) and obesity (BMI for age 95th percentile) among schoolchildren and ado- lescents are also reported in some countries of the Region. The prevalence of over- weight among adolescent males ranges from 17.4% in Tunisia to 30.0% in Kuwait, while for adolescent females it ranges from 13.4 % in Lebanon to 31.8% in Kuwait [33–36]. Data from the Islamic Republic of Iran, Kuwait, Lebanon and Qatar show that obesity prevalence ranges between 9% and 15% among adolescent males and between 2% and 13% among adolescent females. When compared to the National Center for Health Statistics (NCHS) reference data, the BMI of Kuwaiti adolescents exceeded that of the Americans in each centile category [33]. Overall, existing data indicate an in- creasing trend in overweight and obesity in youths from the EMR countries since median values of age-specific BMI have specifically increased with time, as docu- mented by studies conducted in the Islamic Republic of Iran, Bahrain and Saudi Arabia [35,37,38]. These data indicate an increased rate of overweight in all age groups of the popula- tion. The escalating levels among children and adolescents is of particular concern given the recent evidence linking childhood and adolescent obesity to increased risk of obesity and morbidity in adulthood. This calls for a community-based strat- egy to combat the increasing rate of obesity and its subsequent complications such as diabetes, coronary artery disease, hyperten- sion and osteoarthritis in all sectors of the population. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S111 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Concluding remarks Over the past 6 decades several Member States of the Eastern Mediterranean Region have made strong and determined efforts to ensure the provision of adequate food, health care and economic support to their populations, witnessed by the dramatic improvement in the vital statistics and de- mographic indicators. Yet a significant pro- portion of the Region’s population remains impoverished, with high levels of different types of malnutrition. The preceding sections have elaborated on the prevalence rates of a variety of nutri- tional problems but refrained from delving into the causes and complexities of the cur- rent situation. There are several reasons for this. While one may point out lack of politi- cal support and interest, paucity of resources and inadequate technical capacities of the nations as the reasons for the persistence of malnutrition, there are instances where in spite of economic prosperity, strong public distribution of subsidized food and national interest, there is persistence of undernutri- tion and micronutrient deficiencies. Looking at the nutritional trends over the past few decades, one can propose the following: • Dedicated and determined efforts have to be made to understand the epidemi- ology of nutritional disorders in every Member State, with the desegregation of data to the smallest administrative level in the Member State. • Strong governmental interventions will be needed to ensure that food, nutrition and the related sectors of agriculture, commerce, rural development and public distribution of food (where such social backing exists) perform in a coordinated and mutually supportive manner. • Appropriate interventions according to the epidemiologic nutrition profile of the population have to be developed, with particular focus on pregnant women and the first 2 years of life. • National authorities should refrain from establishing nationwide, broad-based nutrition programmes and from overtly relying on external or donor-driven tech- nological interventions. Acknowledgements This article is based on the paper “Food marketing to children and adolescents in the Eastern Mediterranean Region: impli- cations for public health” [1] and on “Re- gional food-based dietary guidelines for the Eastern Mediterranean, Middle East and North Africa region” [39]. The contribution of Professor Nahla Hwalla towards the development of this article is gratefully acknowledged. References 1. Food marketing to children and adoles- cents in the Eastern Mediterranean Re- gion: implications for public health. Paper presented at the Regional Committee for the Eastern Mediterranean, 54th session, October 2007 (EM/RC54/Tech.Disc.2) (http://www.emro.who.int/rc54/media/pdf/ EMRC54TECHDISC02en.pdf, accessed 30 July 2008). 2. De Onis M, Blossner M. Is malnutrition de- clining? An analysis of changes in levels of child malnutrition since 1980. Bulletin of the World Health Organization, 2000, 78:1222–33. 3. UNICEF. Progress for children. Mid- dle East/North Africa. A report card on nutrition: number 4, 2006, (http://www. S112 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ unicef.org/progressforchildren/2006n4/ index_mideastafrica.html, accessed 1 July 2008). 4. Belahsen R, Mziwira M, Fertat F. Anthro- pometry of women of childbearing age in Morocco: body composition and preva- lence of overweight and obesity. Public health nutrition, 2004, 7:523–30. 5. Global database on body mass index. Geneva, World Health Organization, 2006 (http://www.who.int/bmi/index.jsp, accessed 1 July 2008). 6. Hwalla N, Adra N, Jackson RT. Iron de- ficiency is an important contributor to anemia among reproductive age women in Lebanon. Ecology of food and nutrition, 2004, 43:77–92. 7. Progress report on food fortification to combat micronutrient deficiency disor- ders. WHO Regional Committee for the Eastern Mediterranean/North Africa, Fifty- first session, Cairo, Egypt, 3–6 October 2004. Cairo, World Health Organization Regional Office for the Eastern Medi- terranean, 2004 (WHO-EM/RC51/INF. DOC.4). 8. Nutrition country profile – Sudan. Food and Agriculture Organization, 2005 (ftp:// ftp.fao.org/es/esn/nutrition/ncp/sdn.pdf, accessed 1 July 2008). 9. Egypt’s Adolescent Anemia Prevention Programme (a report on programme development, pilot efforts and lessons learned). Cairo, Ministry of Health & Pop- ulation/Health Insurance Organization/ USAID/JSI/Manoff Group, 1998. 10. Curtale F et al. Anaemia among young male workers in Alexandria, Egypt. East- ern Mediterranean health journal, 2000, 6(5/6):1005–16. 11. El-Sahn F et al. Anaemia among Egyp- tian adolescents: prevalence and deter- minants. Eastern Mediterranean health journal, 2000, 6(5/6):1017–25. 12. Al-Quaiz JM. Iron deficiency anemia: a study of risk factors. Saudi medical jour- nal, 2001, 22(6):490–6. 13. Raja’a YA et al. Nutritional status of Yem- eni schoolchildren in Al-Malweet Gov- ernorate. Eastern Mediterranean health journal, 2001, 7(1/2):204–10. 14. Al-Sharbatti SS, Al-Ward NJ, Al-Timmi DJ. Anemia among adolescents. Saudi medical journal, 2003, 24:189–94. 15. Bagchi K. Iron deficiency anaemia—an old enemy. Eastern Mediterranean health journal, 2004, 10(6):754–60. 16. El Ati J et al. Statut en vitamine A de l’enfant tunisien (Vitamin A status of Tuni- sian children). New York, Institut National de Nutrition, Laboratoire de Biochimie de la Rabta, UNICEF, 2007:110. 17. Ghannam NN et al. Bone mineral density of the spine and femur in healthy Sau- di females: relation to vitamin D status, pregnancy, and lactation. Calcified tissue internatonal, 1999, 65:23–8. 18. Fuleihan GE. Hypovitaminosis D in a sunny country. New England journal of medicine, 1999, 340:1840–1. 19. Gannage-Yared MH et al. Hypovitamino- sis D in a sunny country: relation to life- style and bone markers. Journal of bone and mineral research, 2000, 15:1856–62. 20. El-Hajj Fuleihan et al. Hypovitaminosis D in healthy schoolchildren. Pediatrics, 2001, 107:53–9. 21. Bassir M et al. Vitamin D deficiency in Ira- nian mothers and their neonates: a pilot study. Acta paediatrica, 2001, 90:577–9. 22. Al-Faraj S, Al-Mutairi K., Vitamin D defi- ciency and chronic low back pain in Saudi Arabia. Spine, 2003, 28:177–9. 23. Hashemipour S et al. Vitamin D deficien- cy and causative factors in the popula- tion of Tehran. BMC public health, 2004, 25(4):38. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S113 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 24. Moussavi M et al. Prevalence of vitamin D deficiency in Isfahan high school stu- dents in 2004. Hormone research, 2005, 64(3):144–8. 25. Disease control priorities in developing countries, 2nd ed. Washington DC, World Bank, Disease Control Priorities Project, 2006:Tables 28.1, 28.2, 28.3 (http://www. dcp2.org/pubs/DCP, accessed 1 July 2007). 26. Gannage-Yared MH et al. Dietary calcium and vitamin D intake in an adult middle eastern population: food sources and relation to lifestyle and PTH. International journal for vitamin and nutrition research, 2005, 75(4):281–9. 27. Khatib L et al. Folate deficiency is associ- ated with nutritional anaemia in Lebanese women of childbearing age. Public health nutrition, 2005, 9:921–7. 28. WHO Global InfoBase. Geneva. World Health Organization, http://www.who.int/ infobase/report.aspx (accessed 1 July 2008). 29. El-Zanaty F, Way A. Egypt Demographic and Health Survey 2005. Cairo, Ministry of Health and Population, National Popu- lation Council, El-Zanaty and Associates, and ORC Macro, 2006. 30. Azadbakht L et al. General obesity and central adiposity in a representative sam- ple of Tehranian adults: prevalence and determinants. International journal for vitamin and nutrition research, 2005, 75:297–304. 31. Sibai A et al. Prevalence and covariates of obesity in Lebanon: findings from the first epidemiological study. Obesity research, 2003, 11:1353–61. 32. Rashidi A et al. Prevalence of obesity in Iran. Obesity reviews, 2005, 6(3):191–2. 33. Al-Isa AN. Body mass index and preva- lence of obesity changes among Kuwait- is. European journal of clinical nutrition, 1997, 51:743–9. 34. Aounallah-Skhiri H et al. Nutritional status of Tunisian adolescents: associated gen- der, environmental and socioeconomic factors. Public health nutrition, 19 Jun 2008 (doi:10.1017/S1368980008002693) (http://journals.cambridge.org/action/displ ayAbstract?fromPage=online&aid=19106 44). 35. Mohammadpour-Ahranjani B et al. Preva- lence of overweight and obesity in ado- lescent Tehrani students, 2000–2001: an epidemic health problem. Public health nutrition, 2004, 7:645–8. 36. Hwalla N, Sibai A, Adra N. Adolescent obesity and physical activity. World re- view of nutrition and dietetics, 2005, 94:42–50. 37. Abalkhail B. Overweight and obesity among Saudi Arabian children and ado- lescents between 1994 and 2000. East- ern Mediterranean health journal, 2002, 8(4/5):470–9. 38. Al-Sendi AM, Shetty P, Musaiger AO. Anthropometric and body composition indicators of Bahraini adolescents. Annals of human biology, 2003, 30:367–79. 39. Regional food-based dietary guidelines for the Eastern Mediterranean, Middle East and North Africa region. Cairo, World Health Organization Regional Office for the Eastern Mediterranean (in press). S114 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Mental health challenges and possible solutions Mohammad Taghi Yasamy1 1Regional Adviser, Mental Health and Substance Abuse, Division of Health Promotion and Protection, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Mohammad Taghi Yasamy: yasamym@emro.who.int). Introduction The World Health Organization (WHO) was established 60 years ago based on a constitution that in its first paragraph stressed that its principles are basic to the “happiness, harmonious relations and secu- rity to all people…”. The stress on mental health aspects was repeated in the definition of health to show that this was not an inci- dental choice of words [1]. Again 30 years ago when the declaration of Alma Ata was introduced to the world [2], the definition was reaffirmed and a new opening to scaling up mental health inter- ventions through integration into primary health care was put forward. Yet, although considered formally an integral part of general health worldwide, and the WHO definition of health and its constitution implies that mental health is an integral part of health and as important as physical health [1], mental health is a somewhat paradoxical area of health. In reality, convincing data on the great burden of mental health [3,4] is juxtaposed with the low political will and insufficient resource allocation to deal with and avert the burden [5,6]. In fact, the low priority of mental health is not just a technical problem but an important moral one as well [7]. There is international documentation on the con- spicuous shortage of mental health services in low- and middle-income countries [8] in the face of the increasing burden as a result of rapid economic and social change [9]. What are the reasons for this service gap and how can the problem be resolved? This paper tries to tackle these issues and propose possible future directions. Burden of mental disorders The updated projections of global mortality and burden of disease, 2002–2030 based on country projections for 192 WHO Member States in 2006 support the groundbreaking work of Murray and Lopez a decade earlier and indicate that the burden caused by men- tal disorders continues to rise as predicted by them [3,4]. In a recent review it has been highlighted that, in addition to the 14% of the global burden of disease attributed to neurological/psychiatric disorders, the indirect burden of mental health problems should be sought beyond the realm of men- tal disorders and encompass a wide range of communicable and noncommunicable diseases; in fact, the indirect burden may even negatively influence progress towards the achievement of the Millennium Devel- opment Goals [10]. Current status of mental health services in developing countries Despite the global advocacy for mental health early in the new millennium and a Eastern Mediterranean Health Journal, Vol. 14, Special Issue S115 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ call for action by the ministries of health following the publication of the 2001 World Health Report [11,12], improvements have been inconspicuous, and there remains a wide gap in the provision of services for mental health worldwide. The shortcomings in mental health services, particularly in low-income countries, can be summarized as follows. • The treatment gap for serious mental disorders ranges from 76.3% to 85.4% in developing countries and resources are insufficient in this regard [13]. For example, about a third of people with schizophrenia do not receive any treat- ment in their life. • Scarcity of resources is evident in differ- ent areas: about a third of the countries do not have a mental health policy. Al- though the majority of countries have legislation on mental health, this has not been updated for 15 years in half of them. • People with mental disabilities do not even benefit from disability benefits in 45% of low-income countries. • Only about half of the low-income coun- tries have community mental health services. About a quarter of low-income countries do not even provide essential antidepressant medicines, for example. • Low-income countries have a median of 0.05 psychiatrists and 0.16 psychiatric nurses per 100 000 populations, while the same figures are about 200 times higher in developed countries. • In most developing countries there is no specified public budget or there is only a small budget for mental health insur- ance. • Not only is access to mental health serv- ices limited but service utilization is also quite low [6], Which is commonly due to lack of awareness about mental illness, attributing it to superstitious causes or due to stigma attached to mental illness which is further intensified by domi- nance of isolated hospital based inter- ventions instead of integrated services [14]. Main policy challenges and possible solutions Needs assessment Most countries tend to confine needs as- sessment to measurement of the burden of disease through large-scale epidemio- logical surveys. In situations where the mental health service gap is estimated to be about 90% – simply due to unavailability of trained manpower and resources – measur- ing burden in such a way is not a prudent policy. Mental disorders are universal and very common. No country can postpone service development until the finalization of national level epidemiological surveys. It should be noted also that such surveys are very costly and the quality of mental health research is low in most developing countries; errors of measurement may sometimes exceed the confidence interval of measurements in the sample. Thus, in such situations emphasis on exact figures may create false precision. Most of the time, a simple and less costly qualitative study will provide the health sys- tem with information on the main priority areas. It would be more feasible to conduct a sound mapping of the mental health system that is directly needed before beginning any planning activity. The WHO assess- ment instrument for mental health systems (WHO–AIMS) is a useful tool developed for such a purpose and currently reports from 37 countries are published on the WHO website [15,16]. The important issue is that “the need for more research should S116 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ not be used as an excuse to delay scaling-up of mental health systems” [17]. Service development WHO conducted a qualitative survey at the global level to identify barriers to improve- ment of mental health services in low- and middle-income countries through a quali- tative survey [8]. The barriers identified were: • insufficient funding for mental health services • mental health resources centralized in and near big cities and in large institu- tions • complexities of integrating mental health care effectively in primary care services • low numbers and limited types of health workers trained and supervised in men- tal health care • mental health leaders often lacking in public health skills and experience. The Mental Health Gap Action Pro- gramme (mhGAP) is an action plan de- veloped by WHO to scale up services for mental disorders for low and lower-middle income countries [18]. MhGAP is meant to build partnerships for collective action and to reinforce the commitment of govern- ments, international organizations and other stakeholders to scaling up mental health services. It will be formally launched in WHO in Geneva in October 2008. Inadequacy of prevention and promotion programmes Traditionally, most public health leaders in countries have been specialists in com- municable diseases. With the emergence of noncommunicable diseases as a new prior- ity in many countries, including some of the developing countries, public health leaders have come to understand the importance of prevention and promotion in noncom- municable diseases. But still mental health is not well positioned within this context. For example, for noncommunicable dis- eases the modern approach is to focus on reducing the burden of risk factors (primary prevention); thus the risks have been iden- tified and strategies to avert their burden, such as WHO-STEPS [19], have been de- veloped and launched on an increasing scale in recent years. The WHO-STEPS approach focuses on obtaining core data on the estab- lished risk factors that determine the major disease burden [19]. So, should developing mental health risk aversion strategies follow the methodology of other noncommunicable diseases? One of the best measures to reduce stigmatiza- tion of mental disorders has been integrat- ing mental health programmes within the mainstream of general health, especially noncommunicable diseases. However, the similarities between mental disorders and other noncommunicable diseases in terms of multiple causes, chronic course and prog- nosis, burden and appropriate treatment interventions should not lead to ignoring the differences. There are good reasons why mental health cannot be technically dealt with ex- actly as other noncommunicable diseases. For example, the association between risk factors and mental health problems is more sophisticated compared with other noncom- municable conditions [20]. While evidence on risk factors for and prevention of mental disorders is being generated, we are at an earlier stage of identifying risk factors and we are still in need of more data on effective primary prevention [20,21]. Furthermore, most risk factors identified for common mental disorders are macro issues, which are not easily modifiable or lie outside the health sector [21,22]. In addition, the de- mand for management of mental disorders is stronger and effective interventions are Eastern Mediterranean Health Journal, Vol. 14, Special Issue S117 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ more available than strategies for preven- tion and promotion. Now the main question that arises therefore is whether prevention should be confined mainly to primary prevention and controlling the risk factors as opposed to early detection and management. There remain a few conceptual issues that need to be answered first. When feasible, primary prevention seems to be preferable because it prevents incidence and is more effective than the earliest case detections. But there are limitations as well. First, there is no universal definition for risk factor. Although most authors use the term to imply a factor that is associated with the development of a disease, Brotman defines it as “a variable with a statistical association with clinical outcome” [23]. Second, many well known risk factors such as diabetes and hypertension are in fact intermediate risk factors for other non-communicable diseases such as ischaemic heart disease or stroke. Obesity may be perceived as a risk factor of both, but it is clear that early detec- tion and treatment of these 2 conditions, which are risk factors for ischaemic heart disease, will be a primary prevention for the latter. Secondary prevention of depression may similarly be viewed as primary preven- tion of suicide. Risk factors, therefore, are not realities per se, rather they are relative concepts. Even the statistical validity of risk factors has been questioned by some scholars [23]. Thus, effective secondary prevention will make early detection and active follow-up possible and will reduce the burden of mental disorders as primary prevention may do. The Centers for Disease Control and Prevention in the United States considers lack of mammography screening and lack of sigmoidoscopy or colonoscopy followed by cigarette smoking as risk factors of can- cer [24]. In the same vein, why shouldn’t we coin “lack of screening for mental dis- orders” as a risk factor for the burden of mental disorders. It would be reasonable to conclude that, hand in hand with searching for robust associations between modifiable risk factors and mental health outcomes, we should expand the mental health prevention paradigm to consider early detection and treatment of mental disorders as a legitimate approach to avert the mental health-related burden. Integration of mental health into primary health care There is growing evidence in favour of integration of mental health into primary health care, and there is a tendency to accept that it is more cost-effective compared with hospital-based services [17,25]. Like all other branches of medicine, it is difficult for non-professionals to diagnose and treat all conditions. But is has been shown that well trained general practitioners are capable of diagnosing and treating most common men- tal disorders. There is some evidence from developing countries that mental health can be scaled up at the national level through in- volvement of multipurpose health workers with limited education as the first point of contact with the primary health care system [26,27]. However, still more evidence needs to be generated and systematically reviewed on how integration can be implemented in the most cost-effective way. In the absence of strong health systems, integration is out of the question. Revitalizing the primary health care initiative provides a positive prospect for the future. Until strong primary care systems are in place, community-based interventions should be considered as pos- sible alternatives. S118 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Prevention and management of substance abuse Overall, there is more intense commitment toward containing substance use problems worldwide compared with other areas of mental health. The impact of injecting drug use on the transmission of human immu- nodeficiency virus (HIV) has added to the importance of substance abuse. In addition, the fact that substance abuse was identified as a risk factor for health by WHO also contributed to its prominence [28]. This concern, positive as it is, has however had some unwanted negative consequences in some countries and has resulted in the ne- glect of the rest of mental health. In some countries they have even separated the units and they are sometimes functioning under different divisions. This raises a number of issues that need to be addressed. First, there is a need to ameliorate the general attitude towards substance use and to consider it a public health problem and not only a legal is- sue. Substance abusers need to be dealt with as patients and not criminals; in fact recent evidence indicates that restrictive measures are not consistently associated with better drug control [29]. In many coun- tries developing or amending policies and legislation would be a prerequisite in this regard. Second, evidence-based approaches in promotion and prevention need to be en- couraged. Third, there is a need to advocate for and scale up harm reduction services. Since 2006, methadone and buprenorphine have been included in the WHO essential list of medicines following the 14th WHO Expert Committee on the Selection and Use of Essential Medicines. But still in many countries these medicines are not avail- able in the treatment and harm reduction services, where injecting drug users are vulnerable to HIV infection and hepatitis and can spread the infection among others in the community. Amendments of policies and legislation are important measures to be taken in these countries. On 24 May 2008, the 61st session of the World Health Assembly adopted an important resolution on strategies to reduce the harmful use of alcohol [30]. The resolu- tion calls for the development of a draft global strategy to reduce the harmful use of alcohol by 2010. It is expected that imple- mentation of the strategy will have positive implications in terms of reducing the disease burden. An important issue would be how to adapt the strategy to different regional and country situations, especially in some countries of the Eastern Mediterranean Region where alcohol is already prohibited. Regional committee resolutions would be complementary guidelines in this respect. Brief interventions to manage substance abuse have provided the most cost-effective managements applicable at the primary health care level. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was developed for WHO by an international group of substance abuse researchers to detect and manage substance use and related problems in primary and general medical care settings. The package has been translated/adapted for different cultures/languages and currently the Arabic version is being prepared [31,32]. Protecting the dignity and rights of patients Little progress has been made in most coun- tries to include people with mental illness in the society and improve attitudes and reduce discrimination towards them, although dif- ferent strategies have been proposed [14]. However, still more evidence is needed to identify the most cost-effective interven- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S119 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ tions in this respect. WHO stresses that, “mental health legislation is necessary for protecting the rights of persons with mental disorders in institutional settings and in the community” [33]. But it is not claimed that the development and formal adoption of a piece of legislation would be sufficient to promote the rights of people with mental illness in all situations. WHO has identi- fied the different obstacles to implementing legislation and how to work out factors that can facilitate implementation [33]. Legisla- tion and policy development may be consid- ered a top down approach, which seems to work best in the presence of strong public infrastructures and an organized, advanced and aware civil society. In failed states as a consequence of chronic conflict or crises and in some socioeconomically less de- veloped conditions, a bottom up approach toward improving the quality of services and promoting the dignity and rights of patients seems to be more promising. The chain-free initiative initiated by the WHO Regional Office for the Eastern Mediter- ranean (EMRO), which was commenced as pilot projects in Somalia and Afghanistan in 2006, is a bottom up approach which starts from concrete measures in the hospitals (removing chains from mental health pa- tients and improving hospital care), extends through homes and ends up with community level advocacy dealing with the “invisible” chains affecting the human rights of patients in general [34]. Emergency mental health Development of the Interagency Standing Committee Guidelines (IASC) has been a turning point in the history of mental health and psychosocial support in emergencies [35]. There is now universal agreement that there should be coordinated activities to provide a safe and secure environment for survivors of emergencies and to apply psychological first aid instead of single- session debriefing. The issue of pre-existing mental disorders and services needs par- ticular attention. Great emphasis is put on demarcating between distress and disorder in the new approach. A desirable skill mix of non-professional and interdisciplinary professional contribution is recommended as well [35]. What seems to be in need of further elaboration is i) how to apply non- pharmaceutical interventions for people suffering from disorders and severe distress and ii) how to address the issue of service coverage and how it can be optimized in large scale disasters. Advocacy, fund-raising and strengthening mental health services Mental health is a health area that has long been discriminated against and it needs to be supported by affirmative action. There is a considerable amount of advocacy work going on in the countries. The problem is that it is mostly ad hoc and on the occasions of mental health days or weeks. There is no evidence about the impact of such advo- cacy. Advocacy and anti-stigma activities at the country level need to be planned within a results-based framework with clear out- come measures. Mental health units are not powerful enough within many ministries of health and non-existent in others. They need to be established, strengthened and provided with budgets. In countries where mental health and substance abuse units lie in separate units there is a lot of duplication of work and consequent waste of time and energy. Unification of mental health and substance abuse units under one umbrella would save on human resources and costs. S120 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Fund-raising is equally important and all mental health policies should, accordingly, have a fund-raising component. WHO/ AIMS has included an item for budget for mental health, the problem is that there has been no uniform approach to calculating a mental health budget. Most countries spend less than 3% of their health budget on men- tal health [6]. In 2007, EMRO supported by WHO/Headquarters initiated a new ap- proach: the mental health sub-accounts within the national health accounts exercise [36]. The framework for methodology, clas- sification and glossary was prepared and it is expected that the new approach will allow more precise estimations of mental health expenditures. A prudent approach would be to include a mental health sub-account exercise in all countries where a national health account initiative is in process. In brief, mental health services need to be integrated in the mainstream of the health systems. At the same time, while such services need to operate horizontally across many health areas, vertical affirma- tive action is also vital to prevent mental health from being sidelined and to give it its due prominence. Possible solutions Although not meant to be comprehensive, the following are some possible solutions to current policy-related problems in regard to mental health. • Development of cheaper, user friendly methodologies and instruments to assess mental health needs. • Scaling up of mental health services through fund-raising, and equitable dis- tribution of such services. • Identification of risk factors for mental disorders through well planned research and systematic reviews so that primary prevention strategies can be built on the evidence generated. Unavailability of early detection and management could be considered a risk factor for disease burden as well. Relevant research in the second area is equally required. • Development of policies and legislation (top down approaches) to improve qual- ity of services and the dignity and rights of patients’ needs to be complemented with bottom up approaches such as the chain-free initiative. • Support of harm reduction strategies globally, hand-in-hand with evidence- based prevention and promotion inter- ventions to deal with substance abuse problems. Developing/amending leg- islation may be important to facilitate harm reduction. Brief interventions in primary health care are effective means to manage the problem of high numbers of substance and alcohol users in the community. • Adherence to IASC guidelines comple- mented further on how to provide full coverage to survivors and how to apply psychological interventions at different levels of need. • Planning of advocacy activities, anti- stigma campaigns and fund-raising within results-based formats. • Strengthening and support of mental health directorates/units in ministries of health with appropriate budgets. • Unification of substance abuse and men- tal health units under one umbrella. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S121 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 11. World health report 2001. Mental health: new understanding, new hope. Geneva, World Health Organization, 2001. 12. Mental health: a call for action by world health ministers. Geneva, World Health Organization, 2001. 13. World Mental Health Consortium. Preva- lence, severity and unmet need for treat- ment of mental disorders in the World Health Organization World Mental Health Surveys. Journal of the American Medical Association, 2004, 291:2581–90. 14. Thornicroft G. Shunned: discrimination against people with mental illness. New York, Oxford University Press Inc., 2006. 15. WHO-AIMS – General information [WHO mental health website] (http://www.who. int/mental_health/evidence/WHO-AIMS/ en/index.html, accessed 14 June 2008). 16. WHO-AIMS Country Reports [WHO mental health website] (http://www.who. int/mental_health/who_aims_country_re- ports/en/index.html accessed 14 June 2008). 17. Patel V et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet, 2007, 370(9591):991–1005. 18. Mental health Gap Action Programme (mhGAP) [WHO mental health website] (http://www.who.int/mental_health/mh- GAP/en/index.html, accessed 21 July 2008). 19. STEPwise approach to surveillance (STEPS) [Chronic diseases and health promotion website] (http://www.who.int/ chp/steps/en/, accessed 4 August 2008). 20. Prevention of mental disorders. Effective interventions and policy options. Sum- mary report. Geneva, World Health Or- ganization, 2004. References 1. Basic documents, 46th ed. Geneva, World Health Organization, 2007. 2. Primary health care: report of the Inter- national Conference on Primary Health Care, Alma-Ata, USSR, 6–12 Septem- ber 1977, jointly sponsored by the World Health Organization and the United Na- tions Children’s Fund. Geneva, World Health Organization, 1978. 3. Murray CJL, Lopez AD, eds. Global Bur- den of Disease. A comprehensive as- sessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, Har- vard University Press, 1996 (Global bur- den of disease and injury series, Volume 1). 4. Mathers CD, Loncar D. Projections of glo- bal mortality and burden of disease from 2002 to 2030. PLoS medicine, 2006, 3: e442. 5. Jacob KS et al. Mental health systems in countries: where are we now? Lancet, 2007, 370(9592):1061–77. 6. Saxena S et al. Resources for mental health: scarcity, inequity, and inefficiency. Lancet, 2007, 370(9590):878–89. 7. Patel V, Saraceno B, Kleinman A. Beyond evidence: the moral case for international mental health. American journal of psy- chiatry, 2006, 163:1312–5. 8. Saraceno B et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet, 2007, 370(9593):1164–74. 9. Phillips MR, Liu H, Zhang Y. Suicide and social change in China. Culture, medicine and psychiatry, 1999, 23:25–50. 10. Prince M et al. No health without mental health. Lancet, 2007, 370 (9590):859– 77. S122 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 21. Eaton W et al. Risk factors for major men- tal disorders: A review of the recent epide- miologic literature. Baltimore, Department of Mental Hygiene, Bloomberg School of Public Health, Johns Hopkins University (http://apps1.jhsph.edu/weaton/MDRF/ main_files/page0001.html, accessed 4 August 2008). 22. Patel V. Is depression a disease of poverty? Regional health forum, 2001, 5(1):14–23 (http://www.searo.who.int/ LinkFiles/Regional_Health_Forum__Vol- ume_5_No._1_rhf-Vol-5_No-1.pdf, ac- cessed 4 August 2008). 23. Brotman DJ et al. In search of fewer inde- pendent risk factors. Archives of internal medicine, 2005, 165:138–45. 24. Risk factors and use of preventive serv- ices, United States, 2004. In: The burden of chronic diseases and their risk factors: National and State perspectives 2004. Atlanta, US Department of Health and Human Services, 2004 (http://www.cdc. gov/nccdphp/burdenbook2004, accessed 4 August 2008). 25. Araya R et al. Cost–effectiveness of a pri- mary care treatment program for depres- sion in low-income women in Santiago, Chile. American journal of psychiatry, 2006, 163(8):1379–87. 26. Yasamy MT et al. Mental health in the Is- lamic Republic of Iran: achievements and areas of need. Eastern Mediterranean health journal, 2001, 7(3):381–91. 27. Yasamy MT, Hadjebi AA, Mohit A. Islamic Republic of Iran, nationwide integration of mental health into primary health care. In: WHO/WONCA. Integrating mental health into primary care: a global perspective. World Health Organization, Geneva, 2008 [in press]. 28. The world health report 2002. Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002. 29. Degenhardt L et al. Toward a global view of alcohol, tobacco, cannabis, and co- caine use: Findings from the WHO world mental health surveys. PLoS medicine, 2008, 5(7):e141. 30. WHO to develop a global strategy on al- cohol [Management of substance abuse website] (http://www.who.int/substance_ abuse/activities/globalstrategy/en/index. html, accessed 21 July 2008). 31. WHO ASSIST Working Group. Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction, 2002, 97(9):1183–94 (http://www.who.int/sub- stance_abuse/activities/assist/en/ ac- cessed 21 July 2008). 32. The ASSIST project - Alcohol, Smoking and Substance Involvement Screening Test. Geneva, World Health Organization, 2008 (http://www.who.int/substance_ abuse/activities/assist/en/, accessed 19 August 2008). 33. WHO resource book on mental health, hu- man rights and legislation. Geneva, World Health Organization, 2005. 34. Chain-free initiative [WHO/EMRO Mental Health and Substance Abuse website] (http://www.emro.who.int/mnh/cfi.htm, accessed 19 July 2008). 35. IASC guidelines on mental health and psychosocial support in emergency set- tings. Geneva, Inter-Agency Standing Committee, 2007 (http://www.humani- tarianinfo.org/iasc/content/products/docs/ Guidelines%20IASC%20Mental%20Hea lth%20Psychosocial%20%28with%20ind ex%29.pdf, accessed 4 August 2008). 36. Summary report on the Consultation on developing a framework of methodology for mental health subaccounts. Cairo, Egypt, 5–7 September 2007. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2008 (WHO_ EM/MNH/179/E) (http://www.emro.who. int/mnh/pdf/subaccounts_07_report.pdf, accessed 4 August 2008). Eastern Mediterranean Health Journal, Vol. 14, Special Issue S123 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Tobacco control in the Eastern Mediterranean Region: overview and way forward Fatimah El Awa1 1Regional Adviser, Tobacco Free Initiative, Division of Health Promotion and Protection, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Fatimah El Awa: elawaf@emro.who.int). Introduction This article is an attempt to highlight the main achievements and the future of to- bacco control in the Eastern Mediterranean Region (EMR) Member States. Tobacco control in the EMR has gone through many important developments dur- ing the last 2 decades. In the beginning tobacco control was an individual initiative held/adopted by few Member States. At that time, there were no collective Regional efforts towards controlling tobacco. More organized efforts marked the 90s in the last century: organizations such as the World Health Organization (WHO) and the League of Arab States adopted regional measures for tobacco control. Celebrations marking World No Tobacco Day were among the main characteristics of tobacco control ef- forts/publicity. However, these celebrations were often criticized for being a 1-day event that lacked continuity and sustainability. A real turn about in the shape of tobacco control came with the development of the Framework Convention on Tobacco Con- trol (FCTC), the first international treaty to protect public health. The idea of having an international treaty was the dream of Dr Ruth Roemer, an academic who had been working in tobacco legislation for decades. The then Director-General of WHO, Dr Gro Harlem Brundtland, adopted the idea and turned it into reality [1]. A totally new era for tobacco control came when the World Health Assembly (WHA), through resolu- tions WHA 49.17 and 52.18, established the working groups for the FCTC in 1999. Moreover; the Director-General turned to- bacco control from being one of the WHO units into a cabinet project. Serious efforts in the organization were dedicated to re- shaping tobacco control in-house. In 1999 the Director-General inaugurated the first working group of the FCTC, which was concluded after 2 working groups and 6 sessions of negotiations; in 2003 the WHA adopted the FCTC by consensus. The growing momentum created by the FCTC negotiations resulted in the involve- ment of key national level government and nongovernmental sectors from the EMR Member States. The Region witnessed ef- forts for developing Regional legislation, with heavy involvement of 3 Regional or- ganizations; the Arab League, the Gulf Cooperation Council (GCC) and WHO Re- gional Office for the Eastern Mediterranean Region (EMRO). During the same period national efforts focused on strengthening the infrastructure for tobacco control as never before. S124 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ The main characteristics of the FCTC negotiation period at the Regional level were: • establishment of a Regional and national surveillance system for tobacco control to obtain evidence-based data on preva- lence; documenting beliefs related to tobacco use and characteristics of popu- lations at both national and Regional levels; • well established Regional coordination between WHO, League of Arab States and GCC; • national and Regional legislation was subject to review and development in a way that reflected the principles and experiences shared during the FCTC negotiations; • confronting the tobacco industry by gov- ernmental and Regional organizations. Immediately after the WHA resolution of May 1999 on the FCTC, the Eastern Mediterranean Member States Regional Committee adopted, at a Regional level, the first generic plan of action for tobacco control. They also called upon the Tobacco Free Initiative (TFI) to submit an annual progress report on the developments [2]. Following on that, in collaboration with the Centers for Disease Control in Atlanta, tobacco surveillance became an important component for completing a comprehensive profile for tobacco control. The Global Tobacco Surveillance System started in the Region with Jordan implementing the Global Youth Tobacco Survey in 1999 in its pilot phase. Nowadays, the Global Tobacco Surveillance System has 3 more components that are being implemented all over the Region. WHO/EMRO, the GCC and the League of Arab States joined forces at Regional level to strengthen tobacco control. In 2001, WHO/EMRO released a report on the to- bacco industry activities in the Region enti- tled Voice of truth [3]. In the 2 subsequent meetings of the Ministers of Health of the GCC, 2 resolutions were adopted which called upon Member States to monitor and stop any collaboration with The Middle East Tobacco Association. Again, imme- diately after the Consultation on litigation and public enquiries as public health tools, held in Jordan in February 2001, a resolu- tion was adopted at the next meeting of the GCC, held in Saudi Arabia in January 2002 (No. 09/52) calling upon Member States of the GCC to explore litigation possibilities. From 2002 onwards, the Arab League Ministers of Health council meetings had tobacco control on its agenda. It called upon its Member States to adopt unified legislation, that developed by the technical committee of the League of Arab States on tobacco control. Although the legislation developed was not as affirmative as recom- mended by WHO policies, especially with regard to 100% tobacco free public places and to the health warning size, it contributed to cultivating the appetite for more work on the legislative front of tobacco control at national level. The FCTC process was very powerful in that it paved the way for legislative changes that were reflections of the intensively di- verse discussions which took place in the negotiation meeting rooms. Some of these legislative attempts were far from being perfect or ideal when it came to the impact on tobacco control. For example, in Qatar the law on tobacco control, adopted in 2002, indicated that the health warning should be 25% of the trademark size, while it was meant at the early drafting stages to be 25% of the pack size. Nonetheless, some major successes were achieved, such as the total ban on advertising, promotion and sponsor- ship in both Egypt and Qatar. During that period it was realized that, after the numerous FCTC negotiation rounds, more attention should be given Eastern Mediterranean Health Journal, Vol. 14, Special Issue S125 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ to disclosing the activities of the tobacco industry and their plans for tobacco trade in the Region, across all 22 countries [4]. Four events marked this era: first, hold- ing the Consultation on litigation and public enquiries as public health tools, in Jordan, February 2001 [5]; second, the release of the WHO inquiry Voice of truth [6]; third, the release in 2002 of the first version of the practical manual The tobacco industry papers, what they are, what they tell us, and how to search them [7]; and finally, a paper on the tobacco industry involvement in illicit tobacco trade in the Region was released [8]. These events, together with the publicity that accompanied the release of the documents and the involvement of high officials in tobacco control activities, led to massive increase in awareness among decision-makers on the tobacco industry’s marketing tactics. Moreover, it revealed the truth about the involvement of many high-ranking politicians with the tobacco industry, a heavy association that brought embarrassment to all those involved [9]. These discoveries resulted in a clear separa- tion between the motives of the tobacco industry and tobacco control policies, at least on the surface. As a result, it is very clear now that any moves to undermine tobacco control efforts and measures might be a direct result of tobacco industry influ- ence: this clear revelation resulted in a certain amount of hesitation on the part of those involved. Why is tobacco control a priority in the Region? Tobacco control is still a priority in this Region despite all the efforts so far exerted. This is a fact easily realized by looking at the prevalence of tobacco use among youth, adults and women, the price of tobacco, the rather weak/non-enforced policies of tobacco control, and the up-coming trends in tobacco use. The initial momentum for tobacco con- trol is already established. Now, all the Re- gional organizations working in the field of public health have tobacco control on their list of priorities. Surprisingly, however, the trend for tobacco use is not decreasing: on the contrary, it is increasing. The Global Youth Tobacco Survey reveals startling facts about the situation in the Region, espe- cially with regard to prevalence of tobacco use and use of other forms of tobacco such as shisha (waterpipe) and more alarmingly with regard to the potential to initiate to- bacco use within a year. The reported rate for students who currently smoke is 4.9% for cigarettes and 12.0% for other tobacco products (especially shisha), while 17.0% of students who ever smoked were suscepti- ble to initiate smoking in the year following the survey [10]. In addition, the burden of diseases asso- ciated with tobacco use is increasing in the Region. In Pakistan, the age standard- ized mortality rate from noncommunicable diseases among adults is 743 per 100 000 population [11]. In Egypt, the age standard- ized mortality rate from smoking-related causes (cancer, respiratory and circulatory diseases) among males 35+ years in 2000 was 5665.4 per 100 000 population [12]. Prevalence of tobacco use among adults is very high. The global tobacco control report, released in 2008, indicates that the current male-consumption in the Region is ranging from 24.8% to 61.7% while current female consumption ranges from 1.0% to 7.9% [10]. WHO confirms that less than 5% of the world population is covered by the policies essential to curb the tobacco epidemic. Sadly, none of EMR Member States has applied the recommended best practices S126 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ strategies in full compliance with the sug- gested approaches of WHO [10]. Currently, there is serious concern about the sustainability of tobacco control activi- ties in the Region. These activities depend largely on financial donations, a reliance which throws a shadow on the government resources allocated for tobacco control. An analysis of government expenditure data from the Region indicates that there is a serious need to divert resources to ensure continued sustainability of the policies and to achieve ultimate success in tobacco con- trol. Nowadays, the Region suffers from a new epidemic which did not exist a few years ago, namely women smoking and high numbers among youth taking up to- bacco in all its different forms. Although the WHO report on women and the tobacco epidemic highlights this new trend, unfortunately, as yet serious efforts are lacking to protect this vulnerable group from being aggressively targeted by the tobacco industry [13]. For example, shisha use is spreading rapidly among young women and the Re- gion needs to combat it. Immediate social, economic and legislative measures need to be implemented to control its spread that were also strongly recommended by WHO in its advisory note on shisha released 2006 [14]. The Framework Convention on Tobacco Control in the Region National tobacco control legislation is one of the main tools for bridging the gap between the known facts on consequences of tobacco use and peoples’ behaviour [15]. There will be no change in the tobacco epidemic on a national level without strong legislation based on evidence and without applying the most advanced successful strategies for tobacco control. Regardless of a country’s position with regard to the FCTC, national legislation should strengthen public health, and either pave the way for successful adop- tion of the FCTC, or fulfil national com- mitments and obligations to implement the FCTC. The FCTC should not be seen as an objective in itself, but rather as a tool to achieve the overall national objective. The completion and entry into force of the FCTC is an achievement that no one can undermine in tobacco control: the momentum that was created by the FCTC negotiations and finally its adoption by the WHA in 2003 paved the way for many changes at national level. It augmented the level of political commitment and political awareness for the importance/vitality of tobacco control. Of the 22 countries in the EMR, 17 have become party to the FCTC. During the negotiations of the FCTC; Member States in the Region realized an im- portant fact owing to their interaction with other nations: that tobacco has become a political priority. It is now considered a glo- bal and Regional problem and not merely a national concern. This realization enhanced Regional and sub-regional exchange of information and cooperation, which is now obvious in the meetings of the GCC and the Arab League. This led to Regional unity in negotiating policy changes required at the national level, e.g. the pricing policy of the GCC, although this is not implemented by all Gulf states [16]. The current position proves that there is no fear that the treaty will remain less effec- tive in national tobacco control efforts [17]. Twelve out of the 17 parties to the FCTC in the Region negotiated and were engaged in the process of implementing pictorial health warnings, already agreed to be implemented in 4 out of the 12 countries: Djibouti, Egypt, Islamic Republic of Iran and Jordan. The Eastern Mediterranean Health Journal, Vol. 14, Special Issue S127 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ remaining 8 are in the final phase of official adoption of the warnings. A similar move- ment is on-going in regard to a total ban on tobacco advertising. At least 10 countries of the Region have already prohibited sales to minors in their national legislation. It seems that the FCTC is seen to be gradually reach- ing its full potential. However, what is alarming and worrying is that the countries are taking a piecemeal approach to the implementation of the treaty rather than following a comprehensive ap- proach in addressing all the legislative needs. This approach delays implementation and increases the difficulty of measuring the ef- fect of FCTC implementation on all aspects of tobacco control. What should also be realized is that internationally evidence- based best practices are being adopted. A clear example of this is the progress on tobacco health warnings. With increasing unfolding evidence, once a strategy for tobacco control is adopted at national level, by the time the next one is due the first one would have already been subject to change at international level. Therefore the devel- opment of tobacco control policies should be regarded as a dynamic process. The need for such dynamism exhausts national efforts and divides energy in many battles, rather than unifying them to win all at once. Some voices sympathetic to industry circles claim that a step by step approach would chal- lenge less. However, it should be realized that in a Region as diverse as ours, once the politically right moment is reached, it should be exploited to its full potential. The possibilities that were raised by the FCTC negotiations are still alive, and this is not a continued opportunity. It is rather variable due to changes in the many other relevant factors, time to say the least. The time has come for a comprehensive change of policy and legislation at national level. The efforts of Regional organiza- tions should support this approach and push towards its fulfilment. Taking into con- sideration that many of the FCTC articles are time bounded, they also emphasize the importance of comprehensiveness rather than division of commitments. The way forward for tobacco control in the Region Although the evidence that legitimizes poli- cies adopted by the FCTC and the Global tobacco control report-recommended poli- cies (MPOWER) are well established at in- ternational level, a similar situation does not exist in the Region. There is a serious lack of economic data, reliable adult prevalence data, and tobacco trade data. Comprehen- sive information is much needed for the multifaceted profile of tobacco, at national level, to develop the solid ground for policy change and development of legislation. A multi-sector approach to tobacco control is not achievable without the completion of such a profile [18]. The completion of a multifaceted to- bacco profile does not mean following the EMR Regional profile of 2002 or the global tobacco control report model of collecting available data [10,19], rather it establishes the information by conducting first hand, original studies according to national pri- orities and needs. Lack of resources is often the excuse for not conducting the required studies and research. Even worse, when resources are available, the preference is to allocate them for activities that result in im- mediate outcomes, such as national training activities, visits of consultants and media campaigns instead of on-site data collec- tion. Lack of adequate resources prevents the completion of such data. Thus, it is important that international organizations and donors realize that providing adequate S128 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ resources for research is the backbone for establishing stronger national policies. One of the approaches to solving this problem of lack of resources is to adopt an earmarking policy, even with no defined percentage, as in the model implemented by the Gulf States (apart from Yemen), though different from the World Bank definition of earmarking. The GCC adopted a decision to dedicate part of the taxation funds for tobacco control. The implementation of this decision was delegated to each coun- try according to its own system. Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates implemented it with no defined percentage. The allocated percentage changes every year according to the agreement between the Ministry of Health and the Ministry of Finance, but the end result is that funds for tobacco control do exist at the level of the Ministry of Heath and this is a major step forward. Despite the promising developments that the Region has been witnessing since the start of FCTC negotiations, a more planned approach has still to be adopted if rapid and sustained reduction in tobacco consumption is to be achieved. Countries of the Region cannot continue rushing from one suggested international policy to another. In order to achieve the expected outcomes, for each of the internationally recommended policies of the FCTC, the following parameters must be in place: • clear and achievable objectives of the plan of action • linkage with a timetable • combination with a monitoring system • a built-in upgrading mechanism. As an example, increasing tobacco con- trol prices could be an objective: the dead- line for achieving it is 6 months and market prices can be monitored through inspectors to ensure control of smuggled tobacco. In addition, a built-in upgrade mechanism would be to increase taxes every 5 years or to link the increase to the inflation rate. Creating opportunity for development is vital in the Region. For example, legislation identifying tobacco-free public places can- not leave out restaurants, cafés and bars. It must take into consideration international developments and the difference in the health impact. Nonetheless, the legislation can adopt a gradual mechanism for enforce- ment. For example, within 5 years all public places shall be tobacco free. The same applies for designated smoking areas; if the modified legislation cannot achieve 100% tobacco free public places, an alternative would be to introduce into the legislation a mechanism to achieve the intended objec- tive gradually, say within 3 years. The existence of legislation on tobacco control is one thing; however, compliance and enforcement is another. The strongest legislation will have zero health effect if there is no compliance and enforcement. This is a real problem in many countries of our Region. The trend of developing legislation and leaving out its enforcement strategy is a widespread phenomenon in many countries [20]. To delegate the implementation of to- bacco control legislation to the interested party is one way of avoiding weak enforce- ment and compliance, i.e. to the Ministry of Health. This was done in Egypt, although its impact is not yet known. At least, the claim that the Ministry of the Interior has other priorities and gives little attention to health- related legislation is now avoided. Besides, there are other ways to ensure compliance and good enforcement, as indicated in the WHO publication on enforcement and com- pliance [21]. The influence of the industry, the “un- derlying cause of the tobacco epidemic”, held back tobacco control efforts for years Eastern Mediterranean Health Journal, Vol. 14, Special Issue S129 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ in countries of the Region [21]. This was revealed through a serious of enquiries and reports released by EMRO. There is no indi- cation that the industry role was minimized or became less friendly towards tobacco control. Despite the diverse exploits of the industry to use the mechanism of “social cooperative responsibility” to be seen as the “vehicle for doing well” [22], countries still have to be mindful of the industry’s ultimate aim, which is not by any means to protect health. To avoid the dilemma that many of our Member States face—being responsible for tobacco control and at the same time being the owner of national tobacco industries—governments have to adopt policies that are in line with the FCTC as follows [23]: • total separation between the tobacco industry and tobacco control • declaration of tobacco advertising budg- ets and plans • explore possible litigation mechanisms in order to ensure full compliance with legislation • raise public awareness on tobacco con- trol in general; and in particular on the industry history and activities. The industry was, and still is, the root cause of all deaths related to tobacco use. This fact should be the foundation for all national policies aiming at controlling the tobacco industry’s influence and activities aimed at undermining tobacco control ef- forts at national level. Another tool to protect public health from tobacco industry interference that is still not used to its full potential in the Re- gion is public enquiries and litigation. The potential is worth studying at this stage, not only by governments but also by civil soci- ety groups, through using national legisla- tion related to liability, compensation, and violation of law. A comprehensive national tobacco control scheme requires action and clear vision in dealing with the tobacco in- dustry [24]. To achieve this, understanding the history of the industry and its influence at each national level becomes a necessity. Way forward and recommendations The future of tobacco control in the Region is promising. Efforts on all levels should be united in achieving a comprehensive vision on the national level, documented in a national plan of action or strategy that is time bounded and gradual. Any national plan of action should contain a strong re- search component to build nationally-based evidence for action. Relying on dependable international data is important; however to maintain policy-makers’ consciousness and support to tobacco control, national data will be more reliable and even more credible. Countries are advised to take a more comprehensive approach in implement- ing the FCTC rather than a step-by-step approach. In line with this, they need to analyse the current level of compliance and enforcement and to generate new strategies based on each individual national situation in order to strengthen both. Attention should still be given to industry activities in under- mining tobacco control efforts. Exploring the possibility of success by using more tools, such as litigation and pubic enquiries, in combating industry activities is vital. Securing funds for tobacco control through a sustainable and prolonged unin- terrupted system is essential. Earmarking has proven to be a successful method in many countries of the Region; such a sys- tem should be considered by the national authorities. S130 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Countries of the Region are now at a historically critical moment. There is strong momentum for tobacco control: the political situation is in favour of tobacco control; the international atmosphere is supportive of tobacco control; taking this chance at this right moment is vital. Undermining this potential will result in non-reimbursable losses for decades. And our loss of lives will continue due to this destructive epidemic. References 1. Taylor A. Ruth Roemer, 1916–2005. To- bacco control, 2005, 14(5):291 2. Plan of action for tobacco control in the Eastern Mediterranean Region. Cairo, World Health Organization Regional Of- fice for the Eastern Mediterranean, 1999. 3. Khoja’i TA. Resolution on tobacco control issued by the Health Ministers Council for GCC States. Gulf Cooperation Council, 2002. 4. Transparency in tobacco control. Geneva, World Health Authority, 2001 (Resolution WHA54.18). 5. [Justice in support of health]. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2002 (WHO- EM//E/G//, WHO-EM/TFI/007/A/9) [in Ara- bic]. 6. Voice of truth 2. Cairo, World Health Or- ganization Regional Office for the Eastern Mediterranean, 2001 (WHO-EM/TFI/002/ E/L/07.02/500). 7. The tobacco industry documents, what they are, what they tell us, and how to search them. Cairo, World Health Or- ganization Regional Office for the Eastern Mediterranean, 2002 (WHO-EM/TFI/005/ E/G). 8. The tobacco industry’s tactics and plans to undermine control efforts in Egypt and North Africa. Cairo, World Health Or- ganization Regional Office for the Eastern Mediterranean, 2003 (WHO-EM/TFI012/ E/G). 9. El Awa F. The tobacco industry’s influ- ence in the East Mediterranean Region (EMRO). Paper presented at the 10th International Anti-Corruption Conference, Prague, Czech Republic, 7–11 October 2001. In: Corruption in health services. Transparency International, 2001. 10. WHO Report on the global tobacco epi- demic, 2008: the MPOWER package. Ge- neva, World Health Organization, 2008. 11. World health statistics 2008. Geneva, World Health Organization, 2008. 12. Shafey O, Dolwick S, Guindon GE, eds. Tobacco control country profiles 2003. Atlanta, American Cancer Society, 2003. 13. Regional tobacco profile. Cairo, WHO Regional Office for the Eastern Medi- terranean, 2003 (WHO/EM/TFI/008/E/ G/07.03/3000). 14. Tobacco use in shisha: studies on wa- terpipe smoking in Egypt. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2006. 15. Roemer R, Daynard RA. Legislative ac- tion to combat the world tobacco epi- demic, 2nd ed. Geneva, World Health Organization, 1993. 16. Khoja TA. Resolutions on tobacco control issued by the Health Ministers’ Council for GCC States. Resolution 3/40, January 1996. 17. Hammond R, Assunta M. The Framework Convention on Tobacco Control: promis- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S131 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ ing start, uncertain future. Tobacco con- trol, 2003, 12:241–2. 18. Wipfli H et al. Achieving the framework convention on tobacco control’s potential by investing in national capacity. Tobacco control, 2004, 13:434. 19. Women and the tobacco epidemic: chal- lenges of the 21st century. Geneva, World Health Organization, 2001 (http://www. who.int/tobacco/media/en/WomenMono- graph.pdf, accessed 28 August 2008). 20. A guide to domestic tobacco control leg- islation, enforcement and compliance. Geneva, World Health Organization (in press). 21. Yach D, Bettcher D. Globalization of to- bacco industry influence and new glo- bal responses. Tobacco control, 2000, 9:208. 22. Hirschhorn N. Corporate social respon- sibility and the tobacco industry: hope or hype? Tobacco control, 2004, 13:447– 53. 23. WHO framework convention on tobacco control. Geneva, World Health Organiza- tion, 2003 (Articles 5–13, 20,21). 24. Blanke D, Humphrey III HH. Putting truth into action: using the evidence for jus- tice. Tobacco control, 2006, 15(Suppl. 4): iv1–iv3. WHO Report on the Global Tobacco Epidemic, 2008 – The MPOWER package In the 20th century, the tobacco epidemic killed 100 million people worldwide. During the 21st century, it could kill one billion. The six policies of WHO’s MPOWER package can counter the tobacco epidemic and reduce its deadly toll. This landmark report presents the first comprehensive worldwide analysis of tobacco use and control efforts. It provides countries with a roadmap to reverse the devastating global tobacco epidemic and outlines the MPOWER package, a set of six key tobacco control measures that reflect and build on the WHO Framework Convention on Tobacco Control. S132 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Health and the environment with focus on the Eastern Mediterranean Region Houssain Abouzaid1 1WHO Representative, Lebanon; Former Coordinator, Healthy Environments Programmes, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Houssain Abouzaid: abouzaidh@leb.emro.who.int). Introduction Environmental effects on health are as- sociated with several factors: absent or inadequate environmental health services, such as water supply, sanitation, solid and hazardous waste management and shelter; environmental degradation, such as pollu- tion of air, water and soil, and food con- tamination; global environmental problems, such as reduction of biodiversity and degra- dation of ecosystems through deforestation, global warming, ozone layer depletion and contamination by persistent organic chemi- cals; and industrial accidents. The indirect health effects of environmental conditions and changes, such as the implications of a limited episode of food contamination on a country’s food exports, may be more sig- nificant than their direct health effects. A significant part of the population of the Eastern Mediterranean Region (EMR) suffers from an insecure or low level of income. In 2006 the average GDP per capita in the Region was estimated at only US$ 2030. Moreover, out of 530 million inhabit- ants, 226 million lived in countries with a GDP per capita less than US$ 1000 [1]. This has far-reaching effects on environmental degradation and impairment of health; poor people are not protected against disease and lack the resources and motivation to protect the environment. The Region is also expe- riencing rapid urbanization, which leads in many instances to haphazard develop- ment. Urban facilities and services are often unplanned and overwhelmed by popula- tion growth and overcrowding, resulting in various health hazards. The high regional population growth rate (2.1%) often out- paces the capacity to provide environmental health services, amplifying adverse effects of environmental pollution. Environmental factors linked to health Water access and quality Water demand in the Region is growing fast and water availability is decreasing to crisis levels. Nevertheless wastage of wa- ter is widespread, and the water resources available are threatened by salt intrusion and other kinds of pollution; indeed the whole issue of water shortage has not been addressed in depth. Mitigation measures are rarely defined in an integrated manner and water demand management is practised in only a few countries. The reuse of waste- water in agriculture, and for the develop- ment of green belts and recreational areas, is practised to varying degrees to alleviate water shortages. However, in many cases, Eastern Mediterranean Health Journal, Vol. 14, Special Issue S133 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ raw or inadequately treated sewage is used in an unregulated manner. Such practices can affect the health of agricultural workers and lead to contaminated foodstuffs, which expose consumers to health risks [2]. Polluted water can be a source of deadly disease: globally, 1.5 million people, most of them children, die each year of diarrhoeal disease linked to inadequate water supply and hygiene and 860 000 deaths per year are caused by malnutrition induced by unsafe water, inadequate sanitation and insufficient hygiene in children under 5 years [3], and in Bangladesh over 35 million people are at risk from drinking-water supplies with high levels of arsenic [4]. In the Region, 78 million people had no access to improved water sources in 2004 and 177 million had no access to sanitation facilities [5]. Figures 1 to 4, based on data Figure 1 Association between access to improved water source and infant mortality in the WHO Eastern Mediterranean Region Figure 2 Association between access to improved water source and under-5 child mortality in the WHO Eastern Mediterranean Region S134 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Figure 3 Association between access to improved sanitation and infant mortality in the WHO Eastern Mediterranean Region Figure 4 Association between access to improved sanitation and under-5 mortality in the WHO Eastern Mediterranean Region in Table 1, show the association between level of access to water supply and sanita- tion and child mortality. In addition, water supply is intermittent in many countries and may compromise the integrity of the water distribution network and the quality of the water distributed. Desalination is one strategy that has been used in the EMR to address water scarcity, mainly in the Gulf Cooperation Council countries where drinking-water is a blend of desalinated water and ground- water. The need to assess the technical problems associated with water quality at the different stages of the desalination proc- esses and the distribution and consumption of water with very low mineral content was addressed by the World Health Organiza- tion (WHO) Regional Office for the Eastern Mediterranean (EMRO), who, on behalf of Eastern Mediterranean Health Journal, Vol. 14, Special Issue S135 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Ta bl e 1 Po pu la tio n ac ce ss to w at er a nd s an ita tio n in c ou nt rie s of th e W H O E as te rn M ed ite rr an ea n Re gi on Co un try Po pu la tio na W at er s up pl y co v er ag e Sa ni ta tio n co v er ag e In fa nt Un de r 5 To ta l Ur ba n R ur al % A cc es s to im pr o v ed % A cc es s to im pr o v ed m o rt al ity m o rt al ity (× 10 00 ) % % w at er s ou rc e sa n ita tio n (p er (p er Ur ba n R ur al To ta l Ur ba n R ur al To ta l 10 00 10 00 liv e bi rt hs ) bi rt hs ) Af gh an ist an 28 5 74 24 76 63 31 39 49 29 34 12 9. 0 19 1. 0 Ba hr a in 71 6 90 10 10 0 N A 10 0b 10 0 NA 10 0b 7. 6 10 .1 D jib ou ti 77 9 84 16 76 59 73 88 50 82 10 2. 0 12 4. 0 Eg yp t 72 6 42 42 58 99 97 98 86 58 70 20 .5 26 .2 Ira n (IR ) 68 8 03 67 33 99 84 94 86 c 78 c 83 c 32 .1 36 .0 Ira q 28 0 57 67 33 97 50 81 95 48 79 10 7. 9 13 0. 0 Jo rd an 5 56 1 79 21 99 96 97 94 87 93 22 .0 d 27 .0 d Ku w a it 2 60 6 96 4 N A N A 10 0b N A N A 10 0b 8. 2 10 .0 Le ba no n 3 54 0 88 12 10 0 10 0 10 0 10 0 87 98 18 .6 19 .1 Li by a n A ra b Ja m a hi riy a 5 74 0 87 13 72 c 68 c 71 c 97 96 97 24 .6 31 .0 M or oc co 31 0 20 58 42 99 56 81 88 52 73 40 .0 47 .0 O m an 2 53 4 78 22 85 73 82 c 97 61 c 88 c 10 .3 11 .1 Pa ki st an 15 4 79 4 34 66 96 89 91 92 41 59 77 .0 94 .0 Pa le st in e 3 58 7 72 28 94 88 92 78 61 73 24 .2 28 .3 Qa ta r 77 7 92 8 10 0 10 0 10 0 10 0 10 0 10 0 8. 1 10 .7 Sa ud i A ra bi a 23 9 50 88 12 97 63 c 92 c 10 0 NA 99 b 18 .6 21 .7 So m al ia 7 96 4 35 65 32 27 29 48 14 26 12 0. 0 22 4. 0 Su da n 35 5 23 40 60 78 64 70 50 24 34 62 .0 91 .0 Sy ria n Ar a b R ep ub lic 18 5 82 50 50 98 87 93 99 81 90 18 .0 22 .0 S136 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Ta bl e 1 Po pu la tio n ac ce ss to w at er a nd s an ita tio n in c ou nt rie s of th e W H O E as te rn M ed ite rr an ea n Re gi on (co nc lud ed ) Co un try Po pu la tio na W at er s up pl y co v er ag e Sa ni ta tio n co v er ag e In fa nt Un de r 5 To ta l Ur ba n R ur al % A cc es s to im pr o v ed % A cc es s to im pr o v ed m o rt al ity m o rt al ity (× 10 00 ) % % w at er s ou rc e sa n ita tio n (p er (p er Ur ba n R ur al To ta l Ur ba n R ur al To ta l 10 00 10 00 liv e bi rt hs ) bi rt hs ) Tu n is ia 9 99 5 64 36 99 82 93 96 65 85 20 .3 30 .0 e U ni te d Ar a b Em ira te s 4 28 4 85 15 10 0 10 0 10 0 98 95 98 7. 7 9. 9 Ye m e n 20 3 29 26 74 71 65 67 86 28 43 75 .0 10 2. 0 a So ur ce : [5 ]; d at a fo r 20 04 . b S ou rc e: [1] ; a ll es tim at es fo r 20 04 u nl es s ot he rw is e no te d. c Y e a r 20 00 . d Y e a r 20 02 . e Ye a r 20 01 . N A = no t a va ila bl e. WHO as a whole, led the preparation of the WHO Guidance Document on desalination for safe water supply [6]. Assessments of the vulnerability of desalination facilities to accidental pollution and other emergencies are also needed. Safe water and adequate sanitation are ba- sic human rights and, together with hygiene education, are fundamental to protecting health, increasing the sense of well-be- ing, and improving, economic and social productivity. EMRO has a 3-year plan to gather scientific data which will allow it to undertake work to determine the minimum water requirement for health, a critical issue in a region where water scarcity is the rule and drought an inescapable fact. Air quality Anthropogenic sources of air pollution have existed at least since humans discovered fire; investigations of ice in Greenland show that 2500 years ago lead and copper concen- trations in the air exceeded natural levels due to extensive smelting of ores in the open air [7]. Air pollution has worsened rapidly with industrialization and the result- ant widespread use of fossil energy sources, increased manufacturing and “chemicaliza- tion” of daily life. Outdoor air quality is a matter of concern in many cities, particularly the megacities, but indoor air pollution is an even greater source of concern. Globally, indoor air pollution from solid fuel use is responsible for 1.6 million deaths due to pneumonia, chronic respiratory disease and lung cancer, with the overall disease burden exceed- ing the burden from outdoor air pollution fivefold [8]. High priority needs to be given to improving indoor air quality in both rural and urban areas. This should include strong action to prevent passive inhalation of tobacco smoke. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S137 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Solid waste disposal In many countries of the Region, particular- ly in the secondary cities, there are serious shortcomings in the collection, transporta- tion and disposal of solid waste. Uncol- lected solid wastes dumped near roads are common features in countries with large populations and high population densities. In some areas, housing may be situated in the midst of dumping sites. The indiscrimi- nate burning of solid waste is also a major problem in certain countries; for example, it contributes to the well publicised autumnal black smoke events over Cairo. Scavengers in the solid waste disposal sites are at high health risk. Disposal of health care wastes mixed with municipal solid waste has been reported in many areas. In recent years, however, health care waste management has started to receive the necessary atten- tion. Climate change The Fourth Assessment Report of the Inter- governmental Panel on Climate Change es- tablished that climate change is unequivocal and is caused by anthropogenic activities [9]. WHO has recognized the importance of climate change and its potential impact on health security for many years [10,11]. Indeed, climate change will adversely and profoundly affect the fundamental determi- nants of health – water, air and food – and is projected to decrease the availability of fresh water in the Region, with conse- quences for public health protection and food production. The public health consequences of climate change include extreme weather- related mortality, affecting the elderly, the chronically sick and the poor; an increase in water-borne and food-borne diseases, and in acute respiratory infections and allergies due to dust storms; an increase in the geo- graphic range and incidence of vector-borne diseases, such as malaria, leishmaniasis and schistosomiasis; and the emergence of dis- eases not seen much before in the Region, such as dengue fever. Forced migration and malnutrition are also likely to result, with health consequences of their own. The public health action that is required includes preventative action aimed at mod- erating the impact of climate change on the key determinants of health (water, air and food) and measures to assess and manage the additional burden of disease that will be brought about. Ionizing radiation and electromagnetic fields The exposure of human beings to ionizing radiation from cosmic rays and radioac- tive nuclides in the earth’s crust is an in- escapable feature of life. The application of ionizing radiation in medicine has be- come widely established for diagnosis and therapy, bringing overwhelming benefits to patients with proper use and represents the largest man-made source of radiation exposure for the global population. How- ever, prolonged exposure to even low levels of ionizing radiation is associated with in- creased ill health, hence the importance of raising awareness of health workers and the population at large to this risk. Concern has been expressed about the potential health risks associated with electromagnetic fields since the 1970s; suspected effects range from change in behaviour, childhood leukaemia and other forms of cancer, to Parkinson and Alzhe- imer diseases. Unlike ionizing radiation, which has enough energy to break chemical bonds (and thus can damage living cells), low frequency electromagnetic radiation (0–300 GHz) has insufficient energy to ionize atoms or fragments of molecules, but may interact with a biological system in a number of other ways, such as by inducing S138 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ small changes of voltage and electrical current within the human body. Numerous studies have been published on the health effects of electromagnetic fields, and expert groups and panels have been established to review and evaluate the available data. So far, such efforts have not provided firm evidence to prove or disprove a causal as- sociation between exposure to electromag- netic fields and outcomes of public health significance. Natural and man-made emergencies The Region is particularly affected by nat- ural and man-made emergencies which degrade environmental conditions in two ways: through catastrophic events that markedly affect the environment, such as floods, drought, earthquakes, fire and in- dustrial accidents; and through disruption of essential environmental health services, such as water supply and sanitation, solid waste and air quality management, which are often already strained [12]. The disruption of water and power sup- plies was widely witnessed during the inva- sion of the Palestinian territories in 2002. In Iraq, wastewater collection and treatment facilities throughout the country were non- functional after the Gulf Wars due to partial destruction of pumping and treatment facili- ties, lack of spare parts and intermittent lack of electricity. Health effects of air pollution are nor- mally characterized by long-term build up; in air pollution emergencies, however, such as in Bhopal, India in 1977, the effects are immediate and often lethal. In 1991, fires in hundreds of Kuwaiti oil wells caused dramatic, visible effects on air quality at the subregional level [13]. Industrial accidents and transport ac- cidents involving hazardous materials are increasing worldwide. The impact on the affected communities is enormous and the medical, psychological and economic bur- den is heavy. Death and injury do not reflect the full health impact of these disasters, as the indirect effects, such as population displacement, economic losses, stress and social upheaval in the community, may be of even greater magnitude [12]. Though rare, radiation accidents have many medical, administrative, legal, social and psychological implications. The most serious nuclear accident occurred in 1986 in Chernobyl nuclear power station, releasing large amounts of radioactive material over vast areas of Belarus, Ukraine and the Rus- sian Federation; even countries far from nu- clear power stations need effective radiation protection programmes. Particular concerns were expressed in the Region in relation to the use of depleted uranium in Iraq and to nuclear powered ships cruising in the Gulf area. The possible use of depleted ura- nium during the 2006 war in Lebanon was the subject of intense debate, even after a joint International Atomic Energy Agency, United Nations Environment Programme and WHO joint fact-finding mission had concluded in February 2007 that there was no evidence of the use of depleted uranium in the conflict. Emergencies are also often the occasion for spreading damaging rumours as the one regarding chemical and radiological contamination of seafood along the Somali coast in the aftermath of the 2006 Asian tsunami. Other factors Many other important sources of environ- mental health hazards are known to exist in the Region, such as noise pollution, soil contamination, and occupational hazards; in fact the Region is subject to the superposi- tion of traditional, modern and emerging environmental health problems. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S139 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Health burden of environmental conditions It is striking to note how the estimations made in 1948 regarding the health effects of environmental conditions (Box 1) are consistent with the recent WHO estimates, that globally 24% of the disease burden and 23% of all deaths are attributable to envi- ronmental factors. Among children 0–14 years of age, the proportion of deaths attrib- uted to the environment was as high as 36% [14]. For the Region, it has been estimated that this proportion varies between 13% in countries where coverage with essential environmental health services is high and an alarming 30% in countries where access to such services is still problematic (Table 2). Table 2 also shows clearly the importance of indoor air pollution and water supply and sanitation in relation to health protection. It should be noted that environmental health is not only important for health pro- tection and promotion but also for health equity (Box 2). Indeed, environmental health is a pillar of health security. Addressing the issue of health and the environment Many national strategies and plans of action related to health and environment have been prepared and implemented throughout the Region but despite some progress in reduc- ing mortality attributable to environmental causes in certain countries, sustained and amplified efforts are needed. The reasons why strategies and actions have not worked effectively relate primarily to weak institu- tional systems, unadapted and unenforced legislation, insufficient access to and use of health and environment information for decision-making, insufficient manpower both in number and training, and lack of leadership of the health sector in push- ing for health and environmental action by other sectors and avoiding conflicting sectoral strategies in matters of health and environment. On the other hand, facilitating factors are often missing; the most impor- tant of these is political commitment, but include also linkage with the basic develop- ment needs approach, environmental health impact assessment and use of economic instruments. WHO’s approach The WHO Eleventh General Programme of Work 2006–2015 [15] has analysed cur- rent health challenges and concluded that health is increasingly seen as a key aspect of human security and occupies a prominent place in debates on priorities for develop- ment. Over the past 20 years there have been major gains in life expectancy overall, but there are widening gaps in health status. The importance of economic, social, and It has been estimated that more than one-fifth of all deaths throughout the world are due to diseases arising out of environmental conditions. In the case of infantile diarrhoea, the number of deaths attributable in large measure to an unhealthy environment has in some countries reached alarming proportions. [...] The [First] World Health Assembly allotted to environmental hygiene a top priority ranking with those accorded to malaria, maternal and child health, tuberculosis and venereal disease. Source: Chronicle of the World Health Organization, 1948, II, No. 8–9. Box 1 S140 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Table 2 Environment burden of disease in countries of the WHO Eastern Mediterranean Region Country Environmental Environmental Selected risk factors (DALYs/ burden of burden of 1000 capita, per year) disease (% of disease Water, Indoor Outdoor total burden) (DALYs/1000 sanitation air air capita, and hygiene per year) (diarrhoea only) Afghanistan 29 217 52 36 0.2 Bahrain 14 16 – – 0.4 Djibouti 30 123 35 3 3 Egypt 19 38 6 0.2 2 Islamic Republic of Iran 20 37 – 0.1 1 Iraq 26 88 17 0.8 5 Jordan 20 31 4 – 0.8 Kuwait 14 15 – – 1.1 Lebanon 18 32 2 – 1.4 Libyan Arab Jamahiriya 17 25 – 0.2 3 Morocco 20 35 7 0.5 0.2 Oman 19 25 – – 1.1 Pakistan 28 83 22 14 2.3 Qatar 16 18 0.6 – 0.6 Saudi Arabia 20 32 – – 1.1 Somalia 27 184 48 – 0.4 Sudan 24 86 18 2.4 1 Syrian Arab Republic 17 26 4 0.6 0.9 Tunisia 17 27 2 0.3 0.6 United Arab Emirates 18 25 0.6 – 1.8 Yemen 28 100 29 13 0.7 Source: [15]. DALY = disability-adjusted life year. environmental determinants of health has grown. Demographic and epidemiological transitions now combine with nutritional and behavioural transitions, influenced by globalization and urbanization, to create unfavourable new trends. To face health challenges in an effi- cient manner, WHO moved into a 6-year mid-term strategic plan, within which 13 organization-wide strategic objectives have been defined which are to be achieved by Eastern Mediterranean Health Journal, Vol. 14, Special Issue S141 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ The adverse health impacts from human-induced environmental changes will be distributed unequally. The poor, the geographically vulnerable, the politically weak and other disadvantaged groups will be most affected. Addressing the intersection between social determinants of environmental change and the impact of environmental change on health inequities will benefit sustainable ecology and population health alike. Health inequities will benefit sustainable ecology and population health alike. Source: Interim Statement, WHO Commission on Social Determinants of Health, 2007 Box 2 the Organization in the 6-year term. This should anchor the Organization in results- based management. Strategic objective 8, which reads, “To promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health”, is entirely relevant to health and environ- ment; however other strategic objectives are equally relevant, namely Strategic objective 5 in relation to environmental health aspects of emergencies, Strategic objective 7 for the promotion of healthy settings approaches and Strategic objective 9 in regard to food safety. An area where WHO/EMRO is looking to lead the way is in social responsibility. The regional Strategic objective 8 plans to demonstrate during the coming 6 years the feasibility that WHO only contract with cor- porations that respect at least occupational health and environmental legislation. Given the emphasis WHO is placing on the determinants of health, prominent among which are environmental factors, it will be in good position in the coming few years to support its Member States in assessing, correcting and preventing health risks related to environmental factors and hence in achieving the health-related Mil- lennium Development Goals [16]. There are however certain important prerequisites if we are to succeed in tackling the effects of environmental conditions and changes on health: individuals and commu- nities need to become the guardians of their health and environment; shared agendas and plans of action need to be formulated around the core functions of public health and environmental management; and alli- ances need to be established between health and environment sectors to develop joint activities and programmes that would be beneficial for both sectors. References 1. Demographic, social and health indicators for countries of the Eastern Mediterra- nean, 2007. Cairo, WHO Regional Of- fice for the Eastern Mediterranean, 2007 (http://www.emro.who.int/dsaf/dsa783. pdf, accessed 3 August 2008). 2. Al Salem SS, Abouzaid H. Wastewater reuse for agriculture: regional health per- spective. Eastern Mediterranean health journal, 2006, 12(3&4):446–58. 3. Prüss-Üstün A et al. Safer water, better health – Costs, benefits and sustainability of interventions to protect and promote health. Geneva, World health Organiza- tion, 2008. S142 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 4. World Water Day 2001. Water-related dis- ease fact sheets (http://www.emro.who. int/wwd/, accessed 31 July 2008). 5. WHO and UNICEF Joint Monitoring Pro- gramme for Water Supply and Sanitation. Water for life: making it happen. Geneva, World Health Organization, 2005. 6. Desalination for safe water supply. Guid- ance for the health and environment as- pects applicable to desalination. Geneva, World Health Organization, Public Health and Environment, 2007 (http://www.who. int/water_sanitation_health/gdwqrevision/ desalination.pdf, accessed 12 August 2008). 7. Nriagu JO. A history of global metal pollu- tion. Science, 1996, 272:223–4. 8. Climate change 2007: The physical sci- ence basis. Contribution of Working Group I to the Fourth Assessment Re- port of the Intergovernmental Panel on Climate Change. Cambridge, Cambridge University Press, 2007. 9. Global burden of disease due to indoor air pollution. WHO indoor pollution website (http://www.who.int/indoorair/health_im- pacts/burden_global/en/index.html, ac- cessed 3 August 2008). 10. McMichael AJ et al., eds. Climate change and human health. An assessment pre- pared by a Task Group on behalf of the World Health Organization, World Mete- orological Organization and United Na- tions Environmental Programme. Geneva, World Health Organization, 1996. 11. World Health Organization. Protect- ing health from climate change – World Health Day 2008. (http://www.who.int/ world-health-day/toolkit/report_web.pdf, accessed 3 August 2008). 12. Health effects of environmental condi- tions. Technical discussion presented at the Forty-ninth Session of the WHO Re- gional Committee for the Eastern Mediter- ranean, 30 September–3 October 2002 (EM/RC49/Tech.Disc.2). 13. Regional report of the state of the marine environment. Kuwait, Regional Organiza- tion for the Protection of the Marine Envi- ronment, 1999. 14. Prüss-Üstün A, Corvalán C. Preventing disease through healthy environments: towards an estimate of the environmental burden of disease. Geneva, World Health Organization, 2006. 15. Engaging for health. Eleventh General Programme of Work 2006-2015. A global health agenda. Geneva, World Health Organization, 2006. 16. UN Millennium Development Goals (http:// www.un.org/millenniumgoals/, accessed 4 August 2008). Eastern Mediterranean Health Journal, Vol. 14, Special Issue S143 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Food safety Mohamed Elmi1 1Regional Adviser, Food and Chemical Safety, Division of Health Promotion and Protection, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Mohamed Elmi@ elmim@emro.who.int). Background It is interesting to note that the World Health Organization (WHO) Constitution, which was adopted in 1948, included a specific mandate apropos food standards. Article 2 (U) of the Constitution states clearly that WHO should develop, establish and pro- mote international standards with respect to food. This recognition would lead to seminal work on the part of WHO in the field of food safety. Food is of fundamental importance to life. However, it is also a ve- hicle for transmitting hazards and causing disease and death to humans. Illness due to contaminated food is considered the most widespread transmissible health problem today and also an important cause of re- duced economic productivity. Among the duties and responsibilities of WHO, as one of the original agencies of the United Nations, established on the first World Health Day (7 April 1948) is the protection of the consumer against any health hazard which could be transmitted as a result of consuming unsafe food. After over 2 decades of fighting small- pox, WHO declared in 1980 that the disease had been eradicated, the first disease in history to be eliminated by human effort; this has not, however, been the case with regard to foodborne diseases, which remain a great challenge. Globalization and food The globalization of the food trade and the urbanization of populations are changing the pattern of food production and distribu- tion, creating the conditions conducive to widespread outbreaks of foodborne disease. In a recent crisis, more than 1500 farms in Europe received dioxin-contaminated feed from a single source over a 2-week period and food produced from animals fed on this contaminated fodder found its way onto every continent within weeks. To give an- other example, the international propagation of meat and bonemeal prepared from cattle affected by bovine spongiform encephalitis (BSE) caused widespread proliferation of the disease among consumers. In developed countries, up to 50% of the food budget may be spent on food prepared outside the home. In both developing and developed countries, there are millions of single workers constituting a large float- ing population who move in and out of the city for work and largely depend upon street foods for their daily sustenance. In developing countries, such food is prepared and/or sold by vendors or hawkers mainly in streets or other convenient public places under unacceptable conditions of hygiene. The resulting widespread foodborne illness needs no elaboration. As a matter of fact, food safety is an essential public health issue for all countries since foodborne disease, whether due to microbial pathogens, biotoxins or chemical contaminants of food, represents a serious threat to the health of millions of consum- ers: significant serious foodborne disease outbreaks have been documented in many countries in the past and are still liable to occur in any part of the world. S144 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Such foodborne outbreaks not only af- fect the health and well-being of the people but also have economic consequences for individuals and nations; they impose a sub- stantial burden on health-care systems of the country and reduce economic productiv- ity. The globalization of food production and trade is aggravating the widespread outbreaks of foodborne diseases. Food safety programmes are increasingly focusing on a farm-to-table approach in the control of food-related risks as an effective means of reducing foodborne hazards since hazards can enter the food chain at any point from the initial stage of production all the way through to consumption. There is no doubt that significant progress has been made towards making food safer; the emergence of increased antimicrobial resistance of disease-causing bacteria is, however, aggravating the situa- tion. Furthermore, there is increasing doubt and concern among the public with regard to the introduction of new technologies in the farm-to-table chain; i.e. irradiation and genetic engineering. The safety of such technologies has to be thoroughly proved if they are to be accepted by certain countries. Confidence in the safety and integrity of the food supply is an important requirement for consumers. Specific hazards Specific concern about food hazards have usually been focused on microbiological hazards, pesticide residues, misuse of food additives and chemical contaminants, in- cluding biological toxins. Until recently, most systems for regulating food safety were based on legal definitions of unsafe food, enforcement programmes for the re- moval of unsafe food from the market and sanctions for the responsible parties. Such traditional systems cannot today provide, or stimulate, a preventive approach. During the past decade, there has been a transition to risk analysis based on better scientific knowledge of foodborne illness and its causes. This provides a preventive basis for regulating measures for food safe- ty at both national and international levels. The risk-based approach must be backed by information on the most appropriate and effective means to control foodborne hazards. International regulation/agreements At both the 11th session of the Conference of the Food and Agriculture Organization (FAO) in 1961 and the 16th World Health Assembly in 1963, resolutions were passed to establish the Codex Alimentarius Com- mission, and both adopted the Statutes and Rules of Procedure for the Commission. Its main objectives are to protect the health of consumers and ensure fair practice in food trade. Also included are the formula- tion of food standards and other specific requirements covering pesticide residues, food additives, veterinary drug residues, hygiene, food contaminants, radionuclides and labelling. Recently, the Codex has embarked on a series of activities based on risk assessment to address microbiological hazards in foods, and thus generated worldwide awareness of food safety and consumer protection issues and how to deal with them scientifically through a risk-based approach. Consequent- ly, a continuous appraisal of the principles of food safety at the international level was created as well as an increasing tendency to adopt these principles at the national level. Since consumers expect protection from hazards occurring along the entire food chain, from farm-to-table, factors that could contribute to potential hazards in foods should be considered; these include improp- er agricultural practices; poor hygiene (at all stages of the food chain); lack of preventive Eastern Mediterranean Health Journal, Vol. 14, Special Issue S145 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ controls in food processing operations; misuse of chemicals; contaminated raw materials, ingredients and water; and inade- quate or improper storage. Usually concerns about food hazards focus on microbiological hazards, pesticide residues, misuse of food additives, chemical contaminants including biological toxins, adulteration, genetically modified organisms, allergens, veterinary drug residues, growth promoting hormones used in the production of animal products, and radionuclides. As a result of the Multilateral Trade Negotiations in Morocco, the World Trade Organization (WTO) was established on 1 January 1995, and 2 agreements, the application of Sanitary and Phytosanitary Measures (SPS) and the Technical Barriers to Trade (TBT), came into force. They are relevant in understanding the requirements for food protection measures at the national level and the rules under which food is traded internationally. According to the SPS agreement, WTO Member Countries have the right to apply measures to protect humans, animal and plant life and health. It covers decrees, regu- lations, testing, inspection, certification and approval procedures and packaging and la- belling requirements directly related to food safety. All Member Countries are asked to apply only those measures for protection that are based on scientific principles, only to the extent necessary and not in a manner which may constitute a disguised restriction on international trade. The agreement en- courages the use of international standards, guidelines or recommendations where they exist, and identifies those from the codex (related to food additives, veterinary drugs and pesticide residues, contaminants, meth- ods of analysis and sampling and codes and guidelines of hygienic practices) that are consistent with the provisions of the SPS. In other words, the Codex standards serve as a benchmark for comparison of na- tional sanitary and phytosanitary measures. It is also compulsory for Member States to apply Codex standards; they should, how- ever, harmonize their national food stand- ards with those elaborated by the Codex. The TBT agreement also encourages the use of international standards and requires that technical regulations on aspects such as traditional quality factors, fraudulent practices, packaging and labelling imposed by countries will not be more restrictive on imported products than they are on products produced domestically. Benefits of globalization The globalization of the food trade offers many benefits to consumers, as it results in a wider variety of high-quality foods that are accessible, affordable and safe, meeting consumer demand. However these changes also present new challenges to safe food production and distribution and have been shown to have widespread repercussions on health. Although significant progress has been made in many countries in making food safer, it is impossible to provide adequate protection to the consumer by merely sam- pling and analysing the final product. The introduction of preventive measures at all stages of the food production and distri- bution chain, rather than only inspection and rejection at the final stage, makes bet- ter economic sense, because unsuitable products can be identified earlier along the chain. The preventive approach that may be applied at all stages in the processing and handling of food products involves the Hazard Analysis Critical Control Point (HACCP) system, the principles of which have been formulated by the Codex Com- mittee on Food Hygiene and provide a systematic structure for the identification and control of foodborne hazards. Govern- ments should recognize the application of S146 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ the HACCP approach by the food industry as a fundamental tool for improving the safety of food. According to the Codex, risk analysis consists of 3 components: assessment, man- agement and communication. Risk assessment is a scientifically based process consisting of 4 steps: hazard identi- fication, hazard characterization, exposure assessment and risk characterization. The definition includes quantitative risk as- sessment, which emphasizes reliance on the numerical expression of risk, and also qualitative expressions of risk as well as an indication of the attendant uncertainties. Risk management is the process, distinct from risk assessment, of weighing policy alteration in consultation with all interested parties, and taking into consideration risk assessment and other factors relevant to the health protection of consumers and the promotion of fair trade practices, and, if needed, selecting appropriate prevention and control operations. Risk communication is the interac- tive exchange of information and opin- ions throughout the risk analysis process concerning hazards and risks, risk-related factors and risk perceptions among risk assessors, risk managers, consumers, in- dustry, the academic community and other interested parties, including the explanation of risk assessment findings and the basis of risk management decisions. Foodborne disease The major challenging foodborne diseases caused by microorganisms are: • Salmonellosis, which constitutes a ma- jor problem in most countries. Foods involved in salmonellosis outbreaks are mostly eggs, poultry and other meat, raw milk and chocolate. • Campylobacteriosis, which is a wide- spread infection caused by certain spe- cies of Campylobacter bacteria. In some countries, the reported number of cases surpasses the incidence of salmonell- osis. Foodborne cases are mainly caused by raw milk, raw or undercooked poultry and drinking water. In 2%–10% of cases the infection may lead to chronic health problems including reactive arthritis and neurological disorders. • Infections due to enterohaemorrhagic (causing intestinal bleeding) Escherichia coli (e.g. E. coli 0l57) and listeriosis are important foodborne diseases which have emerged over the past few decades. Although their incidence is relatively low, their severe, and sometimes fatal, health consequences, particularly among infants, children and the elderly, make them among the most serious foodborne infections. • Cholera (a major public health problem in developing countries) also causes enormous economic losses. The disease is caused by the bacterium Vibrio chol- erae. In addition to water, contaminated foods can be the vehicle of infection. Rice, vegetables, millet gruel, and vari- ous types of seafood have been impli- cated in outbreaks of cholera. There are other food safety problems, major examples of which are: • naturally occurring toxins, such as my- cotoxins, marine biotoxins, cyanogenic glycosides and toxins occurring in poi- sonous mushrooms, periodically cause severe intoxications. Mycotoxins such as aflatoxin and ochratoxin A are found at measurable levels in many staple foods such as sorghum, maize and mil- let; the health implications of long-term exposure of such toxins are poorly un- derstood. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S147 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ • unconventional agents, for example the agent causing bovine spongiform encephalopathy (BSE, mad cow dis- ease) which is associated with variant Creutzfeldt–Jakob disease (VCJD) in humans. Consumption of bovine prod- ucts containing brain tissue is the most likely route for transmission of the agent to humans. • persistent organic pollutants (POPs) are compounds that accumulate in the envi- ronment and the human body. Known examples are dioxins and polychlorin- ated biphenyls (PCBs). Dioxins are unwanted products of some industrial processes and waste incineration. Expo- sure to POPs may result in a wide variety of adverse effects in humans. • heavy metals such as lead and mercury cause neurological damage in infants and children. Exposure to cadmium can also cause kidney damage; this is usu- ally seen in the elderly. These (and also POPs) may contaminate food through pollution of air, water and soil. Biotechnology and food There are some other challenges and devel- opments in food safety such as the safety of foods derived from biotechnology, which needs to be carefully assessed to demon- strate the scientific basis for decisions re- garding human health. New methods and policies to assess such foods need to be developed and agreed upon internation- ally. Crops modified to resist pests, foods with allergens removed or with essential nutrients augmented are possible using food biotechnology, while antimicrobial markers in some genetically modified foods have been suggested but are not yet available on the market. The weighing of potential risks and benefits is an important aspect of as- sessment of foods derived from biotechnol- ogy that has not received much attention in the past. Foods derived from biotechnology should be assessed on a case-by-case basis. Likewise, clear communication of the basis for safety assessment in this area is gener- ally lacking at national and international levels. Continuous monitoring is necessary to ensure the safe use of pesticides, veteri- nary drugs and food additives. WHO involvement In partnership with other stakeholders, WHO is developing policies that will further promote the safety of food. These policies cover the entire food chain from production to consumption and will make use of differ- ent types of expertise. The work of the WHO Department of Food Safety and other WHO programmes and departments are strengthening food safety systems, promoting good manu- facturing practises and educating national consumers about appropriate food handling. Education of consumers and training of food handlers for the safe handling of food is one of the most critical interventions in the prevention of foodborne illness. Through continuous feedback and support, various Member States are being assisted in their efforts to improve national food control systems. On a Regional level a manual on Devel- oping food legislation: guidelines for devel- oping legislation for food control systems in the countries of the Eastern Mediterranean is being prepared. This manual is intended to enable the countries of the Region to develop legislation suited to the local situa- tion. It incorporates a generic description of food control infrastructure, and explains the importance of food inspection, laboratory S148 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ food analysis, administration and enforce- ment of legislation, and includes the general legal framework for food control acts and executive regulations, including food stand- ards, in line with the Codex Alimentarius and SPS and TBT agreements of the WTO. The WHO Regional Office for the East- ern Mediterranean has continued working towards putting food safety firmly on na- tional public health agendas by addressing the issue with health and agricultural au- thorities. Plans also include the continuous creation of awareness of food safety as a public health priority, along with the need for collaboration of all key players; the establishments of integrated of food moni- toring and foodborne disease surveillance systems and the implementation of studies on foodborne burden of disease; participa- tion and increasing use of the International Food Safety Authority Network, both in size and in responsiveness, in an everlasting effort to reach the goal of “safer food for all”. Acknowledgement Thanks are due to Dr Mohamed Ragab, Professor Emeritus Food Science and Tech- nology, Faculty of Agriculture, Alexandria University and formerly FAO Senior Expert for Food Safety and Quality Control, for sharing his experience with the author. Bibliography 1. 60th anniversary of the World Health Organization. Our health, our future: a guidebook for organizers of activities. Ge- neva, World Health Organization, 2008. 2. Application of risk analysis to food stand- ards issues. Report of the Joint FAO/ WHO Expert Consultation, Geneva, Swit- zerland, 13–17 March 1995. Geneva, Food and Agriculture Organization/World Health Organization, 1995. 3. Archives of the Smallpox Eradication Programme. Geneva, World Health Or- ganization, 2008 (http://www.who.int/ archives/fonds_collections/bytitle/fonds_ 6/en/, accessed 3 June 2008). 4. Assuring food safety and quality: guide- lines for strengthening national food con- trol systems. Rome, Food and Agriculture Organization/World Health Organization, 2003 (FAO Food and Nutrition Paper No. 76). 5. Codex Alimentarius Commission. Codex alimentarius, suppl. to Vol. 1B, General requirements (food hygiene), 2nd ed. Rome, Food and Agriculture Organiza- tion/World Health Organization, 1997. 6. De Vries J. Food safety and toxicity. Florida, CRC Press, 1996. 7. Derived intervention levels for radionu- clides in food, guidelines for application after widespread radioactive contamina- tion resulting from a major radiation acci- dent. Geneva, World Health Organization, 1988. 8. Evaluation of certain food additives and contaminants, forty-ninth report of the Joint FAO/Who Expert Committee on Food Additives. Geneva, World Health Organization, 1999 (WHO Technical Re- port Series No. 884). 9. Food safety and foodborne illness. Ge- neva, World Health Organization, 2007 (Fact sheet No. 237). 10. Food safety and globalization of trade in food: a challenge to the public health sec- tor. Geneva, World Health Organization, Food Safety Unit, 1998. 11. GEMS/Food regional diets. Geneva, World Health Organization, Food Safety Unit, 2003. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S149 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 12. Global Forum of Food Safety Regula- tors, 28–30 January 2002, Marrakesh, Morocco. Final report. Rome, Food and Agriculture Organization/World Health Organization, 2002. 13. Global surveillance of foodborne dis- eases: developing a strategy and its in- teraction with risk analysis, Report of a WHO consultation. Geneva, World Health Organization, 2001. 14. Guidelines for strengthening a national food safety programme. Geneva, World Health Organization, Food Safety Unit, 1996. 15. Health implications of acrylamide in food, report of a joint FAO/WHO consultation. Geneva, World Health Organization, 2002. 16. Hester RE, Harrison RM, eds. Food safety and food quality. Issues in environmen- tal science and technology. Cambridge, Royal Society of Chemistry, 2001. 17. Joint FAO/WHO Food Standards Pro- gramme. Rome, Food and Agriculture Organization/World Health Organization. 18. McWilliams M. Food safety experimental perspectives, 3rd ed. Cambridge, Royal Society of Chemistry, 1997. 19. Nutrition, food security and food safety. In: The work of WHO in the Eastern Medi- terranean Region. Annual report of the Regional Director. Cairo, World Health Organization Regional Office for the East- ern Mediterranean, 2003:55–8. 20. Regional meeting on food safety for the Near East, FAO/WHO, Amman, Jordan, 5–6 March 2005. Final report. Geneva, World Health Organization, FAO, 2005. 21. Rocourt J et al. Present state of foodborne disease in developing countries. Geneva, World Health Organization, Food Safety Department, 2003. 22. Safety assessment of foods derived from genetically modified animals, including fish. Report of the FAO/Who Expert Con- sultation, Rome, 17–21 November 2003. Geneva, World Health Organization, 2003 (Food and Nutrition Paper No. 79). 23. Steinhart CE, Doyle ME, Cochrane BA. Food safety 1996. New York, Food Re- search Institute, 1996. 24. Strategies for implementing HACCP in small and/or less developed business. Report of a WHO consultation in collabo- ration with the Ministry of Health, Welfare and Sports, the Netherlands, The Hague, 16–19 June 1999. Geneva, World Health Organization, Department of Protection of the Human Environment, 1999. 25. Summary report of the FAO/WHO/ILSI, Regional workshop on risk analysis, ex- posure assessment, (Cairo, Egypt, 27–28 January 2001). Cairo, World Health Or- ganization Regional Office for the Eastern Mediterranean, 2001. 26. Unnevehr LJ, ed. Food safety in food security and food trade. Washington DC, International Food Policy Research Insti- tute, 2003. 27. WHO global strategy for food safety—saf- er food for better health. Geneva, World Health Organization, Food Safety Depart- ment, 2002. 28. WHO/FAO. Risk assessments of salmo- nella in eggs and broiler chickens. Ge- neva, World Health Organization, 2002 (Microbiological risk assessment series No. 1). S150 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ The humanitarian consequences and actions in the Eastern Mediterranean Region over the last 60 years – a health perspective Altaf Musani1 and Irshad A. Shaikh2 1Regional Adviser; 2Medical Officer, Emergency and Humanitarian Action, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Altaf Musani: musania@emro.who.int). Humanitarian crises – historical context Globally, countless lives and livelihoods have been affected by the impact of natural and man-made disasters in both developed and developing countries. However, more than 90% of deaths related to natural dis- aster occur in developing countries and the economic losses in relation to GNP are far greater in developing countries as compared to industrialized ones [1]. During the period from 1984 to 2003 more than 4.1 billion people were affected by natural disasters alone [1]. The overall trend of disasters and their impact on the world clearly illustrate: i) an exponential increase in the frequency of reported events; ii) a substantial eco- nomic burden to national economies; and iii) an increasing number of affected people who have to recover from such events. A number of major earthquakes, floods, droughts, cyclones, conflicts and civil strife has triggered humanitarian relief to ensure the resilience in survivors. Displacement and migration are a significant consequence of disasters and have posed a new challenge to the humanitarian assistance community. As a direct result of conflict and violence, the Office of the United Nations High Com- missioner for Refugees (UNHCR) reports that by the end of 2007, the world’s refugee population exceeded 11 million, while 26 million people were internally displaced; an additional 25 million people were displaced because of natural disasters [2]. Recent reported natural disasters such as the South-East Asia tsunami, the cyclone in Myanmar and the earthquake in China underscore that the poor are the most vul- nerable and suffer the greatest impact. How- ever, the hurricanes that have affected the south-east of the United States of America (USA) clearly demonstrate that no nation is immune to natural hazards and disaster preparedness, across the globe, leaves much to be desired. Additionally, conflict, wars, sanctions and civil unrest have contributed to death, displacement, migration and dis- ability. The major lesson learnt from all these crises is that nations and communities must be better prepared! Looking back at 60 years in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) there have been many types of crises, from conflict to natural disasters. Tables 1 and 2 summarize the magnitude of some of the major crises reported in the Region. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S151 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Table 1 Migration in the Eastern Mediterranean Region due to war and conflict Country Period Refugees Internally (originating displaced persons from) assisted/protected by UNHCR (1993–2007) Sudan 1963–2007 11 520 713 81 589 66 Afghanistan 1979–2007 10 3139 506 10 089 984 Iran (IR) 1974–2007 2 180 111 No data Iraq 1968–2007 17 578 886 10 974 576 Somalia 1975–2007 10 378 319 4 439 206 Palestine 1976–2007 3 471 303 No data Source: The Office of the United Nations High Commissioner for Refugees (UNHCR) Statistical online population database (http://www. unhcr.org/statistics/45c063a82.html). Table 2 Natural disasters and their impact in the Eastern Mediterranean Region (1950–2008) Event Country Deaths Affecteda Homeless Injured Total Damage (No.) (No.) (No.) (No.) affected (× 103 (No.) US$) Earthquakes Iran (IR) 65 074 818 091 575 19 963 838 629 1 135 000 Egypt 20 NA NA 28 28 – Afghanistan 2 663 152 440 6 580 5 518 164 538 340 00 Pakistan 4 989 42 975 5 200 17 605 65 780 8 255 Morocco 12 000 NA NA 25 000 25 000 120 000 Floods Iran (IR) 5 757 1 140 200 – 70 1 290 270 17 43 000 Pakistan 6 308 13 909 527 38 732 – 15 166 527 1 169 800 Yemen 657 625 000 154 750 612 907 862 1 052 900 Afghanistan 479 785 044 – 140 792 684 312 000 Sudan 130 1 847 000 30 000 – 2 877 000 25 000 Droughts Djibouti NA 255 000 NA – 255 000 – Sudan 150 000 11 850 000 NA – 11 850 000 – Somalia 19 650 1 483 500 NA – 1 483 500 – Yemen NA 2 000 000 20 000 – 2 020 000 10 000 Iran (IR) NA 625 000 – – 625 000 – Afghanistan – 48 000 – – 48 000 200 aAffected = people requiring immediate assistance during a period of emergency, it can also include displaced or evacuated people. Source: Centre for Research on the Epidemiology of Disasters – Emergency Events Database (CRED EMDAT) (http://www.emdat.be/Database/terms.html). NA = not available. – = not reported. S152 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ Over the past 2 decades in particular, the Region has experienced a number of complex emergencies as well as large scale natural disasters; 15 of the 22 Member States (roughly 85% of the Region’s popu- lation) have suffered in protracted conflict situations [3]. In particular, the situations in Afghanistan, Iraq, Lebanon, Palestine, Somalia and Sudan go unabated and have collectively affected over 10 million people, 6.5 million of whom have been displaced from their homes and over 200 000 have died [4]. In Iraq, with the on-going vio- lence and insecurity coupled with previous humanitarian needs, almost a third of the country is cut off from essential health services [5]. The conflict in the occupied Palestinian territories has been ongoing for over 6 decades and still 80% of the popula- tion living in Gaza depends on humanitarian assistance. Because of the burden of these crises, the world’s highest proportion of internally displaced persons still lives in EMR. To make matters worse, as the remain- der of the world continues to realize health gains and achievements, due to the ongoing crises in Somalia and Afghanistan, these 2 EMR countries still have the worst national records of infant and maternal mortality indicators in the world. In addition to a high frequency of natural disasters and conflict, the Region is also vulnerable because of many other factors, such as population growth (Pakistan [6] Islamic Republic of Iran [7], Yemen [8]), crop failure/food in- security (Somalia [9], Sudan [10], Afghani- stan [11], Pakistan [12]), environmental degradation (Pakistan [13,14]) and water scarcity (Yemen [15], Sudan [16], Somalia [9], Jordan [17]). These vulnerabilities to a varying degree have also contributed to rural-to-urban migration and subsequent “premature urbanization” in major cities whereby the urban sector cannot generate compensatory economic growth to absorb the massive influx. This has resulted in thousands living in slums and/or low in- come housing that are unsafe when it comes to natural hazards, either because of poor structural quality or risk prone locations. Newly emerging threats in the Eastern Mediterranean Region In addition to the aforementioned obvious and localized threats and vulnerabilities that conventionally affect the poorest members of a population, there are newly emerging threats, which include a possible human pandemic influenza, sky rocketing food and oil prices, and climate change. These are global threats and combined with the existing vulnerabilities, if left unaddressed, will result in potentially catastrophic conse- quences for marginalized populations. Health impact of an influenza pandemic Should the Region experience a phase 5 or 6 situation with regard to the influenza virus (evidence of significant or efficient and sustained human-to-human transmis- sion), the impact on countries could be crip- pling. Models and scenarios that have been developed on the pandemic anticipate that the health institutions will be overwhelmed with patients seeking care (at an expected attack rate of 35%, it is estimated that in the EMR, more than 180 million people will fall ill, 96–168 million will require medical care and 6–28 million will need hospitalization). Moreover, with already weakened and rundown health infrastruc- tures in places like Afghanistan, Somalia and Sudan and existing vulnerable groups, such as refugees and internally displaced populations, the pandemic influenza virus will flourish. Countries, thus, will need to Eastern Mediterranean Health Journal, Vol. 14, Special Issue S153 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ be prepared to contain the epidemic within their borders. The Region has already witnessed the largest cluster of human cases of the highly pathogenic avian influenza virus A/H5N1 outside Asia. Out of 22 countries in the Region, H5N1 has been reported from 10, including 2 countries with H5N1 in wild and migratory birds (Kuwait and Islamic Republic of Iran), 5 with H5N1 in poultry (Afghanistan, Jordan, occupied Palestine territory, Pakistan and Sudan) and 4 coun- tries with confirmed human cases (Egypt, Iraq, Pakistan and Djibouti). Food crisis and its impact on vulnerable populations The world is witnessing some of the sharp- est rises in food prices ever; since Janu- ary 2008, rice prices have soared 141%. This food inflation could push at least 100 million people into poverty (to add to the 800 million people already suffering from hunger), which will wipe out all the gains the poorest billion of the world’s popula- tion has made during almost a decade of economic growth [18]. The United Nations Economic Commission for Africa estimates that the number of food insecure people could rise by 16 million for every percent- age point increase in real prices of staple foods, meaning 1.2 billion people could be chronically hungry by 2050 [19]. In EMR, countries at highest risk from the food crisis include Somalia, Sudan, Pakistan, Palestine and Yemen. The impact is already obvious and profound. In Somalia, this has meant an additional 600 000 urban poor, a 40% increase since January 2008, who now face conditions of acute food and livelihood crisis and humanitarian emergency and are in need of assistance [8]. In the case of Palestine, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) reports that whereas in 2004 it spent about US$ 8 per refugee every 2 months in Gaza, today costs have risen to US$ 19 to provide the same 60% of their basic needs, these increases have forced the agency to significantly reduce the number of recipients of aid [19]. Ad- ditionally, the global food crisis threatens to spark even more violence and social unrest in war zones where millions of already marginalized people have had no or very limited success in their efforts to secure access to sustainable food commodities. It is therefore crucial that the health sector is able to respond quickly to excess violence and injury. Climate change and its humanitarian impact Climate change is expected to trigger, com- pound and increase disasters and exacerbate existing humanitarian situations. Most of the effects of climate change will be on low income, resource-starved countries with limited ability to adapt and respond. Extreme events such as changes in rain patterns, more severe tropical cyclones, drought, floods, extreme temperature fluc- tuations, possible rise in sea levels, coastal erosion and reduced biodiversity are ex- pected to have a broad-ranging influence on agricultural production, food security, access to water, habitat and livelihoods. Likewise, there would be a considerable impact on human health. Scientists consider that most of the health impacts of climate change would be adverse. WHO, in its World Health Report 2002 [20], estimated that climate change was responsible in 2000 for approximately 2.4% of worldwide cases of diarrhoea and 6% of malaria in some middle-income countries. According to a World Bank study [21], just a 1 metre rise in sea levels would turn at least 65 million people in the developing world into envi- ronmental refugees; in terms of number of S154 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ populations affected, the top 10 countries in such a scenario include 3 countries from EMR: United Arab Emirates, Egypt and Tu- nisia. From a water scarcity perspective as a result of climate change, again, the Mediter- ranean and the Middle East Regions are the ones expected to be the worst off. The high number of refugees and internally displaced people indicate the existing vulnerabilities in EMR; because of these, greater humani- tarian efforts will be required to deal with the consequences of climate change in order to prevent further erosion of their capacity to cope. Responding to Regional crises The inherent hazards and vulnerabilities that have been faced over the past 60 years in EMR, coupled with emerging threats, clearly indicate the changing nature and dy- namics of humanitarian crises. It is apparent therefore that humanitarian strategies and methods used to deal with crises will need to be significantly different from the verti- cal relief approach of the present. Emerg- ing causes of humanitarian crises – human pandemic influenza, climate change, food insecurity or bioterrorism – require multi- disciplinary and multisectoral prevention and preparedness measures to build, sustain and promote national and local capacities. Moreover, the position of health, although clearly linked to better quality of life and livelihood, has often taken a back seat com- pared with the models and operations for food aid and water distribution. Hence the challenge for WHO, ministries of health and health partners in the humanitarian arena is to promote a public health preven- tive approach before disasters occur as well as to ensure that public health best practices apply in times of crises in order to ensure human survival. Over the last 30 years WHO’s humani- tarian response actions and policies in the Region have focused on relief aid and en- suring the availability of and access to health services for those most in need. The approach was challenged by a number of major emergencies in the past that required WHO to become more involved in op- erations while still maintaining its technical leadership in health. As the frequency of natural and man-made disasters has in- creased, WHO has gradually evolved to be an active humanitarian partner among the international aid agencies. However, the technical leadership and health guidance to work with national and international partners and promote standards in health assistance still remain a core strength of the Organization. The role of WHO as the leader in health and humanitarian assist- ance has been echoed and re-enforced by Member States and partners through several World Health Assembly resolutions. More recently the humanitarian reforms have thrust WHO to the fore as the “convener” of the global and country health clusters in times of emergencies [22]. Over the last 2 decades WHO has been challenged by several emergency situa- tions requiring the provision of health and humanitarian assistance to affected popula- tions. Establishing operational capacity to respond to the earthquakes in the Islamic Republic of Iran and Pakistan as well as the conflict/violence in Lebanon, Iraq, Somalia, Afghanistan and Sudan has been a driving force behind WHO’s regional response activities; however, more recently a strong shift from purely response to include and integrate preparedness and risk-reduction measures has been addressed within the Or- ganization’s strategy. Additionally, WHO is tackling the aspect of health in a post-crisis phase in order to ensure the bridge between relief and development. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S155 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ What does the future for hold for the Region with regard to crises? The newly emerging threats coupled with the long- standing and inherent vulnerabilities do not present an optimistic prospect for health in the Region. Despite tremendous efforts to increase emergency response measures to safeguard lives and livelihoods, humani- tarian partners, and in particular Member States, will have to intensify efforts to deal with the growing demand for humanitarian assistance. WHO has attempted to respond to the call of Member States for investment in national and local capacities for disaster preparedness and response. Ensuring the in- tegrity and resilience of the health system in times of crisis has been the focus of a recent World Bank, United Nations International Strategy for Disaster Reduction and WHO global campaign of hospitals safe from disasters [23]. Additional challenges facing humanitar- ian assistance were outlined in a recent report of an interagency standing committee and addressed a number of key factors that we must take into consideration [24]. These include the ever-evolving and negotiating space for provision of humanitarian assist- ance; the global nature of various crises, such as a possible pandemic; greater en- gagement of local and national partners, including the private sector; use and en- gagement of national and foreign military assets in humanitarian crises; the erosion of protection of humanitarian workers; and the increased need for accountability by the humanitarian community. EMR, despite its richness, heritage and diversity, has been beset by crisis situations for decades. Although there may have been several milestones in health throughout the Region, countries like Somalia, Af- ghanistan and Sudan stand on a precipice and risk falling deeper into poverty and ill health. Beyond the long-standing conflicts in the Region, all countries are vulnerable to impacts of climate change which threaten development and prosperity. Our challenge, if we are to reach the targets of the United Nations Millennium Development Goals, is to ensure the resilience of nations and com- munities to the effects of disasters. References 1. Hazards of nature, risks to development: an IEG evaluation of World Bank assist- ance for natural disasters. Washington DC, World Bank, 2006. 2. The Office of the United Nations High Commissioner for Refugees. 2007 Glo- bal Trends: Refugees, Asylum-seek- ers, Returnees, Internally Displaced and Stateless Persons (http://www.unhcr.org/ statistics/STATISTICS/4852366f2.pdf, accessed 26 July 2008). 3. Ghosh N, Mohit A, Murthy RS. Mental health promotion in post-conflict coun- tries. Journal of the Royal Society of Health, 2004, 124(6):268–70. 4. Gauha-Sapir D, Degomme O. Darfur: counting the deaths (2) What are the trends? Brussels, Centre for Research on the Epidemiology of Disasters, Universite Catholique de Louvain, 2005. 5. Strengthening of coordination of emer- gency humanitarian assistance of the United Nations. Report of the Secretary United Nations General. Economic and Social Council. Substantive session of 2008 (A/60/87–E/2005/78) (http://www. re l ie fweb. in t / rw/RWFi les2005.nsf / FilesByRWDocUNIDFileName/HMYT- 6E9RR2-unga-gen-23jun.pdf/$File/unga- gen-23jun.pdf, accessed 9 July 2008). 6. Feeney G, Alam I. New estimates and projections of population growth in Paki- stan. Population and development review, 2003, 29(3):4. S156 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 7. Heilig GK. World Population Prospects: analyzing the 1996 UN Population Projec- tions. Chapter 1. World population: major trends (www.iiasa.ac.at/Research/LUC/ Papers/gkh1/chap1.htm, accessed 16 July 2008). 8. Alkaff HF. Water scarcity problem in Yemen. Yemen Update (42 (2000):51- 54) (www.aiys.org/webdate/alku.html, ac- cessed 9 July 2008). 9. ReliefWeb. Somalia: rapidly rising food prices and deepening drought, more than 2.6 million people are in crisis. Food Security Analysis Unit (FSAU) (www. reliefweb.int/rw/rwb.nsf/db900sid/muma- 7e84ht?opendocument, accessed 9 July 2008). 10. Food and Agricultural Organization (FAO). Nutrition and consumer protection nutri- tion country profiles, Republic of Sudan (http://www.fao.org/countryprofiles/index. asp?lang=en&iso3=SDN&subj=4, ac- cessed 16 July 2008). 11. ReliefWeb. Afghan food production hit by drought and pests; poor face rising food prices http://www.reliefweb.int/rw/rwb. nsf/0/a86d35de462e9e3ac1256f190030 8194?OpenDocument, accessed 9 July 2008). 12. Helbock RW. Urban population growth in Pakistan. Population research bulletin, 1978, 1(1):4. 13. Environment and biodiversity of Pakistan. Environmental degradation in Pakistan (http://www.edu.iucnp.org/eipenv.htm, accessed 17 July 2008). 14. United Nations Development Programme, Pakistan. Environment and Energy: Envi- ronmental Challenges in Pakistan (http:// www.un.org.pk/undp/energy/overview. htm, accessed 15 July 2008). 15. United Nations Office for the Coordination of Humanitarian Affairs. Yemen. Water shortages a looming disaster (http://www. irinnews.org/report.aspx?reportid=26077, accessed 16 July 2008). 16. United Nations Environment Programme. The environment in the news. Monday, 18 September 2006. Eco-paradises in cross- fire of water scarcity fight (http://www. unep.org/cpi/briefs/2006Sept18.doc, ac- cessed 16 July 2008). 17. Ohlsson L. Water conflicts and social re- source scarcity. Physics and chemistry of the earth, Part B, 2000, 25(3):213–20. 18. Taking the strain. The political fallout from the rising cost of food has been manage- able—so far. The Economist, 10 May 2008 (http://www.economist.com/world/ international/displaystory.cfm?story_ id=11332931, accessed 9 July 2008). 19. Koser K. Rising food prices and displace- ment. BROOKINGS, Thursday May 29, 2008 www.brookings.edu/opinions/ 2 0 0 8 / 0 4 2 3 _ f o o d _ p r i c e s _ k o s e r . aspx?p=1, accessed 9 July 2008). 20. The world health report 2002: Reducing the risks, promoting healthy life. Geneva, World Health Organization, 2002. 21. Dasgupta S et al. The impact of sea level rise on developing countries: a com- parative analysis. Washington DC, World Bank, 2007 (Policy Research Working Paper Series, no. WPS 4136) 22. Humanitarian response review. New York, United Nations, 2005 (http://www. reliefweb.int/library/documents/2005/ ocha-gen-02sep.pdf, accessed 16 July 2008). 23. International Strategy for Disaster Re- duction. Hospitals Safe from Disaster Campaign [website] (http://www.unisdr. org/eng/public_aware/world_camp/2008- 2009/wdrc-2008-2009.html, accessed 16 July 2008). 24. The Humanitarian Futures Programme. Integrated Action Plan. Final Report, 31 March 2008. London, The Humanitarian Futures Programme, 2008. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S157 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ e-health in the Eastern Mediterranean Region: a decade of challenges and achievements Najeeb Al-Shorbaji1 1Coordinator, Knowledge Management and Sharing, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Najeeb Al-Shorbaji: shorbajin@emro.who.int). Introduction The World Health Organization Eastern Mediterranean Region (EMR) has made huge progress in terms of use of information and communication technology (ICT) in the healthcare sector. Despite the late entry of ICT in health in the Region, there have been many impressive developments both as public health applications and in medical care. The article attempts to draw a picture of the current status of e-health applications in the Region with some specific examples of milestones and achievements made. The overall ICT situation and economic factors coupled with the health situation in the Re- gion dictate the state-of-the-art of e-health. Health situation and socioeconomic indicators in the Region The EMR consists of 22 countries: 15 in Asia and 7 in Africa. A variety of official and local languages are used including Ara- bic, English, Farsi, French, Kurdish, Pashto, Somali and Urdu. The Region has some of the world’s richest and the world’s poorest countries in Africa and in the Gulf Region. The burden of disease differs among the countries as some suffer from a range of communicable diseases such as malaria, tuberculosis and poliomyelitis while others have started to suffer from chronic diseases such as obesity, diabetes and cardiovascular diseases. The Region has a huge disparity in level of development of national (health) information systems. Difficult political environments persist in the Region, particularly for countries with complex emergencies such as Iraq, Palestine, Somalia and Sudan. Weak capac- ity for policy formulation and analysis, strategic planning, economic analysis of health systems and long-term scenarios for human resource development remain major challenges. Health care delivery sys- tems in the Region have widely differing characteristics and performance. However, all countries in the Region face an overrid- ing dilemma: how to meet rising demand with finite, and in some cases shrinking, resources. Most countries in the Region have “mixed” systems of health care, with a varying degree of mix of providers—public, private and government—although usually with 1 sector dominating. One of the most crucial issues facing health systems in the EMR countries is the weakness in planning human resources development. The problems range from absolute shortage to under-employment, where national health systems are unable to absorb human resources, to geographi- S158 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ cal and skills-related maldistribution. The role of governments in health financing is decreasing, and there is limited interest among donors to support health systems and service development projects. The Region is at risk for epidemic-prone diseases because it is a crossroads for in- ternational trade, travel and tourism, and a centre for religious mass gatherings, and is continuously exposed to a changing expatri- ate workforce [1]. e-health is viewed against the above background in the Region. Use of ICT in health is an integral part of national health information systems. These systems rep- resent the backbone of the national health system, being the glue that ties all the com- ponents together. e-health (use of information technology and telecommunications in health) has 3 ba- sic elements: ICT infrastructure, health and biomedical knowledge and people (users). The ICT infrastructure in EMR countries has witnessed rapid development and sus- tained improvement as has been demon- strated by the latest figures and statistics on governance and legal framework, con- nectivity and Internet penetration, personal computer availability for both home use and business applications, training and skills development and applications. The Region is characterized by a huge diversity in ICT readiness in the same way as it has diversity in health situation and other socioeconomic indicators. Information technology and telecommunications in the Region: overview A recent study covering the 6 Levant coun- tries, Egypt, Iraq, Jordan, Lebanon, Pales- tine and Syria; the North African countries of Algeria, Libyan Arab Jamahiriya, Moroc- co, Tunisia and Sudan; along with Yemen in the Arabian peninsula revealed that these 12 countries collectively had a lower personal computer penetration rate than the global average. The 6 Gulf Cooperation Council (GCC) states, Bahrain, Kuwait, Oman, Qa- tar, Saudi Arabia and United Arab Emirates, however, registered a higher number of PCs sold compared to the global norm [2]. Assessment and ranking of 127 countries on factors ranging from the cost of mobile phone calls and available Internet bandwidth to the quality of higher education indicated that Arab countries have risen significantly in the rankings as Egypt moved from rank 80 to 63 and Bahrain, Jordan and Qatar leapt 6, 4 and 11 places respectively. Oman and Saudi Arabia, new to the report, entered at positions 53 and 48 respectively [3]. Table 1 shows the ranking of EMR countries in the Networked Readiness Index. The International Telecommunication Union (ITU) maintains the Information and Communication Technology Opportunity Index [4]. The main objective of the Index is to track the progress of developing countries and highlight their opportunity to become Information Societies which allows it to track the digital divide and to help develop- ing countries particularly measure their progress (or shortcomings). Table 2 shows the 2001–2005 values and 2005 ranking. EMR countries that rank high in the index are more likely to introduce e-health ap- plications. This has become evident from the number and types of e-health projects implemented in these countries and, more importantly, the approach that has been followed by many of them. Internet penetration rates in the Re- gion vary, ranging from a minimum of 0.1% in Iraq to 38.4% in the United Arab Emirates. According to the Internet World Stats, none of the EMR countries is among the top 38 countries that have a penetra- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S159 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ tion over 50%, as of November 2007 [5]. The same classification shows that 3 EMR countries (Bahrain, Kuwait and the United Arab Emirates) are among the 65 “aver- age Internet penetration countries”, with a penetration of 15.2%–49.9%. The 158 “low Internet penetration countries” include all other EMR countries. Table 3 shows the latest available number of Internet users and penetration rates in the EMR countries. In fact 9 EMR countries have a penetration of less than 10%. What is e-health? e-health, or the use of information and com- munication technology in health, is defined as “the use, in the health sector, of dig- ital data—transmitted, stored and retrieved electronically—for clinical, educational and administrative purposes, both at the lo- cal site and at a distance” [6]. The Millen- nium Declaration acknowledges that ICT is an important tool to achieve the Millennium Development Goals; ICT can help alleviate poverty, improve the delivery of education Table 1 Ranking of Eastern Mediterranean Region (EMR)countries in the Networked Readiness Index [3] EMR country Rank in Rank the EMR globally United Arab Emirates 1 29 Qatar 2 32 Tunisia 3 35 Bahrain 4 45 Saudi Arabia 5 52 Kuwait 6 75 Oman 7 53 Egypt 8 63 Morocco 9 74 Pakistan 10 88 Libyan Arab Jamahiriya 11 105 Syrian Arab Republic 12 110 Table 2 Information and communication technology opportunity index for the Eastern Mediterranean Region (EMR): 2001–2005 values and 2005 ranking [4] Country Rank in World Average annual EMR rank growth rate 2005 2005 (%) 2001–05 Qatar 1 39 79.39 United Arab Emirates 2 41 42.99 Bahrain 3 44 39.53 Kuwait 4 54 44.80 Lebanon 5 62 49.61 Saudi Arabia 6 75 45.19 Jordan 7 84 29.89 Oman 8 86 41.01 Tunisia 9 94 50.07 Islamic Republic of Iran 10 98 44.16 Palestine 11 99 35.66 Morocco 12 105 57.95 Egypt 13 107 51.89 Syrian Arab Republic 14 112 82.59 Libyan Arab Jamahiriya 15 122 46.47 Sudan 16 135 99.76 Pakistan 17 139 79.51 Djibouti 18 146 55.25 Somalia 19 158 91.40 Afghanistan 20 180 399.71 Yemen NA NA 97.67 Iraq NA NA NA = not available S160 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ and health care, make government services more accessible, and much more. Target 18 of Goal 8 calls upon countries to “in cooperation with the private sector, make available the benefits of new technologies, specifically information and communica- tions” [7]. e-health in the Regional strategy The World Health Organization (WHO) Regional Office for the Eastern Mediter- ranean developed a Regional strategy for knowledge management to support public health which was adopted by the 53rd ses- sion of the Eastern Mediterranean Regional Committee in 2006 [8]. The strategy cov- ered strategic directions at Regional level, including: managing knowledge policies, strengthening publishing and dissemination, promoting electronic publishing, expanding multilingualism, enhancing networking and communication, and strategic directions at country level, including leveraging e-health: use of ICT in health, building capacity for needs assessment, planning and evalua- tion, strengthening national programmes for knowledge management, enhancing infor- mation and communication infrastructure in health care institutions, developing human resources, supporting knowledge transla- tion, promoting knowledge generation and establishing knowledge hubs. A strategic direction entitled Leverag- ing e-health: use of ICT in health in the Eastern Mediterranean Region covers all aspects of e-health and provides the ra- tionale and areas of application for ICT in health. e-health represents a cornerstone of the Regional strategy as a major enabling factor for implementing strategic initiatives and objectives. The endorsement by Mem- ber States of the strategy represents their endorsement of e-health and commitment to its implementation. Collaborative activities in the area of e-health will be implemented in all areas of work, with particular emphasis on the following: • measuring progress and trend analysis • use of statistics for quality improve- ment Table 3 Number of Internet users, penetration rate and use growth in the countries of the Eastern Mediterranean Region [5] Country Internet users Penetration 2007 (%) United Arab Emirates 1 708 000 38.4 Kuwait 816 700 32.6 Qatar 289 900 32.0 Islamic Republic of Iran 18 000 000 27.5 Lebanon 950 000 24.2 Bahrain 157 000 22.2 Morocco 7 300 000 21.3 Saudi Arabia 4 700 000 17.0 Tunisia 1 722 000 16.6 Jordan 796 900 13.2 Egypt 8 620 000 10.5 Palestine (West Bank) 266 000 10.5 Oman 319 200 10.0 Syrian Arab Republic 1 500 000 7.8 Pakistan 12 000 000 7.3 Libyan Arab Jamahiriya 260 000 4.2 Sudan 1 500 000 3.7 Djibouti 11 000 2.2 Afghanistan 535 000 1.7 Yemen 270 000 1.2 Somalia 98 000 1.0 Iraq 36 000 0.1 Eastern Mediterranean Health Journal, Vol. 14, Special Issue S161 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ • health networking and collaboration • representation (geographic informa- tion systems, electronic design, ani- mation and multimedia enable graphic representation of health concepts and geographical knowledge stored as raw data) • decentralization • health education and learning • delivery of health services • income generation and economic oppor- tunities • access to information and knowledge. e-health challenges in the Region The diversity and variation in the socioeco- nomic and cultural situation among coun- tries of the Region has resulted in variation and multiplicity of constraints in e-health implementation [9]. The constraints range from lack of awareness of potential e-health benefits; shortage, and sometimes total lack, of funding by the government and other healthcare providers; privacy concerns and lack of legal framework; weakness of in- formation infrastructure; complex systems coupled with lack of skilled personnel; and lack of data standards that permit exchange of health data in local languages. The specific challenges in the Region include: • challenges in health data management, including absence of policies for data collection, absence of unified coding systems; absence of standards; disparity in quality of systems and data collected; little analysis and possibly no use of data; • challenges to computerization or data processing, including fragmented efforts to develop applications; duplication of computer systems, even in the same in- stitution; disintegration of systems; huge quantities of data stored in computers; • challenges related to value and role of e-health as part of national health system, including what ICT is and how it can improve health; status of ICT among national health priorities; ab- sence of measurement of the impact of ICT health; many pilot projects in small settings; resistance to ICT in health by healthcare professionals; ICT tools are not for health by design; and the com- munication gap between ICT specialists and healthcare specialists limits ability to develop appropriate systems for e- health; • lack of financial support and sustain- ability, including funding e-health as research projects; funding e-health as pilot projects rather than long term com- mitment; funding e-health projects from donor agencies rather than from national budgets; funding for a specific compo- nent of e-health applications in isolation from other elements; funding for paral- lel systems in different institutions to do the same thing (cut and paste type of strategy); and funding for vertical programmes in the absence of integrated solutions; • poor public–private partnerships in e- health, including private sector health- care institutions having their own plans; private ICT companies working with the private health sector; private sector not willing to invest in ICT applications on behalf or in collaboration with the pub- lic sector; funding in the public sector not guaranteed and not appealing to the private sector; • poor quality of ICT infrastructure, in- cluding healthcare institutions not on the priority list for computerization; S162 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ national information infrastructure very weak; ICT services very expensive; ICT services under the monopoly of the gov- ernment; private sector still weak (which reduces competition); Internet penetra- tion very weak; • lack of technically competent staff at all levels, including healthcare profession- als not receiving ICT training as part of their undergraduate programmes; ICT professionals mainly hardware and soft- ware engineers with little orientation on medical applications; in-service training and continuous education missing in the area of health informatics; very few spe- cialized health informatics programmes; and team formation [health and informa- tion technology (IT) specialists] weak; • legal and policy issues, including am- biguous legal framework; poor data management; lack of data security; lim- ited trans-border data flow; open space of information flow and dissemination leads to misinformation, unethical use, concealed bias, covert self-dealing, fraudulent practices and evasion of le- gitimate regulation; • lack of vision and clear policy direction for access to information, ICT and e- health; • lack of political commitment: short- sighted view of the long term value of e-health; • cultural and multilingual challenges as many e-health systems were developed in languages other than those used in the Region; imported systems comply with cultural needs of countries that devel- oped them rather than those importing them. Participants of the inter-country meeting of health informatics focal points held in 2001 concluded that the health and medical informatics situation in the Region had some problems which required immediate inter- vention by top management in ministries of health [10]. Many positive initiatives had been taken by the countries of the Region, especially in terms of developing strategies and long-term plans, as well as applications in specific areas of health informatics. More specifically, the meeting drew the following conclusions: • The mission of IT departments in minis- tries of health needs to be well defined. • Electronic medical records are an es- sential cornerstone for supporting health care services. • Use of telemedicine is growing in the Region. • The move to electronic libraries, virtual libraries and health sciences databases is an essential element in health care provi- sion. The meeting produced a set of recom- mendations for Member States which since then have constituted the basis for e-health activities in EMR countries. They aimed at institutionalization of ICT support in ministries of health, building better infra- structure, investment in human resources, and expansion of the use of ICT to cover technical health areas. Progress in e-health in the Region Health on the Internet In the 22 countries of the Region, all but 4 (Djibouti, Iraq, Libyan Arab Jamahiriya and Somalia) have established websites. These websites vary in quality, language (5 sites in English only, 5 in Arabic only, 6 in Arabic and English, 1 in French and 1 in Farsi) and comprehensiveness. Most of them are not built to function as e-health tools for health professionals and the public: they provide information on the Ministry’s structure, ac- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S163 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ tivities, departments, etc. but do not provide healthcare services or health and medical advice. Health on the Internet is weak in the Region: in early 2006, a total of only 258 medical- and health-related websites were found through an Internet search. Currently there are 335 sites available, an increase of 38%. Of these, 51 were in Pakistan, 42 in Egypt, 56 in the Islamic Republic of Iran, 29 in Lebanon and 32 each in Bahrain, Jordan, Palestine and Saudi Arabia. The other 29 sites were distributed among the other coun- tries. Health websites in the Region were maintained mainly by ministries of health, medical education institutions, research centres and hospitals in the private sector. Internet connections and web presence at health care institutions in the Region are still suffering from the digital divide. e-learning A number of countries in the Region have launched e-learning initiatives in the area of public health and medical education and health education. These range from present- ing offline electronic information resources such as CD-ROMs to the more interactive web-based e-learning systems. e-learning for healthcare professionals In the Islamic Republic of Iran, e-learning was introduced in many medical universi- ties with simple technologies such as com- puter networks, multimedia, search engines, electronic libraries, and distance learning. Among the most prominent universities that have adopted these technologies are the medical universities of Tehran, Shahid Be- heshti, Mashhad, Esfahan, Tabriz, Shiraz, Ahwaz, and Kerman. They have built a network of digital libraries that provides ac- cess to students and faculty to the electronic resources in all these universities. Some of them utilize the Distance Learning Network (DLN), and a national programme is being implemented to train academic staff; some courses have been taught in Tehran and Shahid Beheshti Universities as well [11]. In Pakistan, the Aga Khan University has been developing capacity to make e- learning a common feature of education in its School of Nursing and Medical College. It has more than 1500 computers for its 1000 students and 4000 employees. The university uses the Internet, intranet, ex- tranets, satellite, broadcasts, videos and CD ROM technologies in teaching and learning [12]. In Morocco, the Institute National d’Administration de Santé (INAS) in Ra- bat, which is mandated for the develop- ment of human resources in health, has initiated an e-learning project for training of healthcare professionals. One of the major players in health education in Morocco, INAS reaches out to 45 000 health care workers at different levels (doctors, nurses, health care workers, trainers, etc.) with limited resources; e-learning was, therefore, considered a possible solution. INAS forged collaboration with the Institute of Tropical Medicine, Antwerp, the Netherlands aiming at developing human resources in health using the e-learning approach [13]. e-learning for health education and promotion WHO drafted an e-Health Strategy which was submitted to the 115th session of its Ex- ecutive Board on January 2005 (EB115/39). The e-health resolution (WHA58/28) is the outcome of the proposed e-health strategy to the 58th session of the World Health As- sembly. “e-health for citizen’s education and health promotion” or “Health Acad- emy” is a WHO initiative to create a global health and technology alliance. It provides guidance in terms easily understood by peo- ple from all walks of life and all age groups, S164 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ taking into consideration individual cultural sensitivities. Information is prepared and then translated into the local language of the country in a culturally acceptable form. A pilot phase of the Health Academy was completed and evaluated in Egypt and Jordan. It involved a total of 6785 students in the age range 12–17 years in 45 schools. The students’ evaluation of the courses was most positive. It demonstrated that the Health Academy e-learning approach is an effective tool to learning and it can impact attitudes and behaviour [14]. The Health Academy is currently being expanded to other countries in the EMR and other regions. An expansion phase was com- pleted in Jordan in 2007–08, during which the Academy was introduced in 72 schools in all parts of the country. The Academy was also introduced in Lebanon in 2007–8: 40 schools were covered: governmental 20, private 10 and the United Nations Relief and Works Agency for Palestine Refugees 10. The projects were managed by both the Ministry of Health and the Ministry of Education. An introductory and planning workshop was organized in Saudi Arabia in 2007 for the GCC countries and Yemen. The work- shop resulted in development of plans of action for the introduction of the Academy in these countries. Telemedicine activities and applications Interest in health informatics and telemedi- cine started in the Regional Office in the mid-1990s. Systematic effort was exerted to institutionalize health informatics and telematics (e-health). The Regional Com- mittee in its 44th session in 1997 discussed a technical paper on “Health informatics and telemedicine” which reviewed progress and telemedicine activities in the Region at the time. The reported experience of EMR countries in telemedicine applications was modest and fragmented, and did not reflect the real situation. A resolution was passed in which Member States and the Regional Director of the EMR were requested to strengthen the use of ICT in health and in- troduce the necessary legal framework and infrastructure at both country and Regional level. The Regional Office conducted a survey of telemedicine applications and services in the Region in 1999/2000 (16 countries out of 22 completed the questionnaire) [15]. The survey included questions on all aspects of telemedicine activities. The fol- lowing are the main findings: • The primary objectives of telemedicine in EMR countries are medical consulta- tion and medical education (distance learning), which involve transmission of static black-and-white images, trans- mission of colour images, transmission of slow-scan video and transmission of video images plus voice. • Telemedicine projects in EMR countries mainly comprise consultation between a doctor and another doctor or paramedic outside the country, transmission of im- ages and consultation between a doctor and another doctor or paramedic inside the country. • The participants in and operators of telemedicine programmes in the Region are ministries of health, hospitals or clin- ics and telecommunications authorities. The programmes are offered as public services; a number of them are still at the experimental stage. • The vast majority of telemedicine pro- grammes are funded by government subsidy. The private sector has not come forcefully into this area. • Access to telemedicine services in EMR countries is mainly offered to those par- Eastern Mediterranean Health Journal, Vol. 14, Special Issue S165 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ ticipating in the telemedicine experi- ment or programme, or other medical practitioners, with very little access pro- vided to those in remote and rural areas. • The majority of the EMR countries pro- vide training as part of the telemedicine programme. That training is mainly pro- vided to doctors and health care work- ers. • The telecommunications facilities that are used to provide telemedicine services in the region include satellite, wire-line telephone service and wireless radio. • The vast majority of EMR countries do not have national policies or regulations for telemedicine services. Few countries have the intention to develop national policies covering telemedicine. • The majority of telemedicine services in the EMR function under license ei- ther from the Ministry of Health or the Ministry Communications. A number of countries have no licensing schemes. Health mapping and geographic information systems Health mapping and utilization of geo- graphic information systems in health have been considered key e-health applications as they represent a state of development and maturity in health information man- agement. Health mapping requires robust health statistics and thematic databases combined with spatial databases for geo- graphic entities and locations. The Regional Office developed a strategic plan for health mapping in 2003 which was used to guide and assist countries to implement health mapping activities. The Regional Commit- tee [16] passed a resolution in October 2007 to support health mapping and institutional- ize it EMR countries. A review of published literature showed that a number of countries in the Region have used GIS for health mapping. The common element in all these studies is the strong link between geography (location) and the health problem being addressed. Presenting health data in a map, using GIS, was employed in these studies to help show the influence of geography on health. A GIS-based analysis was conducted in the Islamic Republic of Iran to map the incidence of childhood cancer in districts of the Tehran metropolitan area and to explore possible clustering of cancer cases in the diverse environments of this area [17]. In a study of the Rift Valley fever outbreak in Yemen in 2000–2001, GIS technology enabled researchers to study the spatial dis- tribution of outbreaks at the national and local levels [18]. In Egypt, health mapping techniques have been used for a number of different purposes. Several studies were conducted in which GIS functions were used to identify environmental indicators for villages at high risk of filarial transmission [19,20]. In Afghanistan, a study was conducted using GIS technology and population- weighted raster maps to assess mine educa- tion performance, coverage and costs [21]. In Saudi Arabia, GIS technology was used to produce catchment area and patient pro- file distribution and flow models to support local health planners in their health care decision-making [22]. A study in Lebanon integrated different data sources using GIS techniques to sup- port decision-making in the humanitarian sector. In the humanitarian community, data integration for health mapping has served as a powerful coordination mechanism and led to the creation of UN-led Humanitarian Information Centres [23]. In Kuwait, a GIS application was used to model exposure to smoke from oil fires by integrating spatial and temporal records of smoke concentrations and population S166 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ movements. Exposure was then linked with reports of upper respiratory ailments [24]. Health informatics education in the Region The importance of health (medical) infor- matics education was recognized by the Regional Office as it has the potential to change the status of use of ICT in health. It is believed that qualified health informatics professionals can make the move towards successful national e-health programmes. Health informatics support has been pro- vided in many countries through healthcare professionals interested in ICT or by ICT professionals who found themselves work- ing for ministries of health and healthcare institutions. The problem has been the lack of understanding of needs coupled with lack of skills in health informatics applica- tions. The Regional Office made attempts to develop health informatics education programmes as part of medical education or as full-fledged programmes to gradu- ate qualified professionals in this field. A model curriculum for health informatics was developed and shared with medical and health sciences colleges in the Region. A number of countries have also rec- ognized the need and took major steps to establish postgraduate programmes in health informatics, which holds the promise of producing a generation of health infor- matics professionals in the Region. A few examples are presented here. Islamic Republic of Iran: health informatics MSc programme The MSc in Health Informatics programme is a new 2-year programme and is being delivered in collaboration with Zahedan University of Medical Sciences. The programme provides students the knowledge and skills that will help them maximize the use of information and ICT in the health care sector. It equips students with generic tools to enable them to respond to future developments in health care and in information technology while grounding these in the “real world” of current initia- tives in information policy, technology and management. Students study the programme in Chaba- har, Islamic Republic of Iran via distance learning and also spend a semester at the University of Sheffield in the United King- dom [25]. Saudi Arabia: health informatics MSc programme The College of Public Health and Health In- formatics was established in 2006 as part of the King Saud bin Abdulaziz University for Health Sciences. The college offers gradaute studies in health informatics, health systems and quality management, public health, and epdimology and mediacl statistics. The need to establish a postgraduate programme on health informatics was based on recognition that hospitals and other healthcare institutions in Saudi Arabia had to modernize themselves through the utilization of information technology to improve services, reduce costs and improve efficiency. Lack of trained health informat- ics professionals was believed to hamper development in the healthcare sector [26]. The MSc programme started in Septem- ber 2006 with a group of 25 students, with the intention of keeping the intake within this range. The mission of the programme is to advance the quality and efficiency of the Saudi Arabian healthcare system through improved information management, com- munication and the generation of new forms of knowledge. Oman: postgraduate diploma in medical librarianship The Regional Office recommended in one of its missions to Oman the establishment of Eastern Mediterranean Health Journal, Vol. 14, Special Issue S167 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ a medical librarianship training programme in collaboration with the Department of Library and Information Science at Sultan Qaboos University. The Ministry of Health and the university worked on the implemen- tation of that recommendation and made an agreement to establish a postgraduate di- ploma programme in medical librarianship (N. Al-Shorbaji, unpublished report, 2002). The first batch of students, comprising 12 science graduates, was enrolled in the programme in the academic year 2003/04. The 1-year programme offers courses on medical librarianship as a profession, clas- sification, indexing and cataloguing using specialized systems, medical library serv- ices, health on the Internet and a research project [27]. Health informatics professional associations in the Region Professional associations play a major role in networking and cooperation among e- health professionals. They set and raise the standards of professional practice in e-health, enhance the status of the profes- sion, build capacity of human resources, represent the voice of the practitioners, organize conferences and meetings, publish specialized literature and more importantly build a sense of belonging among members. A common set of objectives among these associations includes: • to provide healthcare professionals and policy makers with knowledge, skills on how to make best use of ICT in health- care, • to enhance communication and build communities of health informatics pro- fessionals, • to promote medical/health informatics as a viable and respected profession, • to encourage collaboration and sharing of experience at national, regional and international level, • to foster enhanced collaboration and establish relationships with relevant or- ganizations world wide, • to further foster and enhance research, development, and the diffusion and dis- semination of medical/health informat- ics, • to establish codes of ethics and practice, • to provide professional and independent advice to national authorities. Examples of associations that are active in the Region are listed below. Syrian Arab Republic The Syrian Medical Informatics Associa- tion was founded as one of the scientific associations of the Syrian Medical Associa- tion (Syndicate) [28]. It aims to improve the status and the professioan of medical infor- matics to become part of medical practice. Islamic Republic of Iran The Iranian Medical Informatics Associa- tion is the premier professional association to advance and advocate the use of ICT at every level in the delivery of healthcare and medical services. It was established in 2005 as a result of recognition of the role of ICT in health and the need to network and col- laborate at national and global levels. The mission of the association is to facilitate continuous quality improvement in health through advocating and advancing the use of advanced ICT throughout the country [29]. Lebanon The Lebanese Medical Informatics As- sociation is a non-profit, nongovernmental organization based on the voluntary work of health professionals and computer sci- entists with a special interest in medical informatics. The purpose of the association is to promote the use of the telecommu- nications and information technology in S168 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ medicine or, perhaps more accurately, in the health sector. This technology is viewed as a means to improve the services offered by the healthcare delivery system, decrease their cost and reduce loss of time in service delivery [30]. Saudi Arabia The Saudi Association for Health Infor- mation was established to work under the direct supervision of King Saud University for Health Sciences to practice public ac- tivities, develop theoretical and applicable knowledge, and provide scientific and ap- plicable studies and consultation, private and public. It aims to act as an umbrella for practitioners in healthcare to better utilize the applications of health informatics in therapeutics, research and e-learning [31]. Pakistan The Telemedicine Association of Pakistan was established to oversee the campaign and future projects of telemedicine in Paki- stan [32]. The association has contributed to training programmes, initiation of projects and fostering international collaboration. Arab region The Arab Telemedicine Society was found- ed under the umbrella of the Arab Medical Union in October 1999 after the recommen- dations of the First International Telemedi- cine Symposium for the Arab World, Africa and Europe held in Tunis in 1998. Founding members were representatives of 6 Arab countries (Algeria, Egypt, Jordan, Kuwait, Morocco and Tunisia). The role and purposes of the society are: • to promote the creation of national asso- ciations in the Arab World and scientific exchange between them; • to support cooperation between Arab nongovernmental organizations, and dialogue and cooperation between gov- ernmental and non governmental institu- tions; • to bring together e-health users: scien- tists, researchers, sponsors, manufactur- ers and distributors; • to support activities relating to the es- tablishment of appropriate legal outline conditions for telemedicine applications [33]. Eastern Mediterranean Region The Middle East Association of Healthcare Informatics (MEAHI) is a geographic chap- ter of the International Medical Informatics Association. The association was estab- lished in response to the need for education and awareness of medical/health informat- ics as a key to continuous quality improve- ment in the health industry in this Region. For several years, there had been a growing recognition that a professional body spe- cializing in biomedical/healthcare informat- ics was needed, however, it was necessary to wait for the emergence of greater aware- ness in the Middle East medical/healthcare professional community before MEAHI could be established. MEAHI includes in its membership health informatics associations and educational institutions and individu- als in the Region [34]. It is a chapter of the International Medical Informatics Associa- tion, and complies with the aims and objec- tives of that association. Research and publication in e-health in the Region Research and publishing in a scientific field is a sign of its development and progress. The e-health field has not been well re- searched and published in the Region due to the novelty of the subject, lack of long term and established experience, lack of expertise and lack of funding to document experience and conduct research. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S169 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ A search on e-health was run in the Index Medicus for the Eastern Mediterra- nean, which is the largest database of health and biomedical literature in the Region [35]. In addition to the standard Medical Subject Heading (MeSH) term “information management” a number of search strategies were used to search the database, including health (or medical) and informatics, (com- puters; health and information and manage- ment; health or medical records; hospital and information and systems; health and Internet; and medical librarianship. The result was a total of 71 articles and research papers of which only 1 paper used the term e-health in its title and abstract. The papers covered a range of topics such as medical informatics (19 articles), medical records (16 articles), hospital information systems, searching the Internet and use of computers in health. Journals from Pakistan (33) and Saudi Arabia (19) produced the highest number of articles. It is worth noting, however, that the majority of research in ICT in health is disseminated through medical conferences that organize special sessions on e-health, or through the specialized conferences or- ganized in the Region on the use of ICT in health. It is estimated that during the past 10 years over 250 research papers have been presented to conferences in the Region on the topic of e-health and its variations. The most prominent and regular conferences have been: • Regional Conference on e-health, which is organized every other year by the Re- gional Office; the 5th in the series was convened in June 2006; • Regional Conference on Virtual Health Sciences Library; the 5th in the series was convened in November 2007; • Regional Conference on Medical Jour- nals Publishing, which is organized by the Regional Office; the 3rd in the series was convened in January 2006; • Middle East Information Technology in Healthcare Forum; the 4th in the series was convened in January 2008; • Annual Meeting of Specialized Medical Centres, Alexandria, Egypt (special ses- sion on e-health); • Syrian National e-Health Conference, November 2005; • Euro-Mediterranean Medical Informat- ics and Telemedicine Conference; the last conference was convened in March 2008; • Saudi e-health Conference, the last con- ference was convened in March 2008; • joint EMR, ITU conferences on compu- ter applications in health; the last was convened in November 2007; • Kuwait Public Health Conference, April 2008 (special session on e-health); • Middle East Medical Congress (special session on e-health); • Medicine in the Information Technol- ogy Era (Tanta, Egypt), 2002. Access to health information Regional partnerships: networks and communities The Regional Office has been working with EMR countries to develop the Virtual Health sciences Library (VHSL) which is a collaborative effort for networking and resources-sharing. The main objective is to facilitate and enhance access to health information in the Region [36,37]. The ac- tive participation of countries is the Region has substantially contributed to the success of this effort. A number of initiatives have been implemented with the full participa- tion of EMR countries. These include: • Union List of Medical Journals in the Region. The List includes complete list- S170 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ ing of holdings of 6280 journal titles in 222 libraries from 18 countries in the Region. The List is supported by an electronic document delivery service that countries run on their own. • Regional Medical Journals Consortium, which is a collaborative effort among countries providing the facility to ac- cess the online version of all journals by any institution that has a subscription to any number of journals within the Consortium. The Consortium includes 950 journal titles, accessible to 87 insti- tutions in the Region. • Index Medicus for the Eastern Mediter- ranean, which includes indexing and abstracting of 420 journals published in 19 countries of the Region. The Index is published on the Internet and is backed up by an electronic document deliv- ery service. The contribution of EMR countries to the Index is considered an example of partnership among countries for better registration, monitoring and access to health research. • Directories of medical colleges, medical libraries, editors, research institutions and collaborating centres. These direc- tories are used as a basis for networking and collaboration among the countries of the Region. The contribution of coun- tries towards the update and mainte- nance of these directories signifies their commitment to information and knowl- edge sharing. Three EMR countries (Af- ghanistan, Djibouti and Somalia) have not yet contributed to the database due to a total absence of medical journal publishing. Networks and communities of practice have been built and maintained through the full collaboration of professionals in the Re- gion. These include the Virtual Health Sci- ences Library, the Eastern Mediterranean Association of Medical Editors, Health Informatics, the Eastern Mediterranean Approach to Non-Communicable Diseases Network and Arabization of Health Sci- ences Network. Global partnerships: HINARI implementation in the EMR countries The Health InterNetwork Access to Re- search Initiative (HINARI) provides free or very low cost online access to the major journals in biomedical and related social sciences to local, not-for-profit institutions in developing countries. HINARI was de- veloped in the framework of the Health InterNetwork, introduced by the United Nations Secretary-General at the UN Mil- lennium Summit in the year 2000. HINARI was launched in January 2002, with some 1500 journals from 6 major publishers, following the principles in a Statement of Intent signed in July 2001. Twenty-two additional publishers joined in May 2002, bringing the total number of journals to over 2000. Since that time, the number of participating publishers and of journals and other full-text resources has grown continuously. Today more than 70 publishers are offering their content in HINARI, and others will soon be joining the programme. An evaluation is in progress which will determine the long term future of HINARI. The publishers and other partners have made a commitment to sustain the ini- tiative until 2015 [37]. Eleven countries in the EMR have benefited from the initiative. To date 198 institutions (Afghanistan 17, Djibouti 4, Iraq 50, Palestine 13, Somalia 7, Sudan 42 and Yemen 27) have registered in HINARI as part of Phase 1, which makes them eligible for access free of charge, and Phase 2 (Jordan 13, Morocco 14, Syr- ian Arab Republic 6 and Tunisia 5), which allows for access at very low cost. The Eastern Mediterranean Health Journal, Vol. 14, Special Issue S171 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ WHO Regional Office provided training sessions in the 11 countries, bringing the to- tal number of trainees to over 1000; this was in addition to the local training provided by national institutions. Conclusion e-health has made substantial progress in the Region. An inventory of projects and activi- ties would not be practical here, but the indi- cators to this progress are evident from the examples and the specific national activities that have been covered. This progress can be better calibrated when legal frameworks are introduced, national e-health policies are developed, more human resources are trained, regular funding is committed and long term plans are made. References 1. Proposed programme budget for the financial period 2008–2009. Regional Committee for the Eastern Mediterra- nean, Fifty-third Session (EM/RC53/3). September 2006. 2. Middle East PC penetration lower than global average says Madar study. Business Intelligence Middle East, 2006 (http:/ /www.bi-me.com/main. php?id=2935&t=1&c=34&cg, accessed 20 August 2008). 3. Global Information Technology Report 2007–2008. Geneva, World Econom- ic Forum, 2008 (http://www.weforum. org/en/initiatives/gcp/Global%20Inform ation%20Technology%20Report/index. htm, and http://www.weforum.org/pdf/ gitr/2008/Rankings.pdf, accessed 20 Au- gust 2008). 4. ICT opportunity index (ICT 01). In: World Information Society report 2007. Geneva, International Telecommunication Union, 2007 http://www.itu.int/osg/spu/publi- cations/worldinformationsociety/2007/ WISR07-chapter7.pdf, accessed 20 Au- gust 2008). 5. List of countries by broadband and In- ternet penetration. Internet World Stats, 2008 (http://www.internetworldstats.com/ list4.htm, accessed 20 August 2008). 6. E-health in the Eastern Mediterranean Region: what is e-health? Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2005 (http:// www.emro.who.int/HIS/ehealth/AboutE- health.htm, accessed 20 August 2008). 7. Tools for development using informa- tion and communications technology to achieve the Millennium Development Goals (working paper). New York, United Nations ICT Task Force, 2003 (http:// www.epol-net.org/pport/pdf/417763324. pdf/, accessed 10 February 2006). 8. Al-Shorbaji N. Regional strategy for knowledge management to support public health. Technical paper presented at the Fifty-third Session of the Regional Com- mittee for the Eastern Mediterranean, 2006 (EM/RC53/6). 9. Al-Shorbaji N. E-health challenges in the Eastern Mediterranean Region. Paper presented at the 4th International Confer- ence, Euro-Mediterranean Medical Infor- matics and Telemedicine, 13–15 March 2008, Tripoli, Libyan Arab Jamahiriya. 10. Report on the inter-country meeting of health informatics focal points. Cairo, World Health Organization Regional Of- fice for the Eastern Mediterranean, 2002 (WHO-EM/HIS/003/E/L). 11. Rokni MB. e-Learning in Type 1 medical universities in Iran. Paper presented at the Fourth Regional Conference on EMR Health Sciences Virtual Library: role in S172 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ e-learning and building the information society, Cairo, 23–25 November 2004. 12. Naqvi SA, Rizvi A, Akram H. Developing an e-learning community at Aga Khan University. Paper presented at the 4th Regional Conference on EMR health sci- ences virtual library: role in e-learning and building the information society, Cairo, 23–25 November 2004. 13. De Waard I. INAS, Rabat, Morocco – starting an eLearning project – the basics. (http://ignatiawebs.blogspot. com/2008/05/inas-rabat-morocco-start- ing-elearning.html, accessed 20 August 2008). 14. Health Academy. Geneva, World Health Organization, 2003 (http://www.who.int/ healthacademy/en/, accessed 20 August 2008). 15. Al-Shorbaji N. Telemedicine in the East- ern Mediterranean Region of the World Health Organization. Paper presented at the 3rd Regional e-health symposium, Dubai, United Arab Emirates, 27–28 Jan- uary 2003. 16. Al-Shorbaji N. Use and potential of geo- graphic information systems for health mapping in the Eastern Mediterranean Region. Technical paper presented at the Regional Committee 54th session (RC54), Cairo, 20–23 October 2007. 17. Mosavi-Jarrahi A et al. Clustering of child- hood cancer in the inner city of Tehran metropolitan area: a GIS-based analysis. International journal of hygiene and envi- ronmental health, 2007, 210(2):113–9. 18. Abdo-Salem S et al. Descriptive and spatial epidemiology of Rift valley fever outbreak in Yemen 2000–2001. Annals of the New York Academy of Science, 2006, 1081:240–2. 19. Sowilem MM et al. Spectral and land- scape characterization of filarious and non-filarious villages in Egypt. Journal of the Egyptian Society of Parasitology, 2006, 36(2):373–88. 20. Hassan AN et al. Prediction of villages at risk for filariasis transmission in the Nile Delta using remote sensing and geo- graphic information system technologies. Journal of the Egyptian Society of Parasi- tology, 1999, 28(1):75–85. 21. Anderson N, Mitchell S. Epidemiological geomatics in evaluation of mine risk edu- cation in Afghanistan: introducing popula- tion weighted raster maps. International journal of health geographics, 2006, 5:1. 22. Murad AA. Creating a GIS application for local health care planning in Saudi Ara- bia. International journal of environmental health research, 2004, 14(3):185–99. 23. Benini AA et al. Integration of different data bodies for humanitarian decision support: an example from mine action. Disasters, 2003, 27(4):288–304. 24. Lange JL et al. Exposures to the Kuwait oil fires and their association with asthma and bronchitis among Gulf war veterans. Environmental health perspectives, 2002, 110(11):1141–6. 25. MSc in Health Informatics (Iran) pro- gramme. Sheffield UK, University of Sheffield, 2008 (http://www.shef.ac.uk/is/ prospectivepg/courses/health/iran.html, accessed 20 August 2008). 26. Master’s program in health informatics. Riyadh, King Saud bin Abdulaziz Univer- sity for Health Sciences, 2007. 27. Jabr N. The Post-Graduate Diploma of Medical Librarianship. In: Report pre- sented at the 4th Regional Conference on EMR health sciences virtual library: role in e-learning and building the information society, Cairo, Egypt, 23–25 November 2004. 28. Shahrour G. The role of professional and non-governmental societies in the promo- tion of e-health: case of Syrian Medical Informatics Association (SMIA). Report presented at the 5th Regional Confer- ence on e-health and related applications, Cairo, Egypt, 27–29 June 2006. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S173 ǂnjǟ Ǟƥơǂdzơ ƾǴƴǸǴdz ǍƢŬơ ǁơƾǏȍơ ƨȈŭƢǠdzơ ƨƸǐdzơ ƨǸǜǼǷ ǖLJȂƬŭơ ǩǂnjdz ƨȈƸǐdzơ ƨǴƴŭơ 29. Iran Medical Informatics Association (http://www.irmia.org/, accessed 20 Au- gust 2008). 30. Lebanese Medical Informatics Associa- tion (http://lmia.org/, accessed 20 August 2008). 31. The Saudi Association for Health Informa- tion (http://www.sahi.org.sa/, accessed 20 August 2008). 32. Telemedicine Association of Pakistan (http://www.telmedpak.com/Telemedicine/ #Telemedicine_Association_of_Pakistan, accessed 20 August 2008). 33. El-Matri A. Role of Arab Telemedicine Society in support of e-health. Report pre- sented at the 5th Regional Conference on e-health and related applications, Cairo, Egypt, 27–29 June 2006. 34. Middle East Association of Healthcare Informatics (http://www.meahi.org, ac- cessed 20 August 2008). 35. Index Medicus for the Eastern Mediter- ranean. Cairo, World Health Organization Regional Office for the Eastern Medi- terranean (http://www.emro.who.int/HIS/ VHSL/, accessed 20 August 2008). 36. Virtual Health Sciences Library. Cairo, World Health Organization Regional Of- fice for the Eastern Mediterranean (http:// www.emro.who.int/HIS/VHSL/Index.htm, accessed 20 August 2008). 37. Information networking and knowledge- sharing in EMR. Cairo World Health Or- ganization Regional Office for the Eastern Mediterranean, 2004 (http://www.emro. who.int/HIS/NetWorking/NetWorking. htm, accessed 20 August 2008). 38. Health InterNetwork Access to Research Initiative (HINARI). Geneva, World Health Organization, 2008 (http://www.who.int/ hinari/en/, accessed 20 August 2008). S174 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما =ëb¯Íº >ÃJÉ>¢Ï³¶=ÍÉEÆeÆÙ=L>§·¶=ÍÉEf£¶=ͧ·¶=K¯Fi*Ìb[¢¹=Ç[{Åfi@E>£¶=ÆÙ=¼·£¶=ͧ¶K¾>²b¯ª fn¢O¶>N¶=Áf¯¶=CËaØÉ=¤i>J¶=Áf¯¶=Àº(ÁÆf®*ð>®fmÍÈaeÙ=ÆÍÈ£¶=ÆÍɾ>Èfj¶=Ld]?>ÿ¢Æ*>ÿºLa>ª?Æ >Ef¦ÍÉ¿ÉIض=*ÃQƶ=ÊÂÆÁÇ[ªf£È×=Ǿ>²b®Æ(ÍÈb¿=ÆÍÉie>«¶=ÆÍɾ>¾Çɶ=ͪ>¯N¶=À¢OVF¶=CIض=f¾K =eÇn®×C>ÿº*>[úǷ¢>[ÃJ¯ÈÆ>[ÃÉ¢ÆÍ[ÉEf£·¶Í¿ÈbºÍNÈb=ÍÉEÆeÆÙ=Ívÿ¶=Á?½Çɶ=ÄE¼·j=ÀºXFq?Æ >þǿªÆ***ÍɶÆb¶=¸ª>=>ÃJ¾>³ºd]@IÍÉEf£¶=ËcÊÂ>ÂÆ[M?>º¸²ÍÉì^JºÏ³¶=ÍÉ>£¶=L>§·¶=G¾>QC L>u=¢=ÆL>EÇ£qÀº>ïÈf{]1[* ÍÈ=bF¶=K¾>²iÇJ=±fn¶Ê»É·®Ý=GJ³= e=cA+le>º1949±f[mÍ[¯ì¿Ê[»É·®Ý=G[J³=Ð>n[¾CÎ[·¢Í[É>£¶=ÍVr[¶=Í[»¿ËdÉ«¿J¶=k·=°ª=Æ ºÄ·»¢?bFÈÁ?η¢(iÇJ=gǹÆ?À+ÇɶÇÈ1949Gr[¿º>[m>EÍ[mÇm°[ɪÇIη¢eÇJ²b¶=É£Ief®>»² iÇJ=±fn¶Ê»É·®Ý=fÈb=Y2*WÍÉj¾f«¶=ÆÍÈhÉ·³¾Ý=>»ÂÄÑ>n¾Cb¿¢Ê»É·®Ý=GJ³>E¸»£¶=>J§¶K¾>²Æ* ¹Ç·È?Æ+»JFi1954ÍÉ¢f«¶=Íɻɷ®Ý=Í¿R·¶=KF·{ ? ?ʻɷ®Ý=fÈb=CÍ[§·¶=¹>»£J[i=Í[ɾ>³ºClebÈÁ iÇJ=±fm¼É·®CÍÉ>£¶=ÍVr¶=Í»¿ÍN¶>M¸»¢Í§·²ÍÉEf£¶=Y3*W The Use of Arabic in the World Health Organization. Part One ABSTRACT The course of Arabic in WHO began in September 1954 when the Regional Subcommittee “A” requested the Regional Director to study the possibility of using Arabic as a working language for WHO in the Eastern Mediterranean Region. At WHO Headquarters, Arabic was used as an official lan- guage in the World Health Assembly in May 1972, and became a working language for the Organization in May 1975. This article reviews the progression of the use of Arabic in WHO since then. ءزــلجا) ةيلماعلا ةحصلا ةمظنم في ةيبرعلا ةغللا مادختسا (لولأا يلع دممح معنلما دبع طسوتلما قرشل ةيحصلا ةلجملل يذيفنتلا ررحلماو .اًقباس ةلماعلا ةحصلا ةمظنلم يسيئرلا رقلماب تاغللا مسق سيئر .اًقباس طسوتلما قرشل يميلقلإا بتكلماب A.M. Aly. Former Chief, Office of Languages. WHO Headquarters, Geneva, Switzerland. Former Executive Editor, Eastern Mediterranean Health Journal, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S175 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ¹Ç·È?ΪÆ+»JFi1955Íɻɷ®Ý=Í¿R·¶=KqÆ?(ÍÉ¢f«¶= ? Í[N¶>M¸»¢Í§¶ÆÍÉeͧ·²ÍÉEf£¶=ͧ·¶=¹>»£Ji>E iÇJ=±fn¶Íɻɷ®Ý=Í¿R·¶=Y4*W±>Éj[¶==d[¸[»£¶=Í[§¶ÆÍ[Éf¶=ͧ·¶=E>®fªµ>¿ÂÁ?f²d¶>EfÈbQÆ* >»JQ×=ÆL=fÖ[=Í[ÈeÇ«¶=Í[¶=z=f[¦Ù(ÍÈÇ«n[¶=Íìn¾Ù=¸»£JjIÍÉf¶=ͧ·¶>ª¸[»£¶=Í[§¶>[º?(L>[¢ ´¶d²ÍÈfÈfVJ¶=¹>»¢Ú¶¸»£JjJª* ʾ>N¶=ÁǾ>²Æ+fÈ>¿È1956Í[§·²Í[ÉEf£¶=Í[§·¶=¹>»£Ji>Et>=\=®×=?bF=OÉUÀºËdÉ«¿J¶=k·=bÈ?( ÍVr[¶=Í[É£Åef[¯I>[ºÆÍ[ɾ=hÉ=L>[ɾ>³ºDE>¿ÂeiÇJ=±fn¶Íɻɷ®Ý=Í¿R·¶=ÍN¶>MY5*W[¯ª=Ƽ[MÍ[É£K ½>¢ÀºÐ=bJE=ÍÉEf£¶=ͧ·¶=¹>»£Ji=η¢´¶cb£EÍ£i>J¶=ÍÉ>£¶=ÍVr¶=1957([iÇJ=±fn[¶Íɻɷ®Ý=Í¿R·¶= ÍÈÇ¿j[[¶=Í[[ɾ=hÉ=L=fÈb[[¯IÆËÇ¿j[[¶=Sº>[[¾¶=´¶d[[¶Í[[ºgض=L=a>[[»J¢×=T=eaD[[E½>[[£¶=fÈb[[»·¶Kr[[]eÆ Í»¿»·¶Y6*W Íɾ>MÍ·UfºL?bE´¶cb£EÊ[»É·®Ý=GJ³>EÍÉEf£¶=ͧ·¶=Ìjº*¹Ç[·È?Ê[«ª+»JF[i1961Í[¿R·¶=K[F·{ ÍÉ¢f«¶=Íɻɷ®Ý= ? G[J³=¸[»¢Í[§¶ÆÍ[ÉeÍ[§·²Í[ÉEf£¶=Í[§·¶=¹>»£J[i=Ͷ@jºlebÈÁ?ʻɷ®Ý=fÈb=C iÇJ=±fn¶Ê»É·®Ý=Y7*WÆÍÉ¢f«¶=Íɻɷ®Ý=Í¿R·¶=Lef®Ê¶>J¶=½>£¶= ? Í[ÉeÍ[§·²Í[ÉEf£¶=Í[§·¶=¹>»£Ji= Í¿[iÀ[ºð=e>FJ¢=´¶cdÉ«¿J¶Íºgض=L=Çì=c>=ʻɷ®Ý=fÈb=CKF·{Æ(ʻɷ®Ý=GJ³»·¶1965Y8*WÁ?×C ÍÉ¢f«¶=Íɻɷ®Ý=Í¿R·¶= H Í[ɶ>=Ä[I>£FIÐÇ[u¥Ç[uÇ»·¶Í[i=eb¶=À[ºb[ÈhºÐ=f[QCLef[®¸ÉÑ=fiC¼vI¶= Èe=aÝ=ÆÍY9*WÌa>=Á?Ï?eJÉ¢f«¶=J¿R·¶=Ëe=f®Î·¢ËdÉ«¿J¶=k·=¤·{=Á?b£EÆ50%Æ$Í»¿=eÇJiaÀº ʻɷ®Ý=G·ì==dÂÍÉF·J¶ÍFi>¿ºÍ·ÉiÆfªÇIY10*WL=a>[»J¢=ÍÉ¿£=¼É¶>®Ù=L>ºÇ³UfªÇIÁ@EÌa>=ÅdÂÊv¯IÆ =Íɾ=hÉ=Àº¼É·®Ý=ÍrUK¾>²=cCÍɪ>uCÍɻɷ®Ý=¬Ñ>Ƕ>E½>ɯ·¶Ê«³I×Í»¿»·¶ÍÈh²f*k[·=e=f®¨·Eî?>Æ ÍÉ¢f«¶=Íɻɷ®Ý=Í¿R·¶=CËdÉ«¿J¶= ? Åe=f[®f[¿¶=b[É£ÈÁ?½>[£¶=fÈb[=°[Èf{À[¢ËdÉ«¿J¶=k·=CKF·{ f²d¶=¬¶>j¶=Y11*WÍÉ¢f«¶=Í¿R·¶=>º? H Ä[E>[»·¢Ld[]?b¯ª*¸[£ªaeÁ>[²ÆÄ[¦ØECb[£EËd[É«¿J¶=k[·= OVF¶=bɮͶ@j=Ð>¯ECÇÂJÉ¢f«¶=Jɻɷ®Ý=J¿R·¶=Ëe=f¯EY12*W ÍÉ¢f«¶=Íɻɷ®Ý=Í¿R·¶=Kþ?Æ ? ʶ>J¶=½>£¶=ÄId=e=f¯EͶ@j=ÅdÂ1965Í[ÉEf£¶=ͧ·¶=¹>»£Ji=Á?b²ÖÈ Î·¢b¢>jÈÇiiÇJ=±fn¶Ê»É·®Ý=GJ³=À[³b[UÎr®?C>ïɯÆÍ»¿==bÂ?fn¾*Á?>[»² Ð>v¢Ù=¹Æb¶=¤º¸i=¶=ÆiÇJ=±fn¶Íɻɷ®Ý=Í¿R·¶=¹>»¢?¸£«¶>E¸»£JjàIÍÉEf£¶=*Í[¿R·¶=ÁDª´¶d¶Æ ÍÉ¢f«¶=Íɻɷ®Ý= ? [i×=ÍQeb¶¸rIÁ?Cʻɷ®Ý=GJ³>E>>»£Ji=ÊebJ¶=¤iÇJ¶>EKqÆ?Ê[f¶=¹>»£J Î[·¢¼É·®Ý>[EÍ[ÉEf£¶=¹>»£J[i=¤[iÇJ·¶Íºgض=ÍÉ·»£¶=L=Çì=c>=ʻɷ®Ý=fÈb=CKF·{Æ(¼É·®Ý=½>J¶= b==d©ǷF¶>É·»¢>»ÑغÅ=fÈËd¶=ÇV¿¶=Y13*W ¢KVFq?ÎJU(_Èe>J¶=´¶cd¿ºÊ»É·®Ý=GJ³>EÍÉEf£¶=½=b^Ji=L=Çì]K·q=ÇIb®Æ¤[ºÌ=Æ>j=½b®Î· Èf[]Ù=J[§·¶=L>º=b^J[i=À[º>[®>쾤[iÆ?Le>[q>ÃI>º=b^Ji=ÁC¸E(ÍÉj¾f«¶=ÆÍÈhÉ·³¾Ý=J§·¶=*À[³Æ iÇJ=±fm¼É·®C½Ù=ͧ·¶=KVFq?>þ@E>ëqÆ*Íɶ>J¶=L>V«r¶=´¶c¸Éq>«IafIÇiÆ* Í»¿»·¶ÊjÉÑf¶=f¯= 8¹ÆÙ=ÁǾ>²+jÈa»1971Í[»¿º½>[¢fÈb[ºCð>[E>ì]ÍÈeÇj[¶=Í[ÉEf£¶=Í[ÈeÇû=ÍV[qfÈgƸie? ÍÉ>£¶=ÍVr¶=ÍÉ£»|ÍÉeͧ·²ÍÉEf£¶=ͧ·¶=¹>»£Ji=¥ÇuǺËdÉ«¿J¶=k·=OVFÈÁ?ÄɪG·ìÈÍÉ>£¶=ÍVr¶=* Ef£¶=ÍÈÂ>»=ÍVqÐ=egÆÀºÍ·M>¸Ñ>ifE°U×K®ÆG·ì¶==dÂgh£IÆÀ»É¶=ÆÁ>¿F¶ÆÁ=aÇj¶=ÆÍÉFÉ·¶=ÍÉ* S176 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ¹>[»¢?¹ÆbQ¥ÇuÇ=T=eaDEð=e=f®d=Æ(£EeÙ=ÆÍ£i>J¶=ÄIeÆa¥ÇuÇ==dÂËdÉ«¿J¶=k·=O}Æ ÀÈfn£¶=ÆÍjº>=ÍÉ>£¶=ÍVr¶=ÍÉ£Y14*WÍ[¶ÆaÁÆfn[¢Æ¤[Ee?Kºb[¯IÍVr[¶=Í[É£Æ%1$e=f[®¥Æfn[ ÆÍÉ£»=ÄJn®>¾Ê·È>»²Är¾Á>²Æ(ÄIb»J¢=Y156W x(ÁÆfn£¶=ÆÍjº>=ÍÉ>£¶=ÍVr¶=ÍÉ£ xL½e=f¯¶>Ef²dIcC49±46ÍVr[¶=Í[É£¹>[»¢?¹Æb[QTeb[ÈÁ?ÄFQÇËdÉ«¿J¶=k·=ef®Ëd¶= ľ=Ç¿¢=b¿EÀÈfn£¶=ÆÍjº>=ÍÉ>£¶= >£¶=ÍVr¶=ÍÉ£ÍÉeͧ·²ÍÉEf£¶=ͧ·¶=¹>»£Ji=ÍÉ ( x(ÍÉEf£¶=ͧ·¶=ÍÉ»ÂÙð=f¾Æ x(ͧ·¶=ÅdÃEͯ{>¿¶=Ð>v¢Ù=¹Æb¶=ab¢bÈ=hJ¶ð=f¾Æ x(½Ç·£¶=ÆGì¶=½b¯I>ÂfM?ÆÍɾ>j¾Ý=Ìe>v=eÇìIÍÉEf£¶=ͧ·¶=½>ÃiC>Âe>FJ¢=¤vIcCÆ 1.ef¯I(ÍÉ>£¶=ÍVr¶=ÍÉ£ÍÉeͧ·²ÍÉEf£¶=ͧ·¶=¹>»£Ji= 2.ef¯I¶d²Ìa>=¸Èb£I´84ʶ>J¶=ÇV¿¶=η¢ÍÉ>£¶=ÍVr¶=ÍÉ£»Ê·]=b¶=½>¿¶=Àº6 Ìa>[=84 (ÍÉj[¾f«¶=ÆÍ[ÉEf£¶=ÆÍÉ¿Ér[¶=ÆÍÉ[iÆf¶=ÆÍ[ÈhÉ·³¾Ý=ÆÍɾ>F[iÙ=Ê[ÂÍÉ>£¶=ÍVr¶=ÍÉ£»ÍÉf¶=L>§·¶=ÁdzI ÍVr¶=ÍÉ£»|¸[»£¶=>J§¶>»ÂÍÉj¾f«¶=ÆÍÈhÉ·³¾Ý=ÁdzIÆ*%e>È?+ÇÈ>º1972$* ËdÉ«¿J¶=k·=ÆÍÉ>£¶=ÍVr¶=ÍÉ£¸»¢Í§·²ÍÉEf£¶=ͧ·¶=¹>»£Ji=G·{ÊÂÍɶ>J¶=ÌÇì=K¾>²Æ*b[®Æ Í[É>£¶=ÍVr¶=Íɣη¢zf£·¶¥ÇuÇ==dÂa=b¢ÝÍÈvÍ¿ÍÉEf£¶=¹Æb¶=K·³m*Í[¿R·¶=Åd[ÂK[£»JQ=Æ fr[ºÆ>[ÉFɶÆÁ>¿F¶ÆKÈdz¶=ÆÍÈeÇiÆÁ=aÇj·¶·NÍÈÇv¢Æ(±=f£¶=HÆb¿ºÍi>ÑfEÌfÂ>¯¶>EÍÉEf£¶=Í£º>=f¯ (Ê[Ef£¶=ÍVr[¶=Ð=egÆk[·Ëd[É«¿J¶=GJ³=η¢zf£·¶¥ÇuÇ=¹ÇUe=f®¥ÆfnºÆÌf²dºLb¢?Æ(À»É¶=Æ Íɣη¢>»Ãuf£¶Í»¿»·¶½>£¶=fÈb»·¶>»Ãb¯I¸F®ÍVr[¶=*Í[¶ÆaÁÆfn[¢e=f[¯¶=¥Æfn[ºÎ[¿FIÁ?b[£EÆ%2$ ÀÈfn[£¶=ÆÍ[¿º>N¶=Í[É>£¶=ÍVr¶=ÍÉ£¥ÇuÇ=o®Ç¾*K[ÃJ¾=ÆÍv[É«JjºÆÍ[¯»£JºÆÍ[ɺ>UÍn[®>¿=K[¾>²Æ ʶ>J¶=e=f¯¶=c>=η¢ÍÉ¢>Ý=ͯª=Ç>EY166W •(ÁÆfn£¶=ÆÍ¿º>N¶=ÍÉ>£¶=ÍVr¶=ÍÉ£ x=eÆb¶=µebIcC½b[¯IÎ[·¢>[ÂfM?ÆÄ[Jª>¯MÆÁ>j[¾Ý=Ìe>v[Ufn[¾Æ «UÍÉEf£¶=ͧ·¶=ÄEKº>®Ëd¶=½> (½Ç·£¶=ÆGì¶= x¼[ºÙ=¸»¢Í§¶>þ?Æ(ÍÉ>£¶=ÍVr¶=Í»¿º=Çv¢Í¶ÆaÀÈfn¢Í§¶ÊÂÍÉEf£¶=ͧ·¶=Á?ð>vÈ?µebIcCÆ ¿ºÆͪ>¯N¶=Ƽ·£¶=ÆÍÉE·¶ÌbVJ=¼ºÙ=Í»¿ºÆÌbVJ=iÇJ=±fn¶Ê»É·®Ý=GJ³=ÆÍɯÈfªÝ=ÌbUǶ=Í» (Ïf]Ù=ÍɶÆb¶=L=a>×=ÆL>»¿=ÀºbÈb£¶=Cͪ>uÝ>E(ÍÉ>£¶=ÍVr¶=Í»¿¤E>J¶= %1$Ê[Âe=f[¯¶=¥ÆfnºK¿FI¶=¹Æb¶=6(ÀÈf[VF¶=(Á>Jj[²>E(Ë=Ç[QÆeÆ?(Ìb[VJ=Í[ÉEf£¶=L=e>[ºÝ=(Á>Jj[¾>§ª?(ÁaeÙ= >I(t[®(Á>[»¢(±=f[£¶=(Á=aÇj[¶=(ÍÉF£n¶=ÍÉ{=f¯b¶=À»É¶=ÍÈeÇÃ(ÍÈeÇj¶=ÍÉEf£¶=ÍÈeÇû=(fÑ=h=(k¾ÇI(b¿·È >ɪØiǦÇÈ(À»É¶=(ÍÈaÇ£j¶=ÍÉEf£¶=ͳ·»=(Hf§=(frº(>ÉFɶ(Á>¿F¶(KÈdz¶=(fì®* %2$ÊÂe=f¯¶=¥ÆfnºK¿FI¶=¹Æb¶=6f£¶=L=e>[ºÝ=(ÁaeÙ=Í[ÉEf£¶=Í[ÈeÇû=(f[Ñ=h=(k¾Ç[I(ÀÈf[VF¶=(Ìb[VJ=Í[ÉE (fr[º(>[ÉFɶ(Á>[¿F¶(K[Èdz¶=(f[ì®(Á>[»¢(±=f[£¶=(¹>ºÇr[¶=(Á=aÇj[¶=(ÍÉF£n¶=ÍÉ{=f¯b¶=À»É¶=ÍÈeÇÃ(ÍÈeÇj¶= (>ɾ>JÈeǺ(ÍÈaÇ£j¶=ÍÉEf£¶=ͳ·»=(Hf§= Eastern Mediterranean Health Journal, Vol. 14, Special Issue S177 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما xbÈhºÆ°MÆ?ʶÆaÁÆ>£I°É¯CÍQ>=µebIcCÆ(ÍÉ>£¶=ÍVr¶=Í»¿ÍÉ>£¶=Àº xd[É«¿I¬É¶>[³I¸[»VJ¶>Âa=b£Ji×ÍÉ>£¶=ÍVr¶=Í»¿ºÐ>v¢Ù=ÍÉEf£¶=¹Æb¶=bɲ@IfÈb¯J¶>E UØIcCÆ ÆÙ=PØN¶=L=Ç¿j¶=¹Ø]e=f¯¶==dÂ* ef¯IÍÉEf£¶=ͧ·¶=¹>]aC½b^JjIOÉ}ÍÉ>£¶=ÍVr¶=Í»¿¸»£¶=L>§¶À»uk[·=Æ(Í[É>£¶=ÍVr[¶=ÍÉ£ tÇr[¿¶=¹b[£IÁ?ƼJ[¿ºÐ=fQD²ÍÉEf£¶=¹Æb¶=¤º¸i=¶=½b^JjI>»²(ÍÉ¢f«¶=ÆÍÉjÉÑf¶=Á>R·¶=ÆËdÉ«¿J¶= ½>¿¶=ÍÉ¿£=e=f¯¶==dÂÆ°«JÈ>Ê·]=b¶=*%e>È?+ÇÈ>º1975$* Òn¾?b®ÆLf[m>E(¬[É¿|Í[»¿»·¶Êj[ÉÑf¶=f¯>EL>§·¶=Ìe=aDEÍÉEf£¶=Í·¶ÌbUÆe=f¯¶==dÂeÆbqeǪK e=f¯¶=>ÃÉ·¢s¾¶=½>Ã=dÉ«¿IeÇ«¶=η¢*Ð=f[QCÍ[É¿£=ÍÉEf£¶=L>ì·j¶=¤ºÍ»¿=K²m=Í¿iÊvºb£EÆ ÆÙ=Í¿j¶=¹Ø]¹>»¢?Àº>¼ÉɯI*×AÁ?FIÆËd[É«¿J¶=k[·=Î[·¢Í[uÆf£=±=eÆÙ=À[ºL>V«r[¶= Ïa?Ëd[¶=f[ºÙ=(ÍÈeb¿³iÝ=ÆÌfÂ>¯¶=ÆkÈe>EƬɿQ=L=fn¢Î·¢K¢gÆb®ÍÉ>£¶=ÍVr¶=ÍÉ£Æ X·ìr[=¸[E>¯ºÍºb^Jj[=Í[ÉEf£¶=L>V·ìr[=ÌN[²L>[ªØJ]=Æ(Í[¶=ÌaÇQL>ÈÇJjºLÆ>«IC ·³¾Ý=bU=Ƕ=ËhÉ*ÍÈe=aCÆÍɶ>º¸Ñ>jº¹Æ>¿JIK¾>²L>V«r¶=L>ÒºÁ?À¢Øvª*½=b^J[i=bÉ[mfIËÕe=d³ÂÆ ÌÇQf=ÌbÑ>«¶=¼É£ICÏaÖI¶=ͯÈfì¶>EÍ»¿>EÍÉEf£¶=ͧ·¶=*ÍVr¶=Ð=egÆk·ËdÉ«¿J¶=GJ³=¤»JQ=b®Æ ½ÇÈHf£¶=2e>È?+ÇÈ>º1976Ín®>¿¬É¿QÍ¿ÈbÍ[ÉEf£¶=Ìb[UǶ=[Ef»Jjº°Éj¿Iͺ>®CÏ?eÆ(¥ÇuÇ==d Hf£¶=ÍVr¶=Ð=egÆk·ÍÉ¿«¶=;>ºÙ=EÆ(>NÈbUÌ@n¿=*k[· CÍÈeÆafÈe>¯IÍÉ¿«¶=;>ºÙ=½b¯IÁ?ef®>»² ¥ÇuÇ=¹ÇUHf£¶=ÍVr¶=Ð=egÆ*£¶=fÈb=¤ºeÆ>nJ¶>EËdÉ«¿J¶=GJ³=kÉÑe½Ç¯ÈÁ?ef¯IÆ=dÂͺ>®CÁ@nE½> ÄJ¯Èf{Æ°Éj¿J¶=*Í[F¦eÀ»v[JIͶ>[ieÄ»·[iÆf·Â>[ºÁ=bª>ÂeÇJ²b¶>EΫìrºÌh¢eÇJ²b¶=ίJ¶=(´¶d¶=dÉ«¿IÆ Í[ɪ=f§=Í[¯ì¿=ÍÉVr[¶=Lسn[>EÌf[m>F=Í·r[¶=L=c>[ÃI>¢ÇFìºÆÍ[»¿=°Ñ>[MÆÍfIÊEf£¶=G¾>= bÈhºCËaÖI¶=´·IÆ(ÍÉEf£¶=>[ÃVÑ=ǶÆ>[ÃIhÃQ?Æ>[ëÑ>ÆÆ>ÃJ¶>ifEÍÉ¢ÇJ¶=ÆÍ»¿>E¬Èf£J¶=Àº*K[¯ªeî?Æ ÍÈǶÆÙ=L=cL>¢ÇFì=Æ°Ñ>MǶ=L>ɢǿE>¾>ÉEÀ»vJIÍ»Ñ>®Í¶>if¶>E*ÄJ¶>[ieËd[É«¿J¶=G[J³=kÉ[ÑeÎqÆ?Æ Í»¿=ͺb^Jj=L>V·ìr=Æ>«¶Ú¶¼R£ºa=b¢DE*>¾fEÍÈ=bEÊÂÅdÂK¾>²ÆÍ[»¿Í[ÉEf£¶=L>¢ÇFì=Sº ÍÉ>£¶=ÍVr¶=* k[·Í[É¿«¶=;>ºÙ=EÌfÂ>¯¶>EÍÉEf£¶=Í£º>=;>º?Í£E>JºÆ°Éj¿IÍj·QLb¯à¢H>ì==dÂÐÇuη¢Æ ÆÆ(Sº>[¾·¶Ê¶>[=¬®Ç=Ín®>¿º>Ãɪ(ÍÉ>£¶=ÍVr¶=Í»¿ÍÉEf£¶=ͧ·¶=ÌbUÆEÆHf£¶=ÍVr¶=Ð=egÆ°Ñ>[M Ðb[F¶=ÌeÆf[uÆ(Í[É>£¶=ÍVr[¶=Í[É£»Í[ɶ>J¶=L=eÆb[¶=Ͷ=ÍÉÑ>¯J¾=ÆÀÈfn£¶=ÆÍ£i>J¶=ÍÉ>£¶=ÍVr¶=ÍÉ£ >[Âe>ÉJ]=¼J[È[¶=a=Ç[=>[Âfª=ÇIG[Q=Ƕ=Æfn¶=ÆÍ»¿=>ÂebrI¶=ÍÉ¿¯J¶=fÈe>¯J¶=Àºe>Jab¢GÈf£JE* =Ç¿¢£Ee?¼vIÍ»Ñ>®Î·¢°«I=ƽ>[¢Í[È>ÿEÊÃJ¿I¶=Ì«¶=Í·¶Í>q>þ?ÏÕe>¾1977*´¶d[²°[«I=Æ F¾>[=[Ef[m>F=eÆ>n[J¶=°[Èf{À[¢Í[·¶ÍV[mf=L>¢ÇFì=e>ÉJ]=Íɶ>J¶=½=Ç¢Ù=¼JÈÁ?η¢*>[»² ÍÉ>£¶=ÍVr¶=ÍÉ£ÄÉ·¢°ª=ÇIÍ»¿=eÇJib¶ÊEf¢s¾a=b¢Cη¢±>«I×=>ɾǾ>®>r¾Åe>FJ¢>E*Ín®>¿=K¶Æ>¿IÆ F¾>=E¹>£«¶=°Éj¿J¶=Á>»v¶Ä¢>FI=ʧF¿ÈËd¶=HÇ·iÙ=Æ(ÍÉEf£¶=ÍÉFì¶=L>V·ìr»·¶¼R£ºa=b¢C¥ÇuǺ* ÌfÂ>¯¶>EÍÉEf£¶=¹Æb¶=Í£º>|Ìb¯£¿=Hf£¶=ÍVr¶=Ð=egÆk·ËdÉ«¿J¶=GJ³»·¶Íɾ>N¶=ÍÑe>ì¶=ÌeÆb¶=뻮 ÇÈʺ1Æ2gÇ+ÇɶÇÈ1976Í[»¿Í[ÉEf£¶=ͧ·¶=Sº>¾¶fÈÇìJ¶=ÆbÉm¶=L=Çì]Àºð=bÈhºËdÉ«¿J¶=GJ³=d= >ûÂ?(ÍÉ>£¶=ÍVr¶=6 xf[¯=Î[¿FºÍÃQ=Æη¢´¶cb£EKFJ=ÆÍ»¿=>ÃJºb®¶=Í»¿=eÇJiaÀºÆÙ=Ìa>=ÍfIa>»J¢= 7¬É¿QÍ»¿»·¶ÊjÉÑf¶= x7ÍU¯=£EeÙ=L>¢ÇFì=Í»Ñ>®Æ(>ÃJfIHÇ·ì=L>¢ÇFì=e>ÉJ]=b¢=Ç®a>»J¢= xL>É»jIÀºÐ=hQ?ÍjͶÍÈǶÆ?Ð>ì¢C7Í»¿=>ÂebrI¶=z=fºÙ= S178 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما x>ÿº¸²ÀºÍÉEf¢Í¶Æa¸²Î·¢Íɾ> _j¾fn¢¤ÈgÇJ¶Ê«³IÍ¢ÇF캸²Àº_j¾¤FìàIÁ?*K[F¦e=cD[ª 7Ð=fn¶>E´¶cÁdzɪ_j¿¶=ÀºbÈhºÎ·¢¹Çr=¹Æb¶=ÏbUC x£¶=GÈf£Iη¢ÀÈea>¯¶=t>^mÙ=Ð>@EÍÉ¿«¶=;>ºÙ=ÍÉEf£¶=¹Æb¶=¨·FIÁ?¨[·FI>[»²(>[ÃJfIÆÍ[ÉFì¶=½Ç· 7Í»¿>EÍÉEf£¶=ͧ·¶=ÌbUÆC¼Ã¿¢L>ºÇ·£º xeÇJ[ib¶Ê[Ef¢s[¾a>»J¢×ͺa>¯¶=ÍÉ>£¶=ÍVr¶=ÍÉ£»e=f®¥Æfn½b¯J¶=L=Ð=fQCÍÉ¿«¶=;>ºÙ=?bFIÁ? 7Ïf]Ù=L>§·¶>EÍj»=tÇr¿¶=ÍÉRUk«¾Ä¶Ê¾Ç¾>®s¿²Í»¿= x½>¿¶=a>»J¢=Í»¿>EÍÉEf£¶=ͧ·¶=ÌbUÆEÆHf£¶=ÍVr¶=Ð=egÆk·ÍÉ¿«¶=;>ºÙ=E°Éj¿J·¶\¯=* ÍÉ>£¶=ÍVr¶=Í»¿ºeÇJib¶ÊEf£¶=s¿¶= 10e>È?+ÇÈ>º1977Hf[£¶=ÍVr[¶=Ð=egÆk·ËdÉ«¿J¶=GJ³=kÉÑe(ÊuÇ£¶=Àf¶=bF¢eÇJ²b¶=GJ² ¶½>£¶=fÈb=CͶ>ie>Ãɪ¹Ç¯ÈÍ»¿»·6k[·ËdÉ«¿J¶=GJ³»·¶ð>jÉÑeÊ«qÇEÊ«[qÇEÆ(Hf[£¶=ÍVr[¶=Ð=egÆ fÈgÆ=ÍVr¶Ê[Ef¢s[¾eÆbqC¤·ìJ¾>¿¾@E¼³§·E?(Hf£¶=ÍVr¶=Ð=egÆÊÑغgÀ¢ÍE>É¿¶>EÆ(KÈdz¶=ͶÆa ÍÉ>£¶=ÍVr¶=ÍÉ£»Íºa>¯¶=ÌeÆb¶=ÍÉ>£¶=ÍVr¶=Í»¿ºeÇJib¶Êe* c>J[iÙ=Í[i>ÑfEeÇJ[ib·¶Í[ÉEf¢ÍfIa=b¢ÝÐ==Àº¸»¢Í¢Ç» Í»¿=K·³mÊEf£¶=G·ì·¶ÍE>RJi=Æ i>ȸº>²Î«ìrºeÇJ²b¶=%±=f£¶=Àº$Í[¢Ç»=Ð>v[¢?Á>[²Æ(=Äe(¬É¿QÍ£º>|ʶÆb¶=ÁǾ>¯¶=c>Ji?( ¼Â6 xL>¯Èeg¼ÉÂ=fECc>JiÙ=%ÁaeÙ=Àº$ͧ·¶=ÌbUÆÀº7¬É¿Q(Í»¿»·¶ÊjÉÑf¶=f¯>EÍÉEf£¶= xÊ«ì¶K£ªec>JiÙ=%frºÀº$ºÙ=f¯ÍÉEf£¶=Ͷ=¼j®kÉÑe¼7¬É¿|ÌbVJ= xEÇmʺ>ic>JiÙ=%±=f£¶=Àº$7¬É¿Q(ÍÉ>£¶=ÍVr¶=Í»¿ºÍi>ÑfEʾǾ>¯¶=e>nJj= x>R¿¶=ÇE?bÉieÇJ²b¶=%frºÀº$ÈeÇ«¶=Ͷ=¼j®kÉÑe7=Äe(¬É¿|ÌbVJ=¼ºÙ=f¯Í xÊ·¢b»¼£¿=bF¢eÇJ²b¶=%frºÀº$7¬É¿Q(Í»¿»·¶ÊjÉÑf¶=f¯>EÍÉEf£¶=ͧ·¶=ÌbUÆkÉÑe xÀº¬iÇÈÁ>¾b¢c>JiÙ=%±=f£¶=$7=Äe(µeÇÈÇɾ(ÌbVJ=¼ºÙ>EÍÉEf£¶=Ͷ=¼j®kÉÑe( xHǯ£Èb»c>JiÙ=%frºÀº$Ñe7=Äe(iÇJ=±fn¶Ê»É·®Ý=GJ³>EͶ=¼j®kÉ xa=fºaÇ»c>JiÙ=%frºÀº$=Äe(¬É¿QÍ£º>|Ͷ=ÆL>§·¶=L>É·³EÍÉEf£¶=Ͷ=c>Ji?* eÇJib·¶tÇr¾ÍMØMÍ¿R·¶=Åd½>º?K¾>²Æ6>Âb[¢?Á?°F[iÍÉEf¢ÍfIÆÊj¾f«¶=s¿¶=ÆËhÉ·³¾Ý=s¿¶= =ʻɷ®Ý=GJ³* ¸»£¶=͢ǻ f¾ÍÃQÆÀº¸NºÙ=ÊEf£¶=s¿¶=η¢±>«I×=(¢ÇFi?ÀºfN²?K®f§Ji=L>j·Qb£EÆ* Ä[É·¢>[ÃI>UغÐ=b[EÝÐ>v[¢Ù=Í[ÉEf£¶=¹Æb[¶=CÄÉ·¢°«J=s¿¶=¸ie?¼M*Í[ÉEf£¶=¹Æb[¶=aÆaeLÐ>[QÆ Í»·²¸Èb£Ib£Es¿¶=η¢Í¯ª=Ç>E ÍÉQǶÇÉF¶= Ìa>=Ìae=Ƕ=2%p$Ìa>=ΪÆ21%a$Æ%[Â$Í»·²C ÍÉI>É= Ð>v¢Ù=¹Æb¶=ÏbUC\=®=η¢Ð>¿E* iÇJ=±fn¶Íɻɷ®Ý=Í¿R·¶=Àºs¿¶=a>»J¢=ÊÂÍɶ>J¶=ÌÇì=K¾>²Æ*k[·=η¢s¿¶=zf¢´¶cb£EÆ ¶=ÍVr¶=Íɣη¢¼MÍÉ>£¶=ÍVr¶=Í»¿ËdÉ«¿J¶=e>È?MØN¶=ÆÍÈa>=ÍÉ>£+ÇÈ>[º1978e=f[¯¶=Ld[=[¶= ʶ>J¶=Y176W x(ÁÇMØN¶=ÆÍÈa>=ÍÉ>£¶=ÍVr¶=ÍÉ£ 1.f¯IÌa>»·¶Í¯ÉMǶ=ÅdÃE°V·=¸Èb£J¶=74ÍÉiÆf¶=ÆÍÈhÉ·³¾Ý=ÆÍɾ>FiÙ>EeÇJib¶==dÂtÇr¾XFrIÎJU(eÇJib¶=Àº ÍÉj¾f«¶=ÆÍÉEf£¶=ÆÍÉ¿Ér¶=Æ(ÍÉR=ÍÈÆ>jJº Eastern Mediterranean Health Journal, Vol. 14, Special Issue S179 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 2.f¯Is¿¶=eÇJ[ib·¶ÍÉR==cÊf¶=ÊEf£¶=s¿¶=XFrÈËd¶=s¿¶=Ä«qÇE(ͯÉMǶ=ÅdÃE°V·=eÇJib·¶ÊEf£¶= ÅØ¢?eDzd=eÇJib¶=¸Èb£I¹Ç£«ºÁ>Èfib¿¢* Í[[»¿=Í[·³ÉÂÌa>[[¢C e>È?+ÇÈ>º1976ð>[Ée>Ið=e=f[®ÍÉ>£¶=ÍVr¶=ÍÉ£Ld=Y18WÄ[ÉQÇIb[É£ÈÁ?½>[£¶=fÈb[=CÄ[ɪK[F·{ ½>[¢¹Ç[·}L>ºb[=¼Èb[¯IÆ [«¶=ÁÆ>[£J·¶Ír[r^=ÍÈa>£¶=Sº>¾¶=Íɾ=hɺL=a>»J¢=¸rIOÉ}Í»¿=¹>»¢? 1980C60%´¶cÆÍÉ·£«¶=ͻɯ¶>E¸®Ù=η¢6 %?$>ÃɪØIÀ³¶=ÍÉi>iÙ=¦L>ªÆfr=¤Ée>rJ]>Ef[¯=Ð=Ç[i(Ìe=aÝ=ÆÐ>n[¾Ý=η¢°«¿I¶=Æ 7Íɻɷ®Ý=GI>³=Æ?ÊjÉÑf¶= %H$7bÉmeÇη¢ÍÈe=aÝ=ÆÍÉ¿Ã=ea=dz¶=¼É¿IÌa>¢DE %T$7>Ãu=f¦?K¯¯U¶=L>¢Æfn»·¶ÊebJ¶=Ð>þÝ>E %a$E¸²ÍU>J=ÍÈe=aÝ=ÆÍÉ¿«¶=ae=Ç»·¶¸NºÙ=½=b^Ji×>EÍɺ>¿¶=Á=b·F¶=Àºb·* L>[U¯=x£F[EKªbÃàJi=>þ?×C(>ÃI@n¾ÍÈ=bE¹=hI×K¾>²ÊjÉÑf¶=f¯>EÍÉEf£¶=ͧ·¶=ÌbUÆÁ?¼¦eÆ ÄɶCe>n=ÍÉ>£¶=ÍVr¶=ÍÉ£e=f¯¶>¯ªÆÍ·³É=Ìa>¢Ce>{CÍÉF·j¶=*CÍ[·¶Ì>[¯J¿=°Ñ>MǶ=Á?ØNº¸É®b¯ª ÍÉEf£¶=¸ £«¶>E>ÃɶCT>J×ÍÉEf£¶=¹Æb¶=Á?ÆʧF¿È>fN²?*Í[É£¹>[»¢?¹Æ=b[QÍEÐ>«J²×=´¶d²\fàJ®=Æ k·=ÆÍÉ£»=L>¢>»JQ×Ìb£=°Ñ>MǶ=ÍɯEÀ¢f¿¶=fqÆËdÉ«¿J¶=k·=ÆÍÉ>£¶=ÍVr¶=*Á?´¶d²ËÕeÆ ²?ÍÉEf£¶=ͧ·¶=ÌbUÇE=Ç¿É¢ÀÈd¶=a=fªÙ=ab¢Ä[£ºÆÍ[ɿúÍ[Qea[¯ªb[U=ÆÐ>¯FJ[i=Ê[«³ÈÄ[¾?ÆÊ[§F¿È>fN ÌbU=ÆÌIf³i*>ÿ¢À·¢?Á?b£EÌf¦>mÍ«ÉƸ§m¸£«¶>E¬®Æ?=d³ÂÆ*CL>U¯=ÅdÂx£EfìI¨·EÆ ®Ý=GJ³=C>ÉÑhQÆ?>É·²>÷¯¾Æ?ÊjÉÑf¶=f¯=ÀºÍÉ·²ÍÉEf£¶=ͧ·¶=ÌbUÆÐ>§¶DEÍF¶>ì=bUʻɷ* C=a>¿J[i=Í[»¿»·¶Êj[ÉÑf¶=f[¯=Ä[JºfEÊEf£¶=Sº>¾¶=Ð>¯EabÃIK¾>²¶=L>ÃQÇJ¶=´·IÍÃQ=ÇºÆ Á?Î[QfàÈÁ>[²Ëd¶=Óm>¿¶=Sº>¾¶=η¢>«V·¶Í»¿=Íi>ÑeÏb¶Hf£¶=ÁǶÆÖj=¸]bI(Í·³É=Ìa>¢CÍÉ·»¢ º>¢ÇÂÆÓQǪĿ³¶Æ(f]Ab£E>º>¢¤iÇJÈÍÉ«n[¯J¶=Íi>Éj[¶=Åd[ÃEʾ>[N¶=Ä*ÍVr[¶=Ð=egÆÊ¢>j[ºK[VÆ ÄÉ·¢ÇÂ>ºÎ·¢¹>=Ð>¯ECÍÉ>£¶=ÍVr¶=ÍÉ£ÆËdÉ«¿J¶=k·=Hf£¶=Ð>v¢Ù=Ƭɿ|Hf£¶=Ð=f«j¶=Æ* ÍÉVr¶=L>¢ÇFì=Æ°Ñ>MÇ·¶ÊEf£¶=h²f=Ì@n¾ ·¶=L=bUÆη¢>Âe>MAÍ»¿=Í·³ÉÂÌa>¢CK²fI«Ç[=ƬÑ>[Ƕ=O[ÉUÀ[ºÊj[ÉÑf¶=f¯>EÍ·º>£¶=L>§* Í[«·J^=L>F[i>¿=Í[»¿=>Âebr[I¶=fÈe>¯J¶=Æ°Ñ>MǶ=a=b¢?xÉ«b¯ª*«Ç[=ab[¢xÉ[«>[»² L=bUǶ=´·I·º>£¶=*h²fºÐ>n¾Cef¯IØNºÍɾ>FiÙ=ͧ·¶ÍFj¿¶>EÆbqCÆÍfIÇJÈ´Éj³=ÀºG¾>Qe= Í»¿=L=eÇn¿º*ð>v[É«´[¶cÆ´Éj[³=h[²fºCÍɾ>F[iÙ=Í[§·¶=Ìb[UÆʫǺÀºF²ab¢¸¯¾ef¯I>»² ·º>£¶=ab£¶ÆL>¯«¿·¶* ÄE·º>£¶=b¢xÉ«À³>»²Ä·ÉUfIÆ?ÄÑ>§¶CL×Æ>ÀºSº>¾¶=>b¯ªÍÉEf£¶=ͧ·¶=ÌbUǶÍFj¿¶>E>º? JÈÀÈd¶=É¿Ã=Àº¿M=¼Âab¢gÆ>R*Æ?Ê[Ef£¶=Sº>[¾¶=L>ºb[]¤[iÇJ¶=À[³À¶Ä¾?ð>Vu=ÆL>EÀ³¶Æ ðØF¯JjºÄE·º>£¶=ab¢Ìa>Èg*ð=e>F²K¾>²¹>ºÛ=Á?Æð>qÇr](b»RJ=¤uǶ==dÂÀºTfa>Cð>º=h¶Á>²Æ K®Ç¶=ÊvSº>¾¶=±>쾤ÉiÇI* =kÉÑeGJ²b¯ª=d³ÂÆ>[Ãe>IͶ>ieHf£¶=ÍVr¶=Ð=egÆk·ËdÉ«¿J¶=GJ³5HA+kìj[¦?1979C e=f[¦Î·¢´¶cÆ(ÍÉEf£¶=Á=b·F¶=ÏbUC½>¯È(ÍÉFì¶=½Ç·£¶=GÈf£J¶ÊEf¢h²fºÐ>n¾C>U¯ºÍ»¿»·¶½>£¶=fÈb= >n[¾C¼J[ÈÁ?η¢(´Éj³=Í»¿=ÄI@n¾?Ëd¶=L>¢ÇFì»·¶Ê¾>FiÙ=h²f=k[· [EÁÆ>[£J¶>Eh[²f==d[ÂÐ ÍÉEf£¶=ͧ·¶=CͶ=¹>»¢?¤Éη¢=fmÝ=ÇJÈÆ(ÍÉ>£¶=ÍVr¶=Í»¿ºÆHf£¶=ÍVr¶=Ð=egÆ*H>[Q?b®Æ S180 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Êv[J¯È>»Fj[U¥Æfn[==d[Âd[É«¿IÁÆ>£J·¶¸º>²a=b£Ji=η¢Í»¿=Á?=b²ÖºÍ¶>if¶=ÅdÂη¢½>£¶=fÈb = fºÙ=*b²?>»²¥Æfn==dÄIb¾>jºÆbÈbn¶=Êr^n¶=ĺ>»JÂ=½>£¶=fÈb=* Hf£¶=ÍVr¶=Ð=egÆk·Íjº>=ÌeÆb¶=ΪÆ1980Ê[Ef¢h[²fºÐ>n[¾CÎ[·¢?b[F=O[ÉUÀ[ºk·=°ª=Æ Â?ÁdzIÍ»¿=ÆHf£¶=ÍVr¶=Ð=egÆk· EÁÆ>£J¶>EÍÉEf£¶=Á=b·F¶=ÏbUCÍÉVr¶=L>¢ÇFì=Æ°Ñ>MÇ·¶Äª=b6 %1$7ÊEf£¶=À{Ƕ=ì¶=¼É·£J¶=GÈf£J¶ÍÉ·»£¶=ÆÍÉ»·£¶=¸Ñ>iǶ=ªÇIη¢¸»£¶= %2$ÍÉVr[¶=L×>[=L=e>v[=À[º>[¦ÆÍÉEf£¶=Ìe>v=EPÇVF¶=ÆL>ºÇ·£=ƽǷ£¶=Æͪ>¯N¶=¹a>FI ÍÉFì¶=Æ* Ð>v[¢?ÀºÍ¿¸É³nIËdÉ«¿J¶=ÄFJ³ºCk·=G·{ÆÍ[i=eb¶Í[É>£¶=ÍVr[¶=Í[»¿ºÀ[¢·N[ÆG[J³= ͺa>®ÌeÆak·R»·¶fÈf¯I¼Èb¯IÆ(h²f=Ð>n¾C¥Æfnͯ·£J=¸Éq>«J¶=* ð=dÉ«¿IÆ=dh[²f=L>[Q>ÉJU=À»v[Jȸr[«º¥Æfnº¤uÆÍ»¿=ÆÍÉEf£¶=L>ì·j¶=EeÆ>nJ¶>E(e=f¯¶= Ç=ÆL=b£=Æʾ>F=Àº\¯=¸ ÈÇ»J¶=Æ«*b[»J¢=Æ\¯=¥Æfn=η¢Hf£¶=ÍVr¶=Ð=egÆk· °ª=Æb®Æ ÅdÉ«¿J¶Íºgض=Íɾ=hÉ=* ÍÉEf£¶=¹Æb¶=EÆËdÉ«¿J¶=GJ³=EeÆ>nJ¶=b£EÆh²f»·¶=f¯ºKÈdz¶=e>ÉJ]=*Æ15e>[È?+ÇÈ>[º1981 eHf£¶=ÍVr¶=Ð=egÆk·ËdÉ«¿J¶=GJ³=kÉÑe¸ie?K[Èdz¶=e>[ÉJ]>E>[Ãɪħ·FÈÍ»¿»·¶½>£¶=fÈb=CͶ>i Í[ºb]CÏaÖ[È>[h[²f=¹>[»¢?ÆÍ[»¿=¹>[»¢?E°Éj¿J¶=ÆÁÆ>£J¶=ki?¤uÆÌeÆfu=b²Öºh²f»·¶=f¯º ¥Æfn==dÂ×>£ª>³ÈfmÍÉ>£¶=ÍVr¶=Í»¿ºÁdzIOÉ}(Ͳn=z=f¦Ù= °[·£¾Æ>ÈÇÉUÅJ£¾Ëd¶=Ä[É·¢ ¹>ºÛ=¼¢?* _Èe>JEaeÆ12Á=f[ÈhU+Ç[ɾÇÈ1981ÁØN[¹>r[I=ÊìE>[uÉ[£IÍ[»¿»·¶½>[£¶=fÈb[=\[®= ¸F¯Jj=ÄJ£E>JºÆµn=¸»£¶=°Éj¿Iªfì¶=*´¶cb®Æ* Í[]eÖºÏf]?Ͷ>ieÆ7>F[m+f[È=ª1984«¿J¶=G[J³=kÉ[ÑeÎ[·¢½>[£¶=fÈb[=\[®=k[·Ëd[É Hf[£¶=ÍVr[¶=Ð=egÆ h[²f»·¶½>[£¶=[ºÙ=Gr[¿ºÄj[«¿EÇ[IËd[¶= Ìfn[¾¤[ÈgÇIÆÍ[Eh[²f=½Ç[¯ÈÁ? Í[É>£¶=ÍVr[¶=Í[»¿ºBulletin Of The World Health OrganizationÍ[É>£¶=ÍVr[¶=Í[»¿ºL>[¢ÇFìºÆ jªÆÙ>EKWHO Offeset Publicationsº½>J¶=ÁÆ>£J¶>E´¶cÆÍ»¿=G¾>QÀ* À[ºÌ[«¶=K[Èdz¶=b[¯£¿=L>[¢ÇFì=Æ°Ñ>MÇ·¶ÊEf£¶=h²f=Ð>¿º?k· η¢Í¶>if¶=ÅdÂKuf¢b®Æ 17C20>Fm+fÈ=ª1984Í»¿»·¶½>£¶=fÈb=\=®>EÐ>¿ºÙ=k· GUeÆ*Ͷ>[ieÊ[uÇ£¶=eÇJ²b¶=b²?Æ Í]eÖº4e=cA+le>º1984 =Á?>ÃI=eÇn[¿ºÆÍ[»¿=L>[¢ÇFìºG[Èf£Iη¢ÄI>ɾ>³ºC¸³E¸»£ÈÇih²f =ÍÒÉnGÈf¯¶=¸F¯Jj=ͺ>=ÍɶÆÖj=ÅdÃE½>ɯ¶=ÄI>£·ìJ¶>¯É¯* [EÁÆ>[£J·¶±>[«I=¤[uÆ\[®=>»² F¾>=Eλ¿IÁ?À³¶=Ïf]Ù=ÁÆ>£J¶=L×> >vÈ?abh²f=ÆÍ»¿=* >ãɮÇIÆ(Í«·J^=ÁÆ>£J¶=L×>R°·£JÈ>»ÉªÆf=η¢>¯¿¶=¤uƸQ?ÀºÍÉ®>«I×=ÅdÂa=b¢Cb®Æ Í»¿»·¶ÊjÉÑf¶=f¯=À¢ÍE>É¿¶>E13>Fm+fÈ=ª1985h²f=À¢ÍE>É¿¶>EÆ18e=cA+le>º1985*K[®ÆÆ ·®Ý=GJ³=EÁdzJ¶ÍÉ®>«I×=K¶b¢°U×h²f=EÆiÇJ=±fn¶Ê»É* À[ºÌ[«¶=Ìf[[Â>¯¶>EÌaÇ[¯£=Ìfn¢Íjº>=ÄIeÆaHf£¶=ÍVr¶=Ð=egÆk· Á?f²d¶>EfÈbQÆ12C 14e=cA+le>º1990ÍÈa>r[J®×=ÏÆb[=Íi=eb¶ÍÉVr¶=L>¢ÇFì=Æ°Ñ>MÇ·¶ÊEf£¶=h²f=Ð>¿º?k· ÄÉQÇIef® f=¹>»¢ÙÍÉ»·£¶=Æea>r[ºªÇ[J¶ÊEf¢Ëfì®>n¾>ÍɺǮfn¾e=ah²f==d¸£t>=eÇrJ¶=¤uÆÆh² Í[§·¶>EG[ì¶=½Ç·¢kÈebIbÃE(ÍÉFì¶=L>q>rJ]ضÊEf£¶=k·=EÆÄ¿ÉEÍɯÉj¿IͧÉqa>CÆ(ĶÍJE>M¸]a ÍÉEf£¶=* g>Cb£Eð=g>C°¯ÊÂÆ(´¶cb£Eh²f=ÌjºK·q=ÇI¼M¹=hI×Æ(* 181S eussI laicepS ,41 .loV ,lanruoJ htlaeH naenarretideM nretsaE المجلة الصحية لشرق المتوسط، منظمة الصحة العالمية، الإصدار الخاص للمجلد الرابع عشر =f=Q[¤ 1. الدكتور إبراهيم بيومي مدكور. مجلـة مجمع اللغـة العربيـة، العدد الثالث والخمسون. شباط/فبراير 4891. الصفحة 4 2. قرار المجلس التنفيذي لمنظمة الصحة العالمية رقم: م ت 3. ق 03، آذار/مارس 9491 3. قرار اللجنة الإقليمية الفرعية »أ« رقم: ش م/ل إ4 »أ« /ق -4، أيلول/سبتمبر 4591 4. قرار اللجنة الإقليمية الفرعية »أ« رقم: ش م/ل إ5 »أ« /ق -5، أيلول/سبتمبر 5591 5. قرار المجلس التنفيذي لمنظمة الصحة العالمية رقم: م ت 71.ق01، كانون الثاني/يناير 6591 6. قرار جمعية الصحة العالمية التاسعة رقم: ج ص ع 9. 52، أيار/مايو 6591 7. قرار اللجنة الإقليمية الفرعية »أ« رقم: ش م/ل إ 11 »أ«/ق- 71، أيلول/سبتمبر 1691 8. قرار اللجنة الإقليمية الفرعية »أ« رقم: ش م /ل إ 21 »أ«/ق- 11، تشرين الأول/أكتوبر 2691 9. قرار اللجنة الإقليمية الفرعية »ب« رقم: ش م /ل إ 21 »ب«/ق- 31، أيلول/سبتمبر 2691 01. قرار المجلس التنفيذي لمنظمة الصحة العالمية رقم: م ت 33 ق 63،كانون الثاني/يناير 4691 11. قرار اللجنة الإقليمية الفرعية »أ« رقم: ش م /ل إ 41 »أ«/ق- 9، تشرين الأول/أكتوبر 4691 21. قرار المجلس التنفيذي لمنظمة الصحة العالمية رقم: م ت 53 ق 41 ،كانون الثاني/يناير 5691 31. قرار اللجنة الإقليمية الفرعية »أ« رقم: ش م /ل إ 51 »أ«/ق- 8، أيلول/سبتمبر 5691 41. قرار المجلس التنفيذي لمنظمة الصحة العالمية رقم: م ت 94 ق 64،كانون الثاني/يناير 2791 51. قرار جمعية الصحة العالمية رقم: ج ص ع 52.05، أيار/مايو 2791 61. قرار جمعية الصحة العالمية رقم: ج ص ع 82.43، أيار/مايو 5791 71. قرار جمعية الصحة العالمية رقم: ج ص ع 13.81، أيار/مايو 8791 81. قرار جمعية الصحة العالمية رقم: ج ص ع 92.84، أيار/مايو 6791 S182 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما L>V·ìr= ¹Ç¯Èc>JiÙ=¤uƹÇU(=Äe(ËeÇj¶=ÍÉEf£¶=ͧ·¶=¤» kÉÑe(XFi jUeÇJ²b¶=L>V·ìr=Í[ÉFì¶= J¶=Áf¯¶=L>È=bEÍÉEf£¶=fn¢¤i>6 ¸F®?dÉI>i?Gì¶=GJ²ÀºL>úÙ=ÍfIη¢¹Ø³¶=f£I×Í»ÃE É£¶=fr®ÍiebºÍÉj¾f«¶=*=ÇìJ]=Æ Àºzf§¶>Eð>ɪ=ÆÅÆbQÆ>º=ÇFU@ª(ÌbÉmeÍì]X·ìr=H>EL>V·ìrºÊºØ[iÝ=ÊEf£¶=Gì¶=*>[ºÆ bQ>¼ÃªØi?G{ðØE>¯ºÄ[¶=ÆbGì¶=OÈb[==Æ@[À[ºÄ[[¶Ð>[?=Ç£[uÆÆÍ[¶=CÄ[ɪ ÍÉEf¢¹Çq?*=Æb»£ÈÆCÈf£IGÍ[UÆb¿º´¶cÀ¢=Æb=cC×C¿QÙ= «·¶=*L=fn[¢X«r[IÀ[ºÆ GJ³¶=¶=¸Ñ=ÆÙ=a=Æf¶=Ð×ÖÂÄE½>®>º³ÈÁ?CÄ£jÈ×ÍF¯=´·IK£F{ÀºÖ[ÈÆ×G¢>r[=Á@[E ½>º?·IÁ?OF·IÁ?¼Ã«·XÉI?ľ?ǶaÇÈÆ(¹>Qf¶=¼»Â=Ç£E>JÈÄj«¾°Èfì¶=η¢j¶=Y1*W b¯¶ÆK¾>²Í§·¶=½=b^Ji=ÍÈ=bEb¿¢ÍÉ>£¶=ÍVr¶=Í»¿ÊjÉÑf¶=f¯=L>V·ìr=¥>uÆ?ÍÉEf£¶=>[ºÄF[m? X[mO[ÉUÀ[º(XF[i j[UeÇJ²b[¶=>ë[qÆ[¶=¥>uÆÙ=´·JEÁdzIL>V·ìr[==Í[ÉEf£¶=¸[E>¯ºÍ[U>J η¢¼²=I¶=ÍÉF¿QÙ=L>É»jJ¶=ÆL>V·ìr=Ç[½Ç[ȸ[²¤Èf[i*Êj[ÉÑf¶=f[¯»·¶ÆÙ=Í[EfRJ¶=K[¾>²Æ ÌbUÆÐ>n¾C¸ÉF®Í»¿»·¶Í§·¶=L>UØìq=aÇQÆÁÆaÀº=ÀºbÈb¢Î·¢L>V«r¶=L>Òº¤ÈgÇJE(ÍÉEf£¶= ÍÈe>É£º>²>ºÎ·¢bÂ>m](>ÃEÁǺhJ·ÈÁ=bÉ=´¶c©=fªÀºbQÇÈÁ* UǶb¯ªab£IK£uƶ=L>¶= bU=Ƕ=¿QÙ=X·ìr»·¶*L>É»jIfn¢ÀºfN²?ÁCÎJUÍ«·JK[Éb[¯ª(Í[É>£¶=ÍVr¶=Í»¿º¼i×K£uÆ ÍjiÖºÆ(ÍÉ>£¶=ÍVr¶=ÍÒÉÂÍVr¶=>[£¶=ÍVr[¶Í[º>£¶=Í[ÒÉ=Æ(ÍVr[·¶ÍÉ>£¶=ÍjiÖ=Æ(ÍÉ>£¶=**C*=d[³ÂÆ ÆÙ=ÍV·¶=d¿ºL>É»jJ¶=ÆL>V·ìr=bÉUÇICÍQ>=LgfE* ءزــلجا) ةيلماعلا ةحصلا ةمظنم في ةيبرعلا ةغللا مادختسا (نياثلا يلع دممح معنلما دبع طسوتلما قرشل ةيحصلا ةلجملل يذيفنتلا ررحلماو .اًقباس ةلماعلا ةحصلا ةمظنلم يسيئرلا رقلماب تاغللا مسق سيئر اًقباس طسوتلما قرشل يميلقلإا بتكلماب. A.M. Aly. Former Chief, Office of Languages. WHO Headquarters, Geneva, Switzerland. Former Executive Editor, Eastern Mediterranean Health Journal, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. The Use of Arabic in the World Health Organization. Part Two ABSTRACT In part one of this paper we discussed the use of Arabic as an official and working language in the Eastern Mediterranean Regional Office and WHO Headquarters. We reviewed the arrangements made to rationalize the Arabic activities in WHO, the development of an authentic Arabic version of the WHO constitution, the impact of WHO restructuring on the Arabic programme and the establishment of the Arab Centre for Medical Literature in Kuwait. In this part we address the developments in Arabic medical terminology, the establishment of the Regional Arabic Programme and the unified WHO Programme of Arabic publications, and last but not least, the production of the Eastern Mediterranean Health Journal in English, French and Arabic. Eastern Mediterranean Health Journal, Vol. 14, Special Issue S183 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما bQÆÆÁǶÆÖj=Ä[eÀ[ÉjUÄ[{eÇJ²b¶=Ìe>F¢Í·³n»·¶ðØU>Ãɪ¹Ç[¯ÈÊ[J¶=(=6 ×fjÈÍÉEf£¶=>¿J§¶ ¬Év¾Á?>¿¶Æ(>þdz·Ð>ºb¯¶=Á>²>»²>ó·ÀÆ(fj¢>ÃɶCfr[£¶=Í·»£Jj[ºÀ[³I>«¶?ÀºÄQ>J>º ¼Èb¯¶= Ìe>F£¶=ÅdÂ=Æd=Æð=e>£mÍ·Uf=´·I¼* ºÍU>J=L>»R£=Àº_j¾=°Èf«¶LfªÇIƸN6¼[R£=Æ(f[mb[»Í[É£ÉFì¶=ÆÍ[ÉFì¶=½Ç·£¶=¼R£º bUÇ=ì¶=¼R£=Æ(ÍvÈÇ¢aǻʷ£¶OÈb=ʶbÉr¶=ì¶=%ÆÙ=Í£Fì¶=$ÎJUlǺ>®Æ*[¦¼Q>[£=ÀºÆ Írr^J=6>¦ÆbR¿=ÆÉiǶ=ÆaeÇ=* [=½>[®Í»¿>EÍÉEf£¶=ͧ·¶=½=b^Ji×ÆÙ=¤ÉE>iÙ=ÆÍɯÉj[¿IÆÍÈa>[mi=Ìe>[ÈhEÊj[ÉÑf¶=f¯>[EÁǶÆÖj ÍÉEf£¶=ͧ·¶=¤» kÉÑe(eDzbºÊºÇÉE¼ÉÂ=fECc>JiÙ>EÆÍÉEf£¶=Í£º>=¶ÆÖj=Àºab£E>Ø]=ǯJ¶=ÌfÂ>¯·¶ ÌfÂ>¯¶>E*ÏbE?b®Æ)=Äe–°Èf«·¶ÏbÂ?Æ(ÁÆ>£J¶=ÅÇQÆÀºÀ³>º¸²¹dF¶¤»=a=b£Ji=Í[¢Ç» fÑ=h¶= =Ä[e(¤»=Çv¢(ÍmÇm°ÉªÇIη¢eÇJ²b¶=ÍÉEf£·¶>ÃfIb®Á>²¶=L>¢>»JQ×=ÆL=fÖ=L>V·ìrº* Êj[ÉÑf¶=f¯>[Eb[¯£IK[¾>²[¶=L=fÖ[=ÆL>[¢>»JQ×=°Ñ>[MÆÍ[fI¤[«¿¶=ͻɢ͢ǻ=ÅdÂK¾>²b®Æ Í»¿»·¶* ¢ÍÉEf£¶=ͧ·¶=ÌbUÆK·»¢¼ML>[»¿ºÀ[¢Ìea>r[¶=L>V·ìr[=¼Ñ=Ç[®ÀºÀ³eb®²?η¢¹Çr=η ¼[R£ºÆ(dzj[¾Çɶ=ͺb^Jj[=Í[Èe=aÝ=ÆÍ[ɶ>=L>V·ìr=ÆL=fÖ=L>V·ìrº¸Nº(Ïf]Ù=ÌbVJ=¼ºÙ= >[Ã=Í[É»¿IÆ>[É·£¶=Í[ÉFÈebJ¶=L>i=eb·¶Ê¶Æb¶=h²f=À¢ea>r¶=ÍÈfrF¶=ÆÍÉ£»j¶=L>V·ìr=Í[»¿Í[É¿«¶=L=e ÍɶÆb¶=¸»£¶=*Ír[r^J=ÆÍ[º>£¶=L>V·ìr[=ÀºÌbÈb¢L>¢Ç» GÈf£IÆÍfIÍÉEf£¶=ͧ·¶=ÌbUÆKìn¾Æ ¸Nº6(z=f[ºÚ¶Ê¶Æb[¶=¬É¿r[J·¶Í£[i>J¶=Í[£Q=f>EÍÉ[i>iÙ=¹Æ=b[=Í[»Ñ>®Æ(ÍÉVr¶=Àû·¶ÍɶÆb¶=L=bUǶ= Û=¼ÉɯIL>V·ìrºÆ(>ÈeØ=L>V·ìrºÆÍÒÉF¶=ÍVqÈ>£ºSº>¾fEÀ¢ea>r¶=ÍÉÒÉF¶=e>ì]Ù=fÈb¯IÆÍÉVr¶=e>M Í[¢=eh¶=ÆÍ[Èd¦Ù=Í[»¿ºÍºb^Jj=ÍÈd§J¶=ÆÍÈd¦Ù=L>V·ìrºÆ(ÍÉ>£¶=ÍVr¶=Í»¿*Ìb[UǶ=K[º>®>[»² ¬É¶@IÀºÍɶÆb¶=ÍM>¦Ý=ÆPe=dz¶=G{L>§·¶=ab£Jº¼R£ºÍÉEf£¶=LØ]b=a=b¢DEl*Æ*k[·{?Æ(áÀßQ? ÍVr·¶ÍÈe>²dJ¶==Æ>²>i>iÍjiÖºÀ¢ea>r¶=½=d=*Á>[»¢Æ°n[ºaÆÌfÂ>¯¶>EÍÉEf£¶=ͧ·¶=¤º>R¹>rI×=Æ À[ºÅªÇ[I>[ÿ³>[º¸[³EÆÍ[ÈeÆb¶=[¦ÆÍ[ÈeÆb¶=>ÃI=e=b[qDEÍ[ÉEf£¶=Í[§·¶=Ìb[UÆb[ÈÆhI>[ÃɶCG·î{Æa=b§EÆ L>É»jJ¶=ÆL>V·ìr=* ÌbUÆKº>®ÆÀ[³IOÉU(L>®>ìE(ÍɺÇɶ=>>»¢?Ð>¿M?L>V·ìrºÀºÄÉ·¢°«JàÈ>º¤É»RJEÍÉEf£¶=ͧ·¶= f³F=K®Ç¶=´¶c>ÍU>JºHÇi>=L>ºb]*Í[ºh·ºK[£Fî{L>V·ìr[=À[º>[²eb[®¤»>ºb¿¢Æ Á=Ç[¿¢K[Ð>v[¢Ù=Á=b·F¶=ÍVr¶=L=e=gÆη¢>ãÈgÇI6[=L>V·ìr[=Í[É>£¶=ÍVr[¶=Í[»¿ºÍ·»£Jj* ¸[]=a¤[É»=>[ÃE½hJ·ÈfºÙ=ÍÈ>þÌbUǺͻÑ>®Î·¢±>«I×=¼JÈÎJU(>Ãɪ>ÃÈ?eÐ=bECL=e=gǶ=CG·{Æ >ÃQe>]ÆÍ»¿=* e=cAÆ+le>º1977a=b[¢CÍ[É>£¶=ÍVr[¶=Í[»¿ºÀ[ºHf[£¶=ÍVr[¶=Ð=egÆk[·ËdÉ«¿J¶=GJ³=G·{ »R£ºËhÉ·³¾C>»ÂbU?ÉF{+Êj¾fªf]Û=ÆÊEf¢+Hf[£¶=Ð>[F{Ù=ÀºÌ=ËÆdE;>£Ji×>EÍÉqÇJ¶=¤ºÊEf¢ ÍÉEf£¶=ͧ·¶=¤º> a>=¤º°Éj¿J¶>EÆ(¹>==dÂ*Hf[£¶=ÍVr[¶=Ð=egÆk[·Ê[i>iÙ=½>[¿¶=Á?f²d[¶>EfÈbQÆ k·==bÂ?ÀºÁ?η¢s¿È fnJ¶=bÉUÇIη¢¸»£¶=ÍÉEf£¶=ÍÉFì¶=L>V·ìr=ÆÍÉVr¶=Ìe=aÝ=¼¾ÆL>£ÈY 2*W Í[¢Ç»=(=Ä[e[iÇJ=±fn[¶Ê[»É·®Ý=fÈb[=(>[F{j[=b[F¢eÇJ²b[¶=>[¢aÍ[F¦f¶=Åd[ÍE>RJ[i=Æ Ì«¶=ÍÈeb¿³iÝ>Eʻɷ®Ý=GJ³>E¥>»JQضÍÉEf£¶=Í·¶ÍÈe>nJi×=22)24HA+kìj[¦?1977[¶cÆ(´ Á@n¶==dÂͺgض=ÌeÇn>EÅbÈÆhJ¶*ͧ·¶=¤» kÉÑe(XFi jUeÇJ²b¶=c>JiÙ=¥>»JQ×==dµe>mb®Æ (z>[Èf¶=Í[£º>|Gì¶=ÍÉ·³EÊ¢fn¶=Gì¶=c>Ji?(Á>»É·ib?b»eÇJ²b¶=c>JiÙ=Æ7=Äe(°nºbEÍÉEf£¶= S184 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ñe(Ê·É·QaÇ»eÇJ²b¶=c>JiÙ=Æ7=ÄeÐ>F{Ù=a>=À¢ðØNʫ춹a>¢eÇJ²b¶=Æ7ð>¯E>i¸qÇ=Í£º>QkÉ Í»¿»·¶ÊjÉÑf¶=f¯=Æʻɷ®Ý=GJ³=Àº¶ÆÖjºCͪ>uÝ>E7Hf£¶=* Á?°F[i[¶=Í[£Fì¶=À[ºð>®Øì¾=bÈb=bUÇ=ì¶=¼R£=a=b¢ÝÍ¿¸É³nJEÍÈe>nJi×=͢ǻ=KqÆ?Æ ¸ F®ÀºLfn¾*·¢Ì[=ËÆcÀ[ºÍ[MØM¼ÃÉ[¶Cð>ª>v[ºb[UÇ=ì¶=¼R£=Ê«¶ÖºÀºÍ¿R·¶=´·IÁdzJIÁ?Î ÊEf£¶=Hf§=*Ìa>j[¶=À[ºÍ[¿R·¶=K[[«¶@I=d³ÂÆ6XF[i j[UeÇJ²b[¶=ÆËe=Ç[=e>Jj[¶=b[F¢b[?eÇJ²b[¶= b¶=ÆËebF¶=¬Éì·¶=bF¢eÇJ²b¶=ÆËb=°Èbr¶=eÇJ²b¶=ÆÁ>FÉmbÉ£ieÇJ²b¶=ÆÁÆf¯[mÀ[E¬[Éì·¶=bF¢eÇJ² i>Á=ÆfºeÇJ²b¶=ÆÊ·É·=aÇ»eÇJ²b¶=Æ>É=¼NÉÂb»eÇJ²b¶=ÆÁ>»É·ib?b»eÇJ²b¶=Æ* ð>[¢>»JQ=fn[¢ÍMØM>ÃɪͿR·¶=Lb¯¢L=Ç¿i¤Ee?bUÇ=ì¶=¼R£»·¶ÌbÈb=Í£Fì¶=a=b¢C±f§Ji=b®Æ Æ°nºaÆk¾ÇIÆa=b§EÆÍÈeb¿³iÝ=¹ÆÙ=ÁǾ>²f]=Æ?>ÃJ>]K¾>²ÆfÑ=h=ÆÁ>»¢Æ>Ef¶=+»jÈa1981* ½>¢¼R£=ÀºÍN¶>N¶=Í[£Fì¶=Lebq¼M1983ʶ=ÇU¸»nIK¾>²Æ(25X·ìrº¬¶?* ÍÉj[¾fªÆÍ[ÈhÉ·³¾CÆÍÉEf¢L>V·ìrºÀºbUÇ=ì¶=¼R£=aeÆ>½=hJ¶×=(=´¶cd¿ºÆ*K[VJªÆ =ÌbUÆ>[U¯ºÆL>UغÀº¼R£=ʺb^JjÀ£È>ºÊ¯·J¶>ÃE=ÇE?ʻɷ®Ý=GJ³>EÍÉFì¶=L>V·ìrL*>[»² Ìb[¢Ê[»É·®Ý=GJ³=ebq?´¶cÁÇv¦Æ(Í£E=f¶=Í£Fì¶=e=bqÝð=bÉÃÄI>ÈÇJ±>쾤ÉiÇJ¶>ÂaÇÃQK·q=Æ ÆͶbÉr¶=ÆL>ÉM=eǶ=ÆÁÇÉ£¶=G{ÆÁ>¿iÙ=G{Írr^Jº¼Q>£º>¦ÆXÈfnJ¶=* Í¿iÆ2004Í[ÈÇJÍ[ÉEf£¶=ÆÍÉj[¾f«¶=ÆÍ[ÈhÉ·³¾Ý=L>§·¶>EbUÇ=¼R£»·¶ÌbÈbQÍɾƳ¶CÍQ=f]CKVÉI? η¢3000ÀºfN²?Æ;ǷºÌeÇq000140X·ìrº* Í¿iÊ[ªÆ2005¯ªÌÐ=f¯¶=Ìf²=dEÌh¿J³ºt=f®?η¢¼[R£=À[º_[j¾¤[ÈgÇI¼[I%CD-ROM$[Éη¢¤ ¼É·®Ý>EÍVr¶=L=e=gÆÆÍÉVr¶=ÆÍÉFì¶=½Ç·£¶=L>É·²*b[UÇ=¼[R£=À[ºÌfj[«ºÍ£F{a=b¢C¸»£¶=¸q=ÇJÈÆ ÀºfN²?η¢ÍÈÇJÍɾ>FiÙ=ÆÍɾ>Ù=ÆÍÉj¾f«¶=ÆÍÈhÉ·³¾Ý=ÆÍÉEf£¶=L>§·¶>E000150Í·r[«º\Æf[m¤ºX·ìrº ÍÉEf£¶=ͧ·¶>E* Í¿iÆ2006É®eÆÍ£F{LebqbUÇ=¼R£=ÀºÍ%Í£E=f¶=Í£Fì¶=$Á>¿F¶ÍFJ³º¤ºÁÆ>£J¶>E* iÇJ=±fn¶Ê»É·®Ý=fÈb=Ëe>nJjºF²ÆL>V·ìr=bÉUÇIÍ¿ef¯º>É=¼NÉÂb»eÇJ²b¶=¹Ç¯È6 fr£¶=ÍÉVr¶=½Ç·£¶=GÈf£IHeaη¢Í»Ã=>£=Àº¼·á£º(¤u=ÇI¸³E(bUÇ=ì¶=¼R£=ÁCË?(OÈb= ÃE>£ÉJi=Æ(ÊEf£¶=f³«¶=¸F®Àº>㺸¢>«J¶=ÆÊEf£¶=Á>j·¶=C>÷¯¾>ÄFj}¸²¼ÃJq>]ÆHf£¶=ͺ>¢¸F®ÀºY3*W ±fn¶Ê»É·®Ý=fÈb=(ËfÑ=h=±=gf¶=bF¢jUeÇJ²b¶=¹Ç¯ÈbUÇ=ì¶=¼R£»·¶Í£E=f¶=Í£Fì¶=ͺb¯ºÆ iÇJ=6f³n¶>Ef²c?Á?bE׸ v[«¶=H>V[q?fÈb¯J¶=Æ)¸ [QÆh[¢=b[£E)(Í[²e>F=Ìj[=Åd[±Ø[{C b[ÉUÇIÌf[³«ETf[]Ëd[¶=Ϋìr[ºÌh[¢eÇJ²b[¶=°F[iÙ=b¢>j=Äà¿Éº?ð>qÇr]Æ(Hf£¶=Ð>F{Ù=a>=>»Éi×Æ ÆÙ=Í£Fì¶=LfÃÎJUÆÙ=Í>=>ÃI=Çì]΢eƤ®=Ƕ=hÉUCÍÉVr¶=ÆÍÉFì¶=L>V·ìr=[ì¶=¼R£»·¶ bUÇ=*Í[»¿Ê[»É·®Ý=GJ³=C>ÃEbâÆ(¼R£=¸»£¶=Í·q=ǺοFIËd¶=(Hf£¶=ÍVr¶=Ð=egÆk· ¼M =Ç»v[¾=ÀÈd¶=Ð>v¢Ù=¼M(Ê·É·=aÇ»c>JiÙ=>Âef¯ºÆ(ÆÙ=L>V·ìr=bÉUÇIÍ¿Ð>v¢?Æ(ÍÉ>£¶=ÍVr¶= η¢L>V·ìr=bÉUÇIÍ¿CGì¶=bɯªÆ(>É=¼NÉÂb»eÇJ²b¶=`Ù=½Çɶ=CÍ¿R·¶=ÅdÂef¯ºÆ(¸U=fº ¸v[ªÌe>[i¼[i>®eÇJ²b[¶=`Ú[¶ÆÄ[¶Á>²Ëd¶=(ÄJfE=Åb»§IʶØ=±a>qeÇJ²b¶=c>JiÙ=¸v«¶=Æͧ·¶=Æ ¬¶?£Ee?ÆÍÑ>ºbUÇ=ì¶=¼R£=L>V·ìrK§·E¶=ÌF³¶=Ìh«¯¶=°É¯Ë?f[E¼Â>[iÀ[º¸³¶Æ(X·ìrº XÉVrIÆ?b¯¾Æ?Y4*W Eastern Mediterranean Health Journal, Vol. 14, Special Issue S185 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ʻɷ®Ý=ÊEf£¶=Sº>¾¶=Ì@n¾ Í[ÉEf£¶=Á=b[·F¶=G[¶>ìºÆL>[Q>ÉJU=Í[ÉF·IÊj[ÉÑf¶=f[¯=ÆÊ[»É·®Ý=GJ³=EÍÈ=bF¶=d¿º°ÉMÆÁÆ>£I @n¾ ½>¢b£Eð>º>¢ÌbÈ=hJ=*(Ê[»É·®Ý=G[J³=GÈf£J¶=ÆͶ=>n¾bÈ=hI¤ºÆ½>[¢Ón[¾?1979Sº>[¾fEÊ[Ef¢ ¸r[JÈ>[»Éª>»É[i×ƹ>r[I×=ƼÂ>[«J·¶Í·É[iDz¼É[·®Ý=Í[ÉEf£¶=Í[§·¶=½=b^Ji=hÈh£ICð>i>i?bÃÈʻɷ®C ¾Æ>£=·º>£¶=ea=Dza=b¢CÆÍɶÆÙ=ÍÉVr¶=ÍÈ>¢f¶=L>ºb~* =a>meÝ=ÆÍÉFÈebJ¶=¸Ñ×b·¶Í¶=ÍÈǶÆÙ=KÉì¢?=d³ÂÆÀ[ºÌF²a=b¢ÙÍɯÉFìJ¶=ÍÉ»ÂÙ=L=cÍÉ»·£¶=L ÉVr[[¶=·º>[[£¶=*ÍVr[[¶=Í[[»¿º¤Ñ>[[®Æa=b[[¢?Í[[fIÊ[[»É·®Ý=Ê[[Ef£¶=Sº>[[¾¶=Ç[[I´[[¶cG[[¾>QCÆ Í[É>£¶=Chronicle of the World Health OrganizationÍ[É>£¶=ÍVr[¶=Í[· ÆWorld Health Magazine ͺ>£¶=ÍVr¶=L>i=eaÆPublic Health PapersÍ[ɻɷ£J¶=a=Ç[=ÆÍÉi=eb¶=ÍÉ£Qf=GJ³¶=Àºe>Jab¢Æ(*>[»² Í»¿»·¶ÊjÉÑf¶=f¯=¤º>Ã>¯IÆ>ÃJfIÍÉEf£¶=L>ì·j¶=KF·{¶=L=eÇn¿=ÀºL=fn¢ÍfIÍɶÆÖjºÇI* ¦ÆbUÇ=ì¶=¼R£=a=b¢Ý>dE¶=aÇÃ=Cͪ>uÝ>E=dÂͧ·¶=ÍÉÑ>¿N¶=Írr^J=ÍÉFì¶=L>»R£=ÀºÅ* Í¿iÏÕeÆ1986[ì¶=ÆÊVr[¶=½Ø¢Þ¶Sº>¾fEÐ>n¾C%HBI$G[J³>EÍÉj[ÉÑf¶=L=e=aÝ=Ïb[UCÁÇ[³É¶ ʻɷ®Ý=*Ê[ÂÍ[«·J^=¹>[»¢Ù=Ä[ÉQÇIÆFv[¶ÍÉj[ÉÑeÁ>[¤[Ee?KÒn[¾?Sº>¾¶==dÂe>{CÆ6°Ñ>[MǶ=Í[¿ Æ(L>¢ÇFì=ÆÍÉEf£¶=ÍÉFì¶=L>V·ìr=Í¿Æ(ÍFJ³=Í¿Æ(fn¿¶=L>U=®=sVªÍ¿* gb[ÈÝ=L>ºÇ·£º¹a>FJ¶h²fºÊ»É·®Ý=GJ³>EÓn¾?UÆ)AIEC ( HA+kìj[¦?1990ÁÆ>[£J¶=Á>[²( =ÆÍÉ»·£¶=L=eÇn¿=ÆL>¢ÇFì=ÀºL=fn¢e=bqCì¶=ÆÊVr¶=½Ø¢Ý=Ìe=aCEÆÄ¿ÉEð>¯ÉMÆÍ=ÍÉºØ¢Ý ð>Éj¿QͶǯ¿=z=fºÙ=ÆgbÈÝ=¹> Í«¶Ö=Æ*Ä[ɪÍ[ÉEf£¶=Á=b[·F¶=K[¾>²K[®Æµn[=¸»£¶==dÂÐ>Qb®Æ Í®ÇMǺÆͯɮaL>ºÇ·£ºÀºÊ»É·®Ý=GJ³=ÅebrÈ>º½>»JÂ=¸³EfJ¿I>[U?Ëd[¶=b[Èb=zf==d¹ÇUÄ[E L>ª=f=ÆL>£Ñ>n¶=ÀºN²* ÍÉEf£¶=L=eÇn¿»·¶bUÇ=ÍÉ>£¶=ÍVr¶=Í»¿ºSº>¾fE G[Èf£J¶=Í[²fUÌÇV[q¤ºð>qÇr]ÍÉ>£¶=ÍVr¶=Í»¿ÊEf£¶=T>J¾Ý=ÀºÍÉEf£¶=Á=b·F¶=L>Q>ÉJU=LbÈ=hI L>¿É¾>»N¶=L?bE¶=*eÇJ²b[¶=°[«I=(L>ɶÆÖj[=Í[ÉQ=Æag=G[¿ÆÍ[U>J=ae=Ç[=e>»NJi=ÀjUη¢ðØ»¢Æ b[ÉUÇIÌeÆf[uÎ[·¢Í[»¿»·¶½>[£¶=fÈb[=(f·Â>[ºÁ=bª>ÂeÇJ²b¶=¤ºÊ»É·®Ý=fÈb=ËfÑ=h=±=gf¶=bF¢jU ʻɷ®Ý=GJ³=bÈb=Sº>¾¶=f¯ºÁdzÈÁ?η¢(ʻɷ®Ý=ÊEf£¶=Sº>¾¶=ÆÊjÉÑf¶=f¯=Sº>¾fEL>ɶÆÖjº* Í¿iʻɷ®Ý=ÊEf£¶=Sº>¾¶=¹Ç=d³ÂÆ1988Í[ÉEf£¶=L>[¢ÇFì»·¶Í[É>£¶=ÍVr¶=Í»¿ºSº>¾fEC*°[«I=Æ ¤ºÍ¶a>FJ=LØi=f=ÆËdÉ«¿J¶=k·=ÆÍÉ>£¶=ÍVr¶=ÍÉ£»Íºgض=Ͷ=L>ºb]ÊjÉÑf¶=f¯=ίFIÁ?η¢ ¥tT¼®eÍÉ>£¶=ÍVr¶=ÍÉ£e=f®s¿¶ð>¯ªÆÐ>v¢Ù=ÍÉEf£¶=Á=b·F¶=28)34* Õeb®ÆÊÂÌbÈb¢>È=hº°¯T>ºb¾×==dÂÁ?Ï6 xÍÉEf£¶=Á=b·F¶=ÆÍ»¿=E½h·È>»FjUÄÃÉQÇIÌa>¢CÆÄ»ÉɯIÆSº>¾¶=¹ÇUf»Jj=eÆ>nJ¶=jÉI* xfr®?K®ÆƸ®?¬É¶>³JE½Æh·¶=b¿¢>ÂbnUÀ³¶=Ͷ=L=]fª=ÇI* x]=aÍÉ¢>Fì¶=He>RJ¶=XÉVrIÆL>¶=Í£Q=fºÀ»v[ÈÆL>[¯«¿¶=fªÇÈËd¶=fºÙ=(ʻɷ®Ý=GJ³=¸ L>V·ìr=ÆHÇ·iÙ=bÉUÇI* x¼É·®Ý=Í¢>Fì¶=¬É¶>³Is]eÀºÌa>«Ji×=* x¼É·®Ý=Íɶ>£¶=ÍÉÑ=fn¶=ÄIÇ®Æ(ÍÉI=Ç=e×Æb¶=fqe>£i?ÀºÌa>«Ji×=* S186 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ý=Á=b·EL>Q>ÉJU=ÍÉF·Iη¢ÄI@n¾d¿ºbUÇ=Sº>¾¶=¸»¢b®Æ=ÀºÊ»É·®Ý=GJ³=Ƽɷ®Í[ÉEf£¶=L=eÇn[¿ Ið=a=b¢?ebq@ªbÈ=hLÀ[ºÍ[=Æ?Í[ÉEf£¶=Í[§·¶>EðØ[q?Í[EÇJ³=fÈe>[¯J¶=Æ°Ñ>MǶ=ÆL=eÇn¿=Àº½>¢b£Eð>º>¢ ÍÈhÉ·³¾Ý=*ÍÉ[ieb=ÆÍ[É£Qf=G[J³¶=Í·j[·iÆÊVr[¶=Ëb[=Í·j[·i¸[NºÍÉEf£¶=L=eÇn¿=Àº¸iØi@n¾?Æ ¶Gì¶=HØì*ÍVr[¶=Í[»¿ºÌfn[¾Æ[iÇJ=±fn¶ÍÉVr¶=Í·=ÍÉEf£¶=LØ]b=a=b¢CÀ¢Øvª´¶cÆ Í»¿»·¶ÊjÉÑf¶=f¯=>Âebrȶ=ÍÉ>£¶=*ð=b[É£E=Æ@[m¨·Eb¯ªì¶=¼É·£J¶=GÈf£IͲfU¼¢aSº>¾¶=eÆa>º? Ƕ=Æʻɷ®Ý=ÀÈbÉ£r¶=η¢ÆÌab£JºL>Â>=Åf²cai>»² {* Ê[Fì¶=¼[[É·£J¶=GÈf£I >Ãj[ÈebIÎ[·¢Í[·ÈÇ{L=Ç¿[iLfºÁ?b£EÍÉEf£¶=ͧ·¶>EÍÉFì¶=ÆÍÉVr¶=½Ç·£¶=kÈebIC¤ªbÈ>»¢¹=ÖiÍ Ä[É·¢X[·IÆG[Èf£J¶=CÇ¢bIÌbÈb¢Ê¢=ÆaÆð>E>Fi?ÍÁ?H=Ç=Æ(ÍÉF¿QÙ=L>§·¶>E*Ê¢=Æb[¶=ÆH>F[iÙ=Åd[ÂÆ ¿JºÌab£JºÍ¢Ç6bU=ÆÁAÍÈe>vUÍÉ¿{ÆÆ(ÍɿúÍÉ¢>»JQ=Æ(ÍÈÇEfIÍÉj«¾Y5*W Í[ÉeÍ[§·²ÍÉEf£¶=ͧ·¶=¹>»£Ji>Et>=ÍÉ>£¶=ÍVr¶=ÍÉ£e=f®¤ºÍNÈb=GÈf£J¶=ÌÇVqK¿º=hIb¯¶Æ ÍÉ>£¶=ÍVr¶=ÍÉ£ ¿¶=Ð>v[¢Ù=¹Æb[¶=ab[¢bÈ=hJ¶ð=f¾Æ(ÍÉEf£¶=ͧ·¶=ÍÉ»ÂÙð=f¾Í£[u=Æ(Í[§·¶=Åd[ÃEÍ[¯{> ½Ç·£¶=ÆGì¶=½b¯I>ÂfM?Æ(Íɾ>j¾Ý=Ìe>v=eÇìIÍÉEf£¶=ͧ·¶=½>ÃiC>Âe>FJ¢=Y 6*W Í¿iÍVr¶=ÍÉ£e=f®eÆbrEGÈf£J¶=ͲfULgh£IÆ1975Í»¿>E¸»£¶=L>§¶À»uÍÉEf£¶=ͧ·¶=¹>]aC ͧ·¶=ÄEKº>®Ëd¶=½>=eÆb¶=µebIÊÂÆG[ì¶=½b[¯Iη¢>ÂfM?ÆÄJª>¯MÆÁ>j¾Ý=Ìe>vUfn¾Æ «UÍÉEf£¶= ½Ç·£¶=ÆY 7*W (Êu>=Áf¯¶=L>¿É£Ee?>ÃÑ>n¾Cd¿ºK¾>²ÌbVJ=¼ºÙ=ͺǿºÍ·»£Jj=¸»£¶=L>§¶Á?f²d¶>EfÈbQÆ >N¶=Í[É>£¶=Hf[=Ìfr[J¿=¹Æb[¶=>[ÃE°ì¿I¶=k»=L>§·¶=η¢ÌeÇr¯ºÍÉj[¾f«¶=ÆÍ[ÈhÉ·³¾Ý=Ê[ÂÆ(Í[ɾ Í[ÉEf£¶=Í[§·¶=Ê[ÂK¾>²k»=L>§·¶=ÅdÂCK«Éu?¶=ÌbÉUǶ=ÍÉ=ͧ·¶=Á?Æ(Íɾ>FiÙ=ÆÍÉ¿Ér¶=ÆÍÉiÆf¶=Æ fÈb¯J¶=ÆhÉ»J¶==d¸NÏf]?ÍÉ>¢Í§¶Ë? Æ* `eÖ=Hf£¶=ÍVr¶=Ð=egÆk·ËdÉ«¿J¶=GJ³=kÉÑeH>ì]¸£¶Æ7e>È?+ÇÈ>º1976Ìea>[E¹Æ?Á>[² G¦fIÍÉEf£¶=Á=b·F¶=Á?Ͷ>if¶=K¿»vIb¯ª(GÈf£J¶=ÇÍ»¿>EÍÉEf£¶=ͧ·¶=Sº>¾fEÄÉQÇJ¶)Ïf[]?eǺ?E– (ÍÉEf£¶=Íɪ=f§=ͯì¿=ÍÉVr¶=Lسn>EÌfm>F=Í·r¶=L=c>ÃI>¢ÇFìºÆÍÉ>£¶=ÍVr¶=Í»¿º°Ñ>MÆÍfI Æ>ëÑ>ÆÆ>ÃJ¶>ifEÍÉ¢ÇJ¶=ÆÍ»¿>E¬Èf£J¶=ÀºbÈhºCËaÖI¶=´·I*>[«¶Ú¶¼[R£ºa=b¢DEͶ>if¶=KF¶>{Æ ÍÉ>£¶=ÍVr¶=Í»¿ºÍºb^Jj=L>V·ìr=Æ* Å>[×=Á>[²(Í[»¿=EÆHf£¶=ÍVr¶=Ð=egÆk·ÍÉ¿«¶=;>ºÙ=ELb¯¢¶=Í£E>J=Æ°Éj¿J¶=Íj·QÆ CÍ·¶ÍVmf=Í»¿=L>¢ÇFìº>Âfª=ÇIGQ=Ƕ=Æfn¶=¤uÆÍQeb¶>Vu=ÆÍÉ¿«¶=L>¢ÇFì=GÈf£IÇ Èh£IÍÉ»Â?η¢bÈbQÀºbɲ@J¶=>»²(ÍÉEf£¶=ÍÉEf£¶=ÍÉFì¶=L>V·ìr=h*Í[¾Ç³ºÍ[»Ñ>®Î[·¢Á>F¾>=°«I=b®Æ ÍÉEf£¶=C>ÃJfIÍ»¿=ÇJJ¶Í«·J^=Gì¶=ÆÍVr¶=L×> Í»¿=L=eÇn¿ºÀº>¾=Ç¿¢£Ee?Àº* `eÖ=Hf£¶=ÍVr¶=Ð=egÆk·ËdÉ«¿J¶=GJ³=kÉÑeH>ì]>º?30ʾ>N¶=ÁǾ>²+fÈ>¿È1977Á>[²b¯ª ĶǮð>Vu=Æ Ä[ª=bÂ?Sº>[¾¶=°[¯Î[JUð>ÉebIÍ»¿=Íi>ÑfEÍÉEf£¶=ͧ·¶=Sº>¾fE¤iÇJ¶=¼JÈÁ?¸º@¾Æ ÍÉEf£¶=¹Æb¶=ì¶=¼É·£J¶=ÆÍÉVr¶=ͪ>¯N¶=ÆÀÈb¢>j=ÆÉ¿«¶=a=b¢Cͺb]* ×=Ïbºk³£IÍ¢e>jJºL=Çì~´¶cb£EGÈf£J¶=ÌjºK·q=ÇIÆ>[ÃJF²[¶=ÍÉv[¯¶=´[·JEʺÇ[¯¶=½>[»J e>j×=e>»£Ji×=d]?Á?b£E>ÃIÇVqCLa>¢¼M(Àºh¶=ÀºÌªe>»£Ji×=* Eastern Mediterranean Health Journal, Vol. 14, Special Issue S187 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ÍÉv¯¶=ÅdÂ(ÄJÉU>¾Àº(Hf£¶=ÍVr¶=Ð=egÆk· Îß¿FIÆ*±fn[¶Ê[»É·®Ý=G[J³=Ïf[]?ÍÉU>¾Àº(>Â>¿FIÆ iÇJ=*bQ>»Ñ=a=b¿EGÈf£J¶=¥ÇuǺ¸Æ>[ºc>=ÆÄI=eÇìIÍ£E>JºÆÄJn®>¿ºÏf(F¾>=ز¹>»¢?¹Æ= f]Û=Æ=Eľ@nEL=e=f¯¶=ÆL>ÉqÇJ¶=Àº½h·È* Í[ÈÂ>»>Ek·E=f[{Ìb[¯£¿=Í[ɾ>N¶=Í[Èa>£¶=Ä[IeÆaHf[£¶=ÍVr[¶=Ð=egÆk· G·{7¹>N=¸ÉFi磪 ÀºÍÉFÉ·¶=ÍÉEf£¶=20C25>Fm+fÈ=ª1977Í[§·¶=¹>»£J[i=Í[ɾ=hɺ>ÃJFr[¾?a=bj[EÍ[ÉEf£¶=¹Æb[¶=ea>[FIÁ? ÍÉEf£¶=CͶ=¹>»¢?hÈh£JEÍ»¿=ÎqÆ?Æ(Í»¿>EÍÉEf£¶=* Í¿ibUÇ=ì¶=¼R£=ÀºÍN¶>N¶=Í£Fì¶=e=bqCÁ>²Æ1983Í[»¿ºÆHf[£¶=ÍVr[¶=Ð=egÆk[· ¸Få®Àº =a>=ÆÍÉ>£¶=ÍVr¶=b[ÉUÇI°[Èf{Î[·¢Í[É»ÂÙ=ͧ¶>EÌÇì]½Ç·£¶=Æͪ>¯N¶=ÆÍÉE·¶ÍÉEf£¶=Í»¿=ÆHf£¶=Ð>F{Ù ÍÉEf£¶=ÍÉFì¶=L>É»jJ¶=ÆL>V·ìr=* e=cAÆ+le>º1987¼v[ȸ»¢°Èfª¸É³nI½Ç{f>EÌfn¢Íɾ>N¶=ÄIeÆaHf£¶=ÍVr¶=Ð=egÆk· ef® iÇJ=±fn¶Ê»É·®Ý=GJ³»·¶·NÍ[ÉFì¶=L>q>r[J]ضÊEf£¶=k·=ƽǷ£¶=Æͪ>¯N¶=ÆÍÉE·¶ÍÉEf£¶=Í»¿=Æ À{Ç[¶=[ì¶=¼É[·£J¶=G[Èf£J¶Í[É£®=ÆÍ[ÈdÉ«¿IÍ[ì]¤[uÆ>[ÃJ»Ãº(ÍÉVr¶=L>¢ÇFì=Æ°Ñ>MÇ·¶ÊEf£¶=h²f=Æ >[«IضHf£¶=ÍVr¶=Ð=egÆÆʶ>£¶=¼É·£J¶=Ð=egÆEµnº¥>»JQ=¼É¿IÆ(ÊEf£¶=¸[U=fºÆÍ[É¿ºgÍ[ì]Î[·¢± ÍVr[¶=Ð=egÆÆʶ>£¶=¼É·£J¶=Ð=egÆÀºÍÒɸɳnIÆ(ÍÉEf£¶=Gì¶=L>É·²ì¶=¼É·£J¶=GÈf£IÐbF·¶>ïÉFìI ¥Æfn=dÉ«¿IÍ£E>JºÎ·¢=fmÞ¶Hf£¶=Y8*W ʾ>N¶=ÁǾ>²Æ+fÈ>¿È1988>¯¶>EÀÈfn£¶=ƤE=f¶=ÅfÖºHf£¶=Ð>F{Ù=a>=b¯¢k[· e=f[®b[ÉÈ@Ief®Æ(Ìf ½>¢e>FJ¢=ef®>»²(GÈf£J¶=Á@nEÄɶCe>n=Hf£¶=ÍVr¶=Ð=egÆ1988½Ç·£¶=ÆGì¶=L>É·²GÈf£J¶=ÐbE½>¢ ÊEf£¶=À{Ƕ=ÍÉVr¶=*½>£E?bFIÊ[J¶=fn£¶=L=Ç¿j¶=ÁØ¢CC>¢aÆ1988½Ç[·£¶=ÆG[ì¶=G[Èf£J¶ð>[ÉEf¢ð=b¯¢ ÍÉVr¶=*b²?Æ–EÏf]?eǺ?–Í[ÉFì¶=L>V·ìr[=GÈf£J¶ð=bÉUÆð>£QfºbUÇ=ì¶=¼R£=a>»J¢=ÌeÆfu ÍÉVr¶=ÆY9*W e>È?Æ+ÇÈ>º1988¼É[·£J¶=GÈf£I¹ÇU°nºaÌÆb¾¼É¿IHf£¶=ÍVr¶=Ð=egÆk·ËdÉ«¿J¶=GJ³=ef® ʻɷ®Ý=GJ³=ÆHf£¶=ÍVr¶=Ð=egÆk· EÁÆ>£J¶>Eì¶=Í[ÈeÇû=Í[EfÎ[·¢¥Ø[{ض([iÇJ=±fn[¶ ì¶=ÆÊVr¶=¼É·£J¶=GÈf£I¹> ÍÈeÇj¶=ÍÉEf£¶=* Àº´¶cb£EÌÆb¿¶=b¯¢b®Æ5C7¹ÆÙ=ÁǾ>²+»jÈa1988Á=Ç¿¢K [ì¶=¼É[·£J¶=G[Èf£IÌÆb¾ ÊEf£¶=À{Ƕ=ÊVr¶=Æ À¢Lf«i?Æ(11ÍÉ[qÇI>ÿÉEÀºÍ»ÃºÍÉqÇIG[Èf£J·¶Í[ÈdÉ«¿IÍ[ì]a=b[¢DE zf[£I ¹Ø]ÍÉFÉ·¶=ÍÉEf£¶=ÍÈÂ>»=b¯£ÉiËd¶=ʶ>£¶=¼É·£J¶=fÖºÆHf£¶=ÍVr¶=Ð=egÆk·¸F¯=¥>»JQ×=η¢ e=cAfÃm+le>º1989>þ@nEÍÈdÉ«¿J¶=L=Ð=fQÝ=c>=Æ>ÃÉ·¢Í®a>r»·¶* e=cAÆ+le>º1989Ð=egÆk· ef®Í²n[ºÍ[¿¸É³nIÍFÉF·¶=ÍÉEf£¶=ÍÈÂ>»=b¯£¿=Hf£¶=ÍVr¶= ÍÉVr[¶=½Ç[·£¶=L>[É·²ÆͶbÉr[¶=L>[É·²ÆÁ>¿iÙ=G{ÆGì¶=L>É·²Ð=b»¢Æʶ>£¶=¼É·£J¶=ÆÍVr¶=Ð=egÆÀº «¿J¶=L=Ç[ì=c>[=ÆÊVr[¶=¼É·£J¶=GÈf£IÍi>Éie=f®CƤuÆÆÐ=eÛ=i¹>»³Ji=ͻä·ìvJ¶Í[·É«³¶=Í[ÈdÉ Î[·¢=fmÝ=Æ(´¶d¶½gض=¸ÈÇ»J¶=¸Ñ>iÆbÈbÆ(L>¢ÆfnºÆSº=fEÆì]ÀºÄE°·£JÈ>ºÆGÈf£J¶=°É¯VJE dÉ«¿J¶=* Á>jɾÆ+¸ÈfE?1989ì¶=¼É·£J¶=GÈf£I¥ÇuǺfrºÍrr^J=Íɺǯ¶=k¶>>EÍÉVr¶=ÍF£n¶=Kn®>¾ eÇJ²b[¶=c>JiÙ=>Âe=a?Í£iǺÍn®>¿º±=gf[¶=b[F¢j[UeÇJ²b[¶=>[Ãɪµe>[mÆ7=Ä[e½Ø[iaÇ[»Åb[F¢ À[ºÁÆf[]AÆ(Í[É>£¶=ÍVr[¶=Í[»¿ÊEf£¶=Sº>¾¶=fÈbº(>É=¼NÉÂb»eÇJ²b¶=Æ7ʻɷ®Ý=fÈb=(ËfÑ=h= ue>£=ÆÀÈbÈÖ=Èfr=Gì¶=ÌdI>i?ÀºL=fn¢G¾>QC(ʻɷ®Ý=GJ³>E¶ÆÖj=G[Èf£J·¶*Lf«[i?Æ frºGÈf£J¶=ÌjÍÉ»ÂÙ=L=cL>ÉqÇJ¶=Àºab¢À¢L>n®>¿=* S188 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ìb=Æ17C20Á=fÈhU+ÇɾÇÈ1990¼É[·£J¶=GÈf£I¹ÇUð>ɻɷ®Cð=fÖºiÇJ=±fn¶Ê»É·®Ý=GJ³=b¯¢ ÍÉEf£¶=Á=b·F¶=ì¶=*=b»¢Ìa>j¶=ÀºÁÇMØMÆÍJifÖ==dÂfvUÆ>[£¶=Í[ÉFì¶=ÆÍÉVr[¶=½Ç·£¶=ÌdI>i?ÆÐ [ì¶=ÆÊVr[¶=¼É[·£J¶=ÍÉEf£¶=¹>»£Ji>EÍÉ¿£=ÍÉEf£¶=L>ÒÉ=ÆL>jiÖ=Ê·NÀºÆ(ÊEf£¶=*=b[Â?K[¾>²Æ fÖ=6Èf£J¶=ÍÉ·»¢L>F·ìJºÍn®>¿ºÆO}Æ(ÊEf£¶=>£¶=Gì¶=L>É·²¤ÉGÈf£J·¶Í¿Â=f¶=Ͷ>=le=bIG ¤[É[EÁÆ>[£J¶=ÆegBJ¶=bɲ@IÆ(Í£»J Gì¶=L>É·²¸Ér«J¶>EL>ÃQÇJ¶=ÆL>ɾ>³ºÝ=ÆL>Q>ÉJU×=bÈbÆ ¸[²>[ïÉFìIÀ[³Í[·F¯=L=Ç¿j[¶=GÈf£J¶=¹>»¢Ù¸»¢Íì]¤uÆƸF¯Jj=Ð>F{?a=b¢C¸ÉFiÉ¿£= a=f«¾=η¢ÍÉ·²*=bÂÙ=Åd½ÇëºÀºð>®Øì¾=ÆL>[¾>³ºÝ>EeÇ«¶=η¢?bFÈÁ?À³°ÉFìJ¶=Á?η¢Ë?f¶=°«I= ÌN²½?K¾>²Í·É·®(ÍÉEf£¶=Á=b·F¶=¸²ÍU>J=*Ç[Â>[ºGj[}(ÌeÇ[ìJºÆ?Í£[u=ÇJºÍÈ=bF¶=ÁdzIÁ?¼ÃÈ×Æ ÍÉVr[¶=ͺb=Ƽɷ£J¶=Ƽ·£¶=¹>QeÏb¶¥>¿J®=Æ(ʶ>º¼¢aÆ(Êi>Éi½h¢Àºµ>¿ÂÆ?>¿Â\>Jº*fÖ[=Î[ÃJ¾=Æ Í·r«ºÍÈdÉ«¿IÍì]ÆL=e=f¯¶=ÀºÍ¢Ç» e=bqCC* ¹ÆÙ=ÀÈfnIiÇJ=±fn¶Íɻɷ®Ý=Í¿R·¶=ÄId=Ëd¶=¼Ã=e=f¯¶=´¶cGÈf£J¶=Ìjº>£ºÀºÆ+fEÇ[J²? 1990¹ÇUì¶=ÆÊVr¶=¼É·£J¶=ÍÉ¿{Ƕ=L>§·¶=½=b^Ji=Y10*WR·¶=Lb²?e=f¯¶=´¶cÊ«ªÍ[É»Â?Íɻɷ®Ý=Í¿ (Ð>v[¢Ù=¹Æb[¶=[ì¶=ÆÊVr[¶=¬[ɯNJ¶=Ƽ·£J[¶=ƼÉ[·£J¶=ƽØ[¢Ý=Íìn¾?¬·JÍÉ¿{Ƕ=L>§·¶=¹>»£Ji= Á=b[·E¤[ÉÀ[³±>[쾤[iÆ?Î[·¢Í[É¿{Ƕ=L>§·¶=¹>»£Ji=hÈh£ICÍɺ=f¶=ʻɷ®Ý=fÈb=Íi>ÉiLb¾>iÆ f»Jj=ÁÆ>£J¶=K£RmÆ(¼É·®Ý=¤ÈgÇIÆÍfIÍÉ¿{Ƕ=L>jiÖ=ÆÐ>v¢Ù=ÍÉEf£¶=¹Æb¶=Æʻɷ®Ý=GJ³=E [ì¶=ÆÊVr[¶=¼É[·£J¶=z=f[¦?>>»£J[i=h[Èh£IÆÍÉ·=L>§·¶>EL=eÇn¿=ÆÍɺآÝ=a=Ç=*Í[¿R·¶=K£R[mÆ =ÆÐ>v¢Ù=ÍÉEf£¶=¹Æb¶=Æʻɷ®Ý=GJ³=Ef»Jj=ÁÆ>£J¶=Íɻɷ®Ý=Ê[Ef£¶=Sº>[¾¶=h[Èh£IÍÉ¿{Ƕ=L>jiÖ Á=b[·F¶=ì¶=ÆÊVr¶=¬É¯NJ¶=Ƽ·£J¶=Ƽɷ£J¶=ƽآÝ=Íìn¾?ÍÉEf£¶=ͧ·¶=¹>»£Ji×ð>»¢aÍ»¿=L=eÇn¿ ÍÉEf£¶>Eͯ{>¿¶=ÍÉEf£¶=*ÀºÍÒ>EÍjsÉrCÐ>v¢Ù=¹Æb¶=Æʻɷ®Ý=fÈb=Íɻɷ®Ý=Í¿R·¶=K¢aÆL>ɾ=hÉ= Í[ɶ>=Ì[«¶=¹Ø[]ÍVr¶=¸Q?ÀºÍÈfnF¶=ae=Ç=ÍÉ»¿ISº>¾¶Ìb»J£=ÍÈf쯶=1992)1993zÇ[ÿ¶=¸[Q?À[º ì¶=ÆÊVr¶=¼É·£J¶=ÍÉ¿{Ƕ=L>§·¶=¹>»£Ji>E* n[¾Ù=À[ºb[Èb¢g>[CCÄFQÇÍrr^=Íɶ>=L=a>»J¢×=fª=ÇI¤º(e=f¯¶==d°ÉFìIÏa?b®ÆÍ[»¢=b¶=Íì ð>qÇr]ÆGÈf£J¶=Ìj6 xÍÉFì¶=ÍÉ£Qf=GJ³¶=Àºab¢ÍfIÆT>J¾C* xÍÉ¿¯J¶=L=eÇn¿=Í·j·iÆ(ÊVr¶=Ïb=Í·j·i¸NºÍ»Ã=L>ÈeÆb¶=ÆL=eÇn¿=Àºab¢T>J¾C* x¼·£J¶=Ƽɷ£J¶=L>ie>GÈebJ¶=ªÇI* xÀ¢ÍÉ¿£=Á=b·F¶=EL==ÆL>ºÇ·£=¹a>FIÍÈe>F]CͶ>ie°Èf{* xÍVQ>¿¶=GÈf£J¶=He>η¢¥Ø{ضGì¶=ÌdI>i?EͶa>FJºL=e>Èg¼É¿I* xÍÉEf£¶=ÍÉFì¶=¤Q=f=Àº_j¿¶=×A¤ÈgÇIÆÐ=fm* xGÈf£J¶>E°·£JIÍìn¾?¸ÈÇ»J¶ÆGÈf£J¶>EÍq>=L>¢>»JQ×=¼¢b¶Íɶ>ºX¿º¼Èb¯I* xF¶=Æf¶ÍFi>¿ºÏf]?Íìn¾?K>»²ÍÉ·L>§¶>ÃÈb¶¶=ÍÉEf£¶=¦Á=b·*e=f[¯¶==d[°ÉFìIf»Ji=Æ ÍiÇ»·ºL=g>Cð>¯¯Íɶ>IL=Ç¿iÌb¢* Éa>²?L>jiÖºÆÍɺdzU¦L>»¿ºÄɪK²e>mÎJUGÈf£J¶=ͲfU±>쾤jI=b®ÆÍÌab[£JºÍÉ¿ÃºÆ Ê»É·®Ý=GJ³=Àº¤ÉRnIÆͲe>nºÆ¼¢bE(ÊEf£¶=À{Ƕ=*£ÉFìEÆÍVr[¶=Í[»¿Ê[Ef£¶=Sº>[¾·¶Á>[²¹>=Í Íìn¾Ù=Åd¸²¸¢>ªeÇvUÍÉ>£¶=*´¶cÍ·Nº?ÀºÆ6 Eastern Mediterranean Health Journal, Vol. 14, Special Issue S189 رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ¹ÆÙ=ÀÈfnI+fEÇJ²?1991Ëd¶=ÀÈfn£¶=ƤE>j¶=ì¶=fÖ=¹>»¢?ʻɷ®Ý=GJ³=ÀºHÆb¿ºµe>m Àºk¾ÇIHf£¶=Ð>F{Ù=a>=Åb¯¢18C20fÃn[¶==dÂÀº*G[Èf£I¹Ç[UÍ[q>]ÌÆb[¾fÖ[=Lb[¯¢Æ ì¶=¼É·£J¶=*G[J³=¸[NÆÐ=b[»£¶=ÆÉ£º>[=ÌdI>[iÙ=ÆÐ>[F{Ù=À[º[«¦¤[ÌÆb¿¶=L>n®>¿ºµe>mb®Æ ÍÉEf£¶=Í£º>=¸NÆʻɷ®Ý=*Åd¼ɻ£IƼ¢a¸FiÆÊEf£¶=À{Ƕ=ÍVQ>¿¶=GÈf£J¶=He>x£Ez=f£Ji=Æ L==* Í[É¿ÈfVF¶=Ð>[F{Ù=ÍÉ£Lb¯¢(ÀÈfVF¶=Æ Ê[Ef£¶=À{Ç[¶=Í[ÉFì¶=½Ç[·£¶=ÆG[ì¶=¼É[·£IG[Èf£IfÖ[º) ÍɯÉFìIL=Çì] Ìb=´¶cÆ16)18>Fm+fÈ=ª1993*K¾>²Ëd¶=¼Ã=fÖ==dÂʻɷ®Ý=fÈb=fvUb®Æ Ī=bÂ?6 x{Ƕ=Gì¶=¼É·£IGÈf£IÌjº¼ÉɯIÆz=f£Ji=ÊEf£¶=À* xGÈf£J¶=dÉ«¿ICbÃI¶=ì=ÀºÅg>C>º¼ÉɯIÆz=f£Ji=* xGÈf£J¶=dÉ«¿J¶ÍÉ¿ºh¶=¹Æ=b=¤uƹ>»³Ji=* xGÈf£J¶=ÍÉ·»¢Í£E>JºÆÍÈdÉ«¿IÍ¿P=bVJi=η¢¸»£¶=* e=bqCCfÖ=ÎÃJ¾=Æ14Æ(Í[º>¢ÍÉqÇI13·¶L>É[qÇIPØ[MÆ(Ê[»É·®Ý=G[J³»·¶ÍÉ[qÇIÊ[Ef£¶=h[²f» ÍÉVr¶=L>¢ÇFì=Æ°Ñ>MÇ·¶* ͪ>v[Ji>EÆ(Á=aÇj[¶>EG[Èf£J·¶>[É·£¶=Í[ÒÉ=À[ºÍ²e>n[Æ(½Ç·£¶=Æͪ>¯N¶=ÆÍÉE·¶ÍÉEf£¶=Í»¿=ÀºÌÇ¢bEÆ À[ºÌb[=½Ç[{f=¤E>j[¶=G[Èf£J¶=fÖ[ºb[¯¢(Á=aÇj[¶=Í[ºÇ³U25ʾ>[N¶=ÁǾ>[²+À[º¹ÆÙ=CfÈ>[¿È >Fm+fÈ=ª1994*[ì¶=¼É·£J¶=GÈf£I¥ÇuǺÍn®>¿ÄI>j·QÏbUCKrr]ÆÎJmL>¢ÇuǺfÖ=¹Æ>¿IÆ Ê»É·®Ý=fÈb=>ÃɪPbÆ*Ð>[»·£¶=À[ºab[¢ÆÁ=aÇj[¶>EÊ[»·£¶=O[VF¶=ƼÉ[·£J¶=ÆÍ[ÉE¶=f[ÈgÆ>Ãɪµe>m>»² GÈf£J¶=ÍÉ·»£ErJ^=* e=bqCCfÖ=ÎÃJ¾=Æ8Æͺ>¢L>ÉqÇI9ÇIÍq>]L>Éq* L=a>[×=ÆL>[É£»=K¾>²(°Èfì¶=η¢Í»ÃºL=Çì]>ãÉJ£I¶=L=Ð>¯·¶=ÆL=fÖ=´·IÀ¢ðØvªÆ η¢>ÿºÆ(Ë?f¶=Ð=bECƬ®Ç=le=bJ¶¸»£¶=L>¯·UÆL=Æb¿¶=ÀºbÈb£¶=b¯£IÍÉEf£¶=Á=b·F¶=ÍÉ¿Ã=L>E>¯¿¶=Æ fr=×¹>N=¸ÉFi6 xb¾ì¶=¼É·£J¶=ÍÉEf£¶=¹>»£Ji=¹ÇUÌÆ* (frº(ÍÈeb¿³iÝ=Í£º>Q(Gì¶=ÍÉ·³¶ËÇ¿j¶=Ê»·£¶=fÖ=25e=cA+le>º1989* xÍÉEf£¶=ͧ·¶>EÍÉFì¶=½Ç·£¶=L>¾>VJº=Ð=a?ÆkÈebIÌÆb¾* (frº(Ð>F{ڶͺ>£¶=ÍE>¯¿¶=¤ºfÂgÙ=Í£º>|Gì¶=ÍÉ·²25e>È?+ÇÈ>º1989* xUÌÆb¾ì¶=¼É·£J¶=GÈf£I¹Ç* (fÂgÙ=G{ÍÉ·³EG·¯¶=Ð>F{Ù¹ÆÙ=ÊEf£¶=fÖ=21)23>Fm+fÈ=ª1990* xGÈf£J¶=¹ÇUÌÆb¾* (Á=aÇj¶=(½Ç{f=Í£º>Q(kÈebJ·¶>É·£¶=ÍÒÉ=(ʶ>£¶=¼[É·£J·¶ÊºÇ¯¶=k·=22)26gÇ+ÇɶÇÈ1990* xì¶=¼É·£J¶=GÈf£I¹ÇUÌÆb¾* fÖ=(ÌfÂ>¯¶=(¤»J=Gì¶ÍÈfr=ÍÉ£»R·¶¤E>j¶=ʺǯ¶=21Æ22¹ÆÙ=ÁǾ>²+»jÈa1991* xÈfr=U=f=ÍÉ£»fm>£¶=ËÇ¿j¶=fÖ=* =G[ì¶=kÈeb[ISÂ>[¿ºGÈf£IÍÉ·»¢Ð>ì¢DEÍÉqÇIÆGÈf£J¶=ÍÉv® FJEð=e=f®b»J¢=ÍÈfr[=L>[£º> Á>jɾ(Íq>]ÍÉ»Â?+¸ÈfE?1992* S190 La Revue de Santé de la Méditerranée orientale Vol. 14, Numéro thematique رشع عبارلا دلجملل صالخا رادصلإا ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما (°n[ºaÍ[ÉEf£¶=Gì¶=L>É·²Ð=b»¢Ìa>j·¶ÍÉFì¶=L>q>rJ]ضÊEf£¶=k[·=ÌÆb¾6)7ʾ>[N¶=ÁǾ>[²+ fÈ>¿È1993* ¹Ç¯¶=ÍqØ]Æ6½>[»JÂ×=ÆÍ[È>¿£¶=À[ºf[ª=Æeb[¯EKÉUb®ì¶=¼É·£J¶=GÈf£IÍÉv®ÁC*>[Lb[¯¢b[¯ª ÆL=e=f¯¶=L=fn¢>ÇULebqÆL=Æb¿¶=ÆL=fÖ=L=fn¢Ê[§F¿È[¶=j[¶=Ç[ì]Lab[U[¶=L>ÉqÇJ¶= GÈf£J¶=bÂC¹ÇqǶ=¸Q?Àº>òǷi*N[²½>Ã[iÝ=¸Ñ>iƬ·J^ÍÉ>£¶=ÍVr¶=Í»¿ºK»Ãi?b®Æ ðØQ>¢Æ?ðØQAÁC°¯VJÈÇiËd¶=b=Ç°Èfì¶=Í·q=ÇJ=Íɻɷ®Ý=Æ?ÍÉ¿{Ƕ=Íìn¾Ù=ÅdÂÀºÐ>mÁC( =* =iÇJ=±fn¶ÍÉVr¶=Í· HA[iÇJ=±fn¶ÍÉVr¶=Í·=Àº¹ÆÙ=ab£¶=ebq+kìj[¦?1995±fn[¶Í[ÉÑ>EǶ=Ìfn[¿¶=¸[¸[VJ¶ d¿ºË?(L=Ç¿ifn¢Ìb>»ÂeÆbqf»Ji=J·¶=iÇJ=±fn¶ÍÉVr¶=L>ºb=Í· ÆiÇJ=1985* eÇJ²b¶=GJ²>ÃÑ=f®CÌbÈb=Í·=¼Èb¯IÆab[£¶=eb[q(Ê[»É·®Ý=fÈb=(ËfÑ=h=±=gf¶=bF¢jU ¹ÆÙ=b·=Àº¹ÆÙ=6 ?fìÈ>º¸²Ì=e> >¿É·¢GQÇJÈÆ(§J¶=¤Èfið>>¢>¿¶ÇUÀºb(ÀÈfn£¶=Áf¯¶==d¼ÉI=Ç]Ð×Æ?À> L×>=¬·JeÇìIÀº*>¿¾>Âc?Æ>¿¿É¢?XJ«¾Á?>¿É·¢´¶c¸Q?ÀºÆPb[[¶=L=eÇ[ìJ¶=Î[·¢e=f»J[i>E ¸[³EL=eÇ[ìJ¶=Åd[ÂÀ[¢½Ø[¢Ý=Ê´¶d¶ÍÉjÉÑf¶=>¿J·ÉiÆÆ(Ð=Çj¶=η¢¤i=Ƕ=ÊQe>=>£¶=ÆÍÉ·=>¿JÒÉE >¿¶Æ>¿Jº¶=¸Ñ>iǶ=*ð×>[»¢?½b¯IÍ®ÇMǺÌeÇn¿º¹Ø]ÀºL>ºÇ·£=¹a>FIabr¶==dÂͶ>£«¶=L=ÆaÙ=ÀºÆ ¬rJIÌbÑ>j[¶=L>[Â>×=ÆÍ[VQ>¿¶=¹Ç[·=ÆÍ[V·=Lسn=ÆÌbÈb=L=eÇìJ¶=¹Æ>¿JIÆ(ÍM=b=ÆͶ>qÙ>E Íɺǻ£¶=ÍVr¶=L×> ¬·JY 11*W ʻɷ®Ý=fÈb=>Ãe>»²iÇJ=±fn¶ÍÉVr¶=Í·=L>«q=ǺÅdÂK¾>²*K£[uÆ>[ÃEð>º=hJ¶=Æ>ð>¯ÉFìIÆ Í·=fÈfÍi>Ñe½g>[=ƹa>[£¶=¼É[³VJ¶=l>[i?Î[·¢½Ç¯I(fn¿·¶zf£I¶=a=Ç=Í·º>£½>³UÝ=ͧ¶>Eð>{Æfm ð>É¢ÇuǺÆð>ÉÑ>rUCÍ>qfn¿·¶Í¶ÇF¯=L×>¯=ÊI@IÎJU* ʶÆb[¶=>Â=ÇJj[K[ª¢=Á?CÍ[·=Åfn[¿I>[º¸²ÍÉ»·£¶=ͺØj¶=Ê]ÇI°É®b¶=½>¿¶==dÂÏa?b¯¶Æ =kº>[=b[·>E¹ÆÙ=ab[£¶=d[¿ºLef[®Æ(Àì¿[m=ÆG[ì·¶Í[É¿{Ƕ=Í[FJ³=h[É»J%1999$ͳFn[E>[ÃJÉì§I MEDLINEÊ[Fì¶=lf[ë¶=ͳFm¢>ÃI>ÈÇJfn¾Æ(INDEX MEDICUSL>[È×Ƕ=Ð>Qe?ÍU>JºÁdzIÎJU >£¶=ÆÍɳÈfºÙ=ÌbVJ=*·º>£Ïf]?ÍÉI>ºÇ·£ºL>³FmKº>®>»²Í[ɶÆaÍ[· >[Âe>FJ¢>EÇ[V¿¶==d[ÂÎ[·¢>[ÃJ Í®ÇMǺ* f[àF£I[¶=ÍÉ·qÙ=PÇVF¶=fn¿¶srL>V«r¶=ÍÉF¶>¦K¾>²(Í·=a=b¢?Àºab¢¸²ÏÇJV°·£JÈ>»ÉªÆ ÊÑ>rUÝ=sV«¶=Æ ¯J¶=¼É³VJ¶=L>É·»¢\>R¿E*L>[§·¶>EÌh[ÉQÆÍqØ]PÇVF¶=ÅdÂÀºO}¸²¤ºfn¿IÆ ·³¾Ý=ÆÍÉEf£¶=ÍÉj¾f«¶=ÆÍÈhÉ* Í¿ief¯IÆ2003ÍɶÆb¶=L>ºÇ·£=ͳFmη¢Í·=fn¿àIÁ?%K¾¾Ý=$ÍÉ®eǶ=>ÃJ£F{eÇøF®* Í[ÉF¶>¦>ÃEfn¿I¶=ÍÈhÉ·³¾Ý=G¾>QCÍÉj¾f«¶=ÆÍÉEf£¶=J§·¶>EL×>¯º>Âa=b¢?Àºab¢¸²Í·=fn¿IÆ L×>¯=* ¤vEb£EÍ·=Le>qb®ÆNU>F¶=ÍÉ®fIƼÉɯIÆPÇVF¶=SÑ>J¾fn¿¶Í¶ÇF¯ºÆÍ®ÇMǺͷÉiÆ>Âe=bqCÀº¿i ¼É·®Ý=L>£º>QÍÉa>²Ù=GI=f=¼í·i* 191S eussI laicepS ,41 .loV ,lanruoJ htlaeH naenarretideM nretsaE المجلة الصحية لشرق المتوسط، منظمة الصحة العالمية، الإصدار الخاص للمجلد الرابع عشر ÆI·£G=·Í=¶rVÉͶnf±=JÇiaÆe=ðºfºÇ®>ðI£hÈh=¶FVÇP=¶rVÉÍÆ=¶ìFÉÍ(ÆIÇUÉb=rì·V>L=¶£fEÉÍ ¶·JìÇe=¶£·»Ê=Ý®·É¼(Æc¶´Æ=Ubº[À=ì>¶[G=¶fÑÉ[jÉÍ=¶[I[jJ¿bC¶ÉÃ[>º[jÌƾnf=«>Âɼ=¶£·»ÉÍ(a¢»>ð *=¶J£fÈG =f=Q[¤ 1. المعجمات الطبية وتوحيد المصطلح الطبي، الدكتور حسني سبح، مجلة مجمع اللغة العربية. الجزء الثالث والخمسون. القاهرة. شباط/فبراير 4891. 2. جامعة الدول العربية. مجلس وزراء الصحة العرب. الأمانة الفنية. النظام الأساسي، المادة الثانية )01( الصفحة 8، تونس 4891. 3. في سبيل العربية. الدكتور محمد هيثم الخياط، الصفحتان 79، 89. 4. المعجم الطبي الموحد، الطبعة الرابعة، منظمة الصحة العالمية ومكتبة لبنان، ناشرون بيروت، 6002، المقدمة. 5. دواعي تعريب التعليم الطبي وفوائده، ورقة العمل الرئيسية المقدمة إلى ندوة التعليم الصحي في الوطن العربي. دمشق، 7-5 كانون الأول/ديسمبر 8891. 6. قرار جمعية الصحة العالمية رقم ج ص ع 52.05. أيار/مايو 2791. 7. قرار جمعية الصحة العالمية رقم ج ص ع 82.43. أيار/مايو 5791. 8. مجلس وزراء الصحة العرب. الدورة الثانية عشرة، الخرطوم، 61-41 آذار/مارس 7891. القرار رقم 01. 9. قـرار المؤتمـر الطبـي العربـي الرابـع والعشرين حول تعريب التعليم الطبي. القاهرة -91 22 كانون الثاني/يناير 8891. 01. اللجنة الإقليمية لشرق المتوسط. الدورة السابعة والثلاثون. استعمال اللغات الوطنية في التعليم الطبي والصحي. القرار ش م/ل أ 73 ق 4. 01 تشرين الأول/ أكتوبر 0991. 11. المجلة الصحية لشرق المتوسط. المجلد1، العدد1، تقديم. الدكتور حسين عبد الرزاق الجزائري. المكتب الإقليمي لشرق المتوسط. آب/أغسطس 5991.
World Health Organization (WHO) · Journal articles
Eastern Mediterranean Health Journal [2008; Vol.14, Issue Supp.]
View original document
The full text is hosted by the publishing organisation. lawenc.com indexes the metadata and links to the official source.
Full text
Key facts
Organisation
World Health Organization (WHO)
Document type
Journal articles
Source
World Health Organization