Our Journey Together. Our Journey Ahead: A more responsive WHO in the South-East Asia Region

1W H O S O U T H - E A S T A S I A F L A G S H I P P R I O R I T I E S Our Journey Together. Our Journey Ahead. WHO South-East Asia 2 Our Journey Together. Our Journey Ahead. Our Journey Together. Our Journey Ahead. WHO South-East Asia 3 A more responsive WHO in the South-East Asia Region Our Journey Together. Our Journey Ahead. WHO South-East Asia 4 2023 Our Journey Together. Our Journey Ahead. WHO South-East Asia 5 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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In no event shall WHO be liable for damages arising from its use. © WHO 2023 ISBN: 978-92-9021-093-1 6 7Dr Poonam Khetrapal Singh Regional Director The WHO South-East Asia Region is home to more than one in four people globally and has a significant impact on global health and well-being. In addition to its size, the Region is disproportionately affected by some of the world’s most serious public health challenges – and has been historically. However, the last 10 years have witnessed decisive changes in how WHO and its Member States in the Region work to improve public health and well-being. In 2014, the Region identified seven Flagship Priorities, bringing unprecedented focus to the most pressing health challenges. In 2017, an eighth Flagship Priority – accelerating efforts to end tuberculosis – was added. In identifying the Flagship Priorities, the Region aimed to advance four strategic imperatives: addressing persisting and emerging epidemiological and demographic challenges; promoting universal health coverage (UHC) and robust health systems; strengthening emergency risk management; and articulating a strong Regional voice in the global health agenda. Crucially, the Flagship Priorities were never a top- down exercise. Rather, they grew directly out of the wisdom and guidance of Member States and other health stakeholders based on comprehensive – and country-specific – situational analyses. As work on the Flagship Priorities progressed, WHO and its Member States and partners in the Region assessed progress, identified challenges and revised or adapted approaches. Together, this informed the Region’s “Sustain. Accelerate. Innovate” vision, launched in 2019. Over 10 years’ work, what have we learned? Most significantly, the importance of focus. By uniting Member States and partners on clearly defined targets and approaches, the Flagship Priorities have catalysed game-changing progress, which it is my pleasure to share in this final progress report. The Flagship Priorities have also highlighted the critical need for accountability, with a focus on concrete targets, measurable results, and active monitoring for timely adjustments. The Flagship Priorities have reminded us all of the need to leave no one behind, centreing equity in all that we do. They have highlighted the ongoing value of dynamic and durable partnerships, and of multi- sectoral, whole-of-government and whole-of- society action for health. Importantly, not only did the Flagship Priorities foreshadow and align with the global Sustainable Development Goals, launched in 2015, but they have also fed into and shaped the global health agenda, raising the Region’s overall profile and influence, and contributing to humanity’s onward progress. Globally, of the 270 million additional people projected to be covered by UHC over the course of WHO’s Thirteenth General Programme of Work, 110 million – more than 40% – are from our Region. This report – the last during my tenure as Regional Director – summarizes the substantial progress that together we have made, while at the same time showing how far we have to go, as we recover from the COVID-19 crisis. But we know that success is possible – when we focus, when we apply what we know to be effective, when we centre the most vulnerable, and when we work together towards a common goal. Message from the Regional Director Dr Poonam Khetrapal Singh 8 1 1 Our Journey Together. Our Journey Ahead. WHO South-East Asia 2 t Background Genesis and Attributes of Flagship Priorities Our Journey Together. Our Journey Ahead. WHO South-East Asia 3 Background Fresh commitments to end poverty, suffering and disease, endorsed by every government in every part of the world at the turn of the century, marked the beginning of a new and unprecedentedly ambitious chapter in international efforts to advance human well-being. The United Nations adopted the Millennium Development Goals (MDGs) in 2000 that were focused on some of the most fundamental health and development-related concerns. In addition, the international community joined together to create the Global Fund to fight what at the turn of the century were the deadliest pandemics confronting humanity: HIV, tuberculosis and malaria. GAVI – the Global Alliance for Vaccines and Immunization – was formed to improve access to life-saving vaccines for children living in some of the world’s poorest regions. These global agendas and initiatives were followed by the overarching Sustainable Development Goals (SDGs) Framework in 2016. The health goal in the Framework was broad and, to achieve it, the SDG Declaration emphasized that the world must ensure universal health coverage (UHC) and access to quality health care. In the WHO South-East Asia (SE Asia) Region, the Regional Flagship Priority Programmes have served as an additional accelerator in this journey towards human health and development. The WHO South-East Asia Region is home to over a quarter of the world’s population. Consisting of 11 countries, the Region bears a disproportionate share of both poverty and the global disease burden. Any meaningful progress to improve human health and development must, therefore, prioritize accelerated gains in this Region. Committed to building a better, healthier future for the nearly two billion people living in the Region, WHO has engaged with all 11 Member States in addressing persisting and emerging epidemiological and demographic challenges. The Region, accounting for nearly 26% of the global disease burden, faces multiple challenges. Government spending on health as a proportion of gross domestic product (GDP) is lower in the Region than the global average. The proportion of out- of-pocket expenditure (OOPE) among total health expenditure in the Region is higher compared to other parts of the world, placing a tremendous financial burden on individuals and families. In addition, countries in the Region are prone to natural disasters, disease outbreaks and health risks accentuated by the unfolding phenomenon of climate change. Tackling health challenges in the Region is not just a question of size and scale but requires an unflagging commitment to “leave no one behind”. Promoting health for all through the pathway of UHC and building robust health systems feature high on the global agenda. While aligning itself with these global- level priorities, the unique challenge in South-East Asia demands that the Region carefully crafts its own roadmap to advance towards the goal of ensuring health for its people. WHO / Marcus Perkins Our Journey Together. Our Journey Ahead. WHO South-East Asia 4 In public health, as in other pursuits, moving successfully towards an agreed target requires a sound strategy, robust plan, clear sense of understanding and commitment, and pursuit of actionable priorities. Resources available for public health are always limited. Therefore, it is paramount to deploy such resources efficiently in order to optimize the return on investments. As demands in the public health space almost invariably outstrip supply, prioritization is essential. This applies at all levels – global, regional, national and local. In 2014, as the MDG period was coming to a close, there was an intensive discourse on priority setting for achieving health and other development goals. WHO was the subject of criticism from some quarters, with concerns expressed that the Organization was focusing on too many areas and failing to fix clear priorities and ensure accountability for results. Both WHO as a global body as well as its regional offices have come under increased public attention and scrutiny during this pivotal moment in global health and development initiatives. Dr Poonam Khetrapal Singh, who was elected Regional Director in 2014, responded by unveiling a bold programme of strategic focus on priority areas and also by shaping crucial reforms. The Regional Director aimed to ensure a clear strategic direction across priority regional programmes, using three The early days of priority setting in WHO South-East Asia: 2014 status Our Journey Together. Our Journey Ahead. WHO South-East Asia 5 technical approaches – epidemiological, economic and evidence-based medical contributions – for set priorities for the Region. The approach was in sync with the reforms at the global level initiated by the then WHO Director-General who emphasized that the Organization should strive to become more effective, efficient, responsive, objective, accountable and transparent. At the moment when the world was charting new directions for global health and development in 2014, the global health landscape also was a repository of stark contrasts. While technological changes underscored the feasibility of universal health coverage being implemented at least partially if not fully, with medical advances offering greater hope than ever for improving health and well- being, universally linking people with these medical innovations seemed a distant aspiration. On the one hand, lives were beginning to be saved through transplantation of the heart, liver and kidney; on the other, people were still dying in thousands and hundreds of thousands from easily preventable and treatable diseases. Just when the world had hoped that it had beaten such age-old diseases as malaria and tuberculosis, these maladies resurged with a vengeance, often in complex manifestations such as drug resistance and co-infection. The world had in its possession WHO / Christine McNab Our Journey Together. Our Journey Ahead. WHO South-East Asia 6 powerfully effective vaccines to eliminate childhood diseases, but health systems struggled to reach all the children in need of such vaccines. Climate change-related natural disasters and health emergencies presented new challenges. The multiple and multisectoral influences underlying such new problems accentuated the need for new health partnerships and collaboration among all health- related sectors and partners. It was against this backdrop that Dr Poonam Khetrapal Singh had visited several Member States of the Region in preparation for her candidature for the post of Regional Director. She met with Heads of State, ministers of foreign affairs and health, as well as public health experts, social scientists and health economists across the board in several countries. These meetings enabled her to discuss in detail the health situation, including the promise of biomedical innovations and the bottlenecks that prevented these from reaching the very people in the greatest need for them. At the time these conversations occurred, it was apparent that the Region was undergoing unprecedented demographic, epidemiological, economic and social transitions. And that a bold strategy would be needed to exert the stewarding role of the WHO Regional Office for South-East Asia (SEARO) to address the unfinished agenda of MDGs 4, 5 and 6, and also to tackle the growing burden of noncommunicable diseases, build resilient and people-centred health systems and prepare for future health emergencies. Distilling the important inputs provided by political leaders and health experts across the Region, Dr Khetrapal Singh laid out her vision for meeting the most urgent and capital public health needs of the people of the Region. She named it the “One by Four Vision and Strategy”. “One” refers to the resolve to build a responsive, accountable and inclusive “One WHO” in the Region. The “Four” referred to four strategic imperatives: Addressing persisting and emerging epidemiological and demographic challenges. Promoting universal health coverage and building robust health systems. Strengthening emergency risk management for sustainable development. Articulating a strong regional voice in the global health agenda. WHO / Shobhan Singh Our Journey Together. Our Journey Ahead. WHO South-East Asia 7 Since 2014, the “One by Four” strategic theme has provided the overarching vision for WHO’s work in the Region. To operationalize this vision, the Regional Director further defined, within each area, several specific initiatives that she christened as “Flagship Priority Programmes”. These Flagships gave the new agenda a clear focus and a structure for accountability. They became a means for driving a more focused approach to work between and within the Regional and Country Offices, informing and guiding WHO operational planning. The Flagships, in essence, represent the areas in which WHO sought to make a real difference in the South-East Asia Region. Although prioritization was and remains essential, it has not been an easy task. The health needs of the Region are massive and varied. However, the finite resources available to WHO made it critical to focus on areas of work where maximum returns could be accrued with limited investments. Following the articulation of the “One by Four” strategic vision, a months-long exercise was undertaken by the WHO South-East Asia Regional Office involving consultations with Member States to identify national priorities, while in tandem matching global priorities from the MDGs and the Organization’s Twelfth General Programme of Work (GPW) 2014– 2019, reviewing past declarations and resolutions, assessing technical advisory group and committee recommendations, conducting situational analyses for disease burdens across the Region, and setting ambitious, measurable results for each priority. As a first step, the Regional Director collated the priority areas that emerged from her consultations with Member States as well as the leadership priorities defined in the Twelfth General Programme of Work. To ensure a bottom-up approach, several rounds of consultations were held with Member States to identify the priorities at the national level, which then guided priority-setting at the regional level. At each and every step of the priority-setting process (conducting situational analysis, document review, addressing global priorities or incorporating recommendations of advisory groups), Member States were consulted to ensure that the Flagship Priorities aligned with and were dovetailed into national priorities. As the world moved towards the completion dates for the MDGs, all work areas where MDG targets were not achieved were identified as priorities for moving forward. The Regional Director insisted on prioritization of the achievement of the unfinished agenda of the MDGs in South-East Asia. Taking action to markedly reduce maternal and child mortality rates represented one such priority emerging from the unfinished MDG agenda. Additionally, suggestions and ideas from pertinent documents and research were thoroughly examined. For example, all Ministerial declarations and resolutions passed by the Regional Committee, recommendations made during high-level meetings and meetings of technical advisory groups were reviewed and matched with the Twelfth GPW and MDGs. To synthesize the latest information, a situational analysis of disease burdens and challenges in the Region was conducted. Insights from the situational analysis provided much-needed guidance on the state of health and disease elimination in the 11 countries of the Region. Operationalizing the ‘Strategic Vision’ – the birth of the Flagship Priorities The Region's vast and varied health needs necessitated focusing on high-impact areas where maximum returns could be accrued with limited investments. Our Journey Together. Our Journey Ahead. WHO South-East Asia 8 In 2014, the crucial “last mile” of polio eradication was underway and all Member States had remained polio-free in 2012–2013. The Region was just a step away from being certified as polio-free. However, on other fronts, the situation was not so satisfactory. In 2010, about 200 000 new HIV cases were estimated along with 170 000 deaths related to HIV. Antiretroviral treatment coverage was only 55% in a Region with 3.4 million living with HIV. In 2012, the Region reported 39% of the global burden of tuberculosis or 450 000 deaths. The burden of multidrug-resistant TB (MDR- TB) was high, accounting for an estimated 90 000 of all TB cases notified in 2012. The management of TB/HIV co-infection remained a major area of concern. Despite the heavy HIV burden in the Region, domestic sources supplied only 50% of total TB funding. When this 2014 situational analysis was conducted, South-East Asia’s burden of neglected tropical diseases (NTDs) was the second highest among all WHO Regions. About 15 000 cases of kala-azar were reported from the Region annually. Though all countries had eliminated leprosy as a public health problem at the national level, it remained endemic in several subnational areas in six countries – Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka – where more than 1000 new cases were detected annually. The Region accounted for 72% of all newly detected leprosy cases in the world. Global advances in malaria control were endangered by the discovery of Plasmodium The health situation in the region in 2014 Our Journey Together. Our Journey Ahead. WHO South-East Asia 9 falciparum resistance to artemisinin-based combination therapy in the Greater Mekong Subregion. Measles remained a significant cause of morbidity and mortality in the Region, accounting for about half of the estimated global measles deaths in 2011. The situational analysis also found that disease surveillance and monitoring systems needed vast improvements. The situational analysis highlighted the growing burden of noncommunicable diseases (NCDs), including mental and neurological disorders and injuries, as the leading cause of mortality, morbidity and disability in the Region. Major risk factors for NCDs were highly prevalent and on the rise in the Region. The prevalence of tobacco use (smoking and smokeless) among males was a cause of concern in most countries, and the widespread consumption of unhealthy diets high in salt and fats also undermined health and well-being. Childhood obesity was found to be increasing in urban areas in some countries, and levels of physical activity were low in many. While improvements were reported in reproductive, maternal, newborn, and child health and survival, the pace of progress often fell short of MDG targets. Despite declines in the maternal mortality ratio between 1990 and 2010 in the Region, it fell short of the required rate to meet MDG 5. Member States showed declines in under-five mortality from 109 per WHO / Karen Reidy Our Journey Together. Our Journey Ahead. WHO South-East Asia 10 1000 live births in 1990 to 55 per 1000 live births in 2012. Some Member States were set to achieve the MDG 4 target, but the Region as a whole was unlikely to reach its MDG 4 target (36 per 1000 live births) by 2015. Newborn mortality showed even lower rates of decline and was responsible for more than half of all under-five deaths. Natural disaster-related deaths in the Region accounted for 37% of global mortality from natural disasters between 2003 and 2012. Numerous drug policies in many Member States, both globally and within the SE Asia Region, were either not implemented or only partially implemented. Situational analysis of the pharmaceutical sector performed during 2010–2013 in South-East Asia indicated that drug supply systems were frequently poorly organized and managed, the quality of drugs available in the market could not be assured, drug regulation was weak, and irrational use of medicines was widespread. The Region had emerged as a major producer of medicines, with pharmaceutical industries in some countries supplying essential medicines on a global scale. However, national regulatory authorities lacked access to the investment and financial support needed to cope with the regulatory challenges posed by new technologies and the increased complexity of medicines (produced domestically or imported). Another area of concern highlighted by the situational analysis was the low government investment in health and high level of out-of-pocket (OOP) expenditure. In addition to financing challenges, progress towards UHC was undermined by two persistent challenges – inadequacies of the health workforce and uneven, suboptimal access to essential medicines. Five countries in the Region faced critical shortages of health workers, and all countries encountered challenges in workforce distribution, retention and performance. The situational analysis confirmed that strengthening the health workforce was essential to hopes for improving access to health services. The three most common causes of health system Our Journey Together. Our Journey Ahead. WHO South-East Asia 11 inefficiency were related to medicines – underuse of generics and higher-than-necessary prices; substandard and counterfeit medicines; and inappropriate and ineffective use of medicines. Another aspect which mattered in the development of the Flagship initiatives was the critical importance of measurable outcomes. A variety of sources of information, concepts and data were used to determine the final list of the Flagship Priorities. The situational analysis, together with the insights gained from personal consultations with health experts and the political leadership that were undertaken by the Regional Director, helped shape the programmes. In 2014 the Regional Office launched seven Regional Flagship Programme Areas (Fig. 1). In 2015, the Sustainable Development Goals (SDGs) were fully aligned with the WHO End TB Strategy, which was adopted by the World Health Assembly in 2014. This was followed by the 2017 Moscow Declaration to end TB by 2030 and by the Political Declaration of the 2018 High-level Meeting (UNHLM) of the United Nations General Assembly on TB that reaffirmed commitment to end the epidemic by 2030. The growing political momentum on efforts to end TB has also been reflected regionally. A key ministerial meeting in March 2017 led to the adoption of the Delhi Call for Action, which acknowledged the need for urgent and unprecedented efforts to tackle the TB epidemic, with Member States committing to end TB by 2030. Following this escalation in overall commitment, the Regional Director added an eighth Regional Flagship Priority – Accelerate Efforts to End TB by 2030 – in 2017, at the request of Member States and in recognition that the Region had the highest TB burden among all WHO regions. WHO Our Journey Together. Our Journey Ahead. WHO South-East Asia 12 1 by 4 Strategy 01 02 03 04 05 06 07 08 Eliminate measles and rubella by 2023 Further strengthen national capacity for preventing and combating antimicrobial resistance Prevent and control noncommunicable diseases through multisectroial policies and plans, with a focus on “best buys” Continue progressing towards universal health coverage with a focus on human resources for health and essential medicines Accelerate reduction of maternal, neonatal and under five mortality Accelerate efforts to end TB by 2030 Scale-up capacity developement in emergency risk management in countries Finish the task of eliminating neglected tropical diseases (NTDs) and other diseases on the verge of elimination Fig. 1. WHO South-East Asia Regional Flagship Priorities Our Journey Together. Our Journey Ahead. WHO South-East Asia 13 Dynamic implementation of the Flagships The Regional Director’s aim in naming the eight Flagship initiatives was to deploy WHO’s technical expertise, convening power and advocacy strength, and strive for a greater and more visible role for the Regional Office in shaping public health priorities globally. The Flagships were carefully built on existing country initiatives and were meant to sustain achievements and accelerate progress, communicating a sense of urgency and clear strategic direction. The Flagships also brought to the forefront areas such as antimicrobial resistance (AMR), which at the time were missing from the agendas of Member States and external partners. The Flagship Priority Programmes focused on quantifiable results and deliverables. While all the Flagships were based on a common vision and philosophy, the implementation approach differed. The Flagships relating to UHC, NCDs and emergency risk management, for instance, were designed to be broad-based, while others suggested specific areas of focus. In this regard, the more specific focus areas were not meant to be prescriptive or exclusive, as needs vary at the country level. The Flagship of AMR fulfilled a different purpose – it represented an area of global and regional significance that had been relatively neglected and required urgent action from all governments. The Flagship helped bring the AMR to the attention of Member States, elevating focus on an issue that may otherwise receive little attention, especially as AMR has not historically been high on the agendas of most external development partners. WHO / Calixte Hessou The Regional Director’s aim in identifying the eight Flagship initiatives was to deploy WHO’s technical expertise, convening power and advocacy strength, and strive for a greater and more visible role for the Regional Office in shaping public health priorities globally. Our Journey Together. Our Journey Ahead. WHO South-East Asia 14 In the case of neglected tropical diseases, the Flagship enhanced focus by adding specific targets. The choice of diseases selected through the Flagships hinged on the realistic hope that the targets, while ambitious, could be achieved in the timeframe specified. Similarly, measles and rubella were selected to demonstrate that it was possible to eliminate major public health problems in the Region with the right level of political and financial support. Such success could boost the confidence of decision- makers at higher levels of government by showing that a focused health investment resulted in real and tangible dividends. The confidence gained through the achievement of such shorter-term targets could provide a persuasive platform for longer-term commitments and investment. A number of Flagships – such as measles and rubella elimination, ending TB, reducing child mortality indicators and elimination of NTDs – focused on clear, quantifiable targets and outputs. These target-driven Flagships also allowed tailoring to address each country’s needs. For Flagships covering broad areas, the objective was to provide a clear strategic direction. The Flagship Priorities identified in 2014 were ahead of their time. These priorities were subsequently prioritized in the SDG Framework as well as WHO’s Thirteenth General Programme of Work 2019–2023. Thus, these Flagships, originally focused exclusively on addressing the most pressing health needs across the Region, have also become part of the global health architecture. Four such Flagships were featured in high-level meetings at the UN General Assembly – antimicrobial resistance, tuberculosis, noncommunicable diseases and universal health coverage. Further, the priorities identified at the regional level were developed in such a way that these priorities were relevant for all the Member States of the WHO South-East Asia Region. Another notable feature of the Flagships is their dynamic nature. The priorities set in 2014 are not static, but instead are constantly being monitored, allowing mid-course changes (such as the additional of a new Flagship Priority on ending TB in 2017). Following a two-day retreat, at New Delhi in 2019, convened by the Regional Director to review all priorities, necessary changes were made to all Flagships to ensure their relevance and results- driven focus in the face of a continually changing environment across the Region. An external evaluation of all Flagship Priorities was conducted in 2020 and several recommendations were made. All the Priorities were again scrutinized closely during the pandemic period. In 2018, after having reviewed the progress and achievements of the Flagships, it was realized that prioritization had worked well and that future efforts must focus on sustaining the gains and accelerating the progress to complete the unfinished agenda. There was a need for bold advancements and innovation wherever possible to find new ways and tools to accelerate public health gains across the Region. This helped in redefining the vision in the form of the Regional Director’s “Sustain. Accelerate. Innovate.” Strategic vision that was unveiled in 2019. Strategic vision unveiled by the WHO SE Asia Regional Director in 2019 Sustain. Accelerate. Innovate. Our Journey Together. Our Journey Ahead. WHO South-East Asia 15 Flagships drive reforms The Flagship Priorities have given the Region a sense of strategic direction and ushered in reforms in the focus and implementation of health programmes. Out of the total of 925 Top Tasks planned for all activities in the Region, 610 (66%) of the measurable Top Tasks in the workplans cover the Flagship Priorities. The Flagships have made a bulk of the programmes in the Region measurable and accountable – a key watershed in the agenda of health reform. The Flagships have helped the Region move towards attaining another fundamental goal of the health reform agenda – prioritizing investment. In the current biennium, the investment on the Flagships is 59% (US$ 141.9 million) of total planned activities in the Base Segment (US$ 241.2 million). The Flagship Priorities are also percolating down to partners whom WHO relies on to achieve the goals. More than 50% of the WHO collaborating centres in the Region are now engaged in areas covered in the Flagship Priorities. A great level of commitment at the highest political levels is vital to accomplish health goals and strategies. This is true for the success of the goals set in the Flagship Programmes. To strengthen commitment, Flagship Priority Programmes have been featured prominently in technical resolutions as well as political declarations. Out of 38 technical resolutions adopted in the Regional Committee sessions in South-East Asia since 2014, 79% (30) addressed one or more of the Flagship Programmes. As many as 18 out of 24 Ministerial meetings and Ministerial Declarations featured the Flagships. Starting as a need-based and evidence-driven strategic vision, the Flagship Priority Programmes have mainstreamed action to address the Region’s key health challenges. This is reflected in investments, collaboration with partners, technical programmes as well as political commitments. In addition, the impact of the Flagships has been felt beyond the Region, as they have had a substantial influence on the global health architecture and are proving to be a great tool for advancing human development globally. WHO / Bernardino Soares, UNMIT Our Journey Together. Our Journey Ahead. WHO South-East Asia 16 Our Journey Together. Our Journey Ahead. WHO South-East Asia 17 WHO SEARO The Flagship Priorities have given the Region a sense of strategic direction and ushered in reforms in the focus and implementation of health programmes. The Flagships have made a bulk of the programmes in the Region measurable and accountable – a key watershed in the agenda of health reform. Out of 38 technical resolutions adopted in the Regional Committee sessions in South- East Asia since 2014, 79% (30) addressed one or more of the Flagship Programmes. As many as 18 out of 24 Ministerial meetings and Ministerial Declarations featured the Flagships. The visionary and pathbreaking Regional Flagship Priorities launched by the Regional Director, Dr Poonam Khetrapal Singh, in 2014 have galvanized all stakeholders in public health across the Region, from Ministers to mandarin alike, into revitalizing their national health systems and infrastructure with renewed vigour and commitment. Dr Poonam Khetrapal Singh engaged in diplomatic initiatives in public health by regularly meeting with health ministers, leaders and changemakers from all Member States of the Region. In these engagements, Dr Khetrapal Singh conveys the vital necessity of placing ‘health’ at the forefront of national agendas and policies. Throughout these high-level dialogues, Dr Khetrapal Singh consistently underscored the importance of augmenting the national health budgets and the imperative need for multisectoral collaboration. Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 20 Flagship Measles and rubella elimination by 2023 Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 21 Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 22 Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 23 WHO / Christine McNab Flagship 1: Measles and rubella elimination by 2023 Overview The WHO South-East Asia Region has made important progress in reducing the incidence of measles and rubella (also known as “German measles”). The annual reported incidence of measles across the Region declined b y 86% between 2014 and 2021 (from 23.4 to 3.3 cases per million population). However, the impact of pandemic resulted in widened population immunity gap and the region experienced large outbreaks of measles in 2022 resulting in increase in incidence to 23.8 per million population, mostly contributed by India and Indonesia. Similarly, the reported incidence of rubella fell from 5.1 in 2014 to 1.1 cases per million population in 2021. More than 619 million persons were vaccinated with measles- and rubella- containing vaccines (MRCV) through supplementary immunization activities between 2014 and 2020. Although these gains are promising, measles and rubella remain major health concerns – in South- East Asia and globally. Measles and rubella can lead to serious health complications, including even death, and primarily affect children. Health problems caused by these diseases overlap, causing brain damage, deafness, and blindness. In addition, measles can cause pneumonia and diarrhoea, while rubella and congenital rubella syndrome can lead to heart disorders. Both these diseases are vaccine- preventable (VPD) and available vaccines are safe and effective and have been in use since the 1960s. Two doses of a measles vaccine provide protection against measles, while one dose of a rubella-containing vaccine provides life-long protection. Measles is one of the most contagious of all human viruses but is almost entirely preventable through vaccination. Rubella is the leading vaccine- preventable cause of birth defects. In 2021, there were an estimated 9 million cases and 128 000 deaths from measles worldwide. Coverage of 95% or greater of 2 doses of measles-containing vaccine is needed to create herd immunity, which protects communities and lays the foundation for measles elimination (Table 1). Globally, coverage is well under this herd immunity target, with only 81% of children receiving their first measles-containing vaccine dose, and only 71% of children receiving their second measles- containing vaccine dose. 24 Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 25 Table 1. Region wise measles and rubella cases (2022) Region Measles cases Rubella Cases Africa 97,237 10,362 Americas 47 81 South-East Asia 49,201 3,728 Europe 825 62 Eastern Mediterranean 56,401 2,678 Western Pacific 1,442 1,006 Recognizing the urgency of efforts to reduce the health burden associated with measles and rubella, the Regional Director in 2014 announced Measles control by 2020 as one of the flagship priorities for the Region. During the 72nd Session of the Regional Committee for WHO South-East Asia Region the goal of ‘Measles elimination and rubella/CRS control by 2020’ was revised to ‘Measles and rubella elimination by 2023’. Measles elimination would by 2023 prevent at least 1.1 million deaths due to Measles across the Region, at an average cost of US$ 1,373 per death averted. Rubella elimination would prevent 52 118 cases of congenital rubella syndrome (CRS) annually in the Region. On average, CRS case management (treatment and disability support) is associated with lifetime costs of US$ 4200 for low-income countries, US$ 57 000 per case in middle-income countries and US$ 140 000 in high-income countries. Every CRS case averted saves 27 disability-adjusted life years (DALYs) in low- and middle-income countries and 18 years in high-income countries. Source: WHO SEARO WHO / Catalin Bercaru Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 26 Total confirmed measles cases Measles incidence per 1'000'000 total population Total confirmed rubella cases Rubella incidence per 1'000'000 total population Bangladesh 311 1.8 236 1.4 Bhutan 7 8.9 4 5.1 DPR Korea 0 0 0 0 India 40,967 28.9 2,525 1.2 Indonesia 7,704 28 839 3 Maldives 0 0 0 0 Myanmar 10 0.2 50 0.9 Nepal 130 4.3 24 0.8 Sri Lanka 0 0 0 0 Thailand 64 0.9 9 0.1 Timor-Leste 8 6 1 1.2 Progress and Results The WHO South-East Asia Region accounts for two (India and Indonesia) of the top 10 countries with the highest number of reported cases of measles (Table 2). Table 2. Measles and rubella cases in the Member States of WHO South-East Asia Region The 72nd Session of the Regional Committee for WHO South-East Asia Region adopted a Regional Strategic Plan for measles and rubella elimination in the WHO South-East Asia Region (2020-2024), setting out the following strategic objectives. Strategic Objective 1: Achieve and maintain high population immunity with at least 95% vaccination coverage with two doses of measles and rubella-containing vaccines in each district of each country. Strategic Objective 2: Develop and sustain a sensitive and timely case-based surveillance system for measles and rubella. Strategic Objective 3: Develop and maintain a proficient measles and rubella laboratory network. Strategic Objective 4: Ensure adequate outbreak preparedness and respond rapidly to measles and rubella outbreaks. Strategic Objective 5 (SO5): Strengthen support and linkages to achieve the above strategic objectives. Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 27 All 11 Member States in the Region have adopted “acute fever and maculopapular rash“ surveillance and good progress has been made to enhance the sensitivity of surveillance, with a non-measles non- rubella discard rate of 1.46 per 100 000 population.* All countries in the South-East Asia Region now have at least one proficient national laboratory to support measles and rubella case-based surveillance. The regional Measles Rubella Laboratory Network (MRLN), which ensures high-quality testing of specimens, expanded from 23 laboratories in 2013 to 58 in 2021, with at least 34 laboratories conducting both serology and reverse transcriptase polymerase chain reaction (RT-PCR) for measles and rubella. Four laboratories conduct sequencing of the viruses. This indicator is calculated as the number of non-measles non-rubella cases in a year divided by the average population in the studied area. Table 3. Key facts for 2022 35.34 million Children received MRCV1 in routine immunization 33.37 million Children received MRCV2 in routine immunization 2.76 million Children with zero-dose of measles and rubella vaccine 5.30 million Children partially vaccinated with measles vaccine WHO / Iqbal Lubis * This indicator is calculated as the number of non-measles non-rubella cases in a year divided by the average population in the studied area Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 28 Table 4. Key performance indicators Region Baseline (2015) 2022 Number of countries in the SE Asia Region with the absence of endemic measles transmission for ≥12 months in the presence of a well-performing surveillance system. None Five (Bhutan, DPR Korea, Maldives, Sri Lanka and Timor-Leste) Number of countries in the SE Asia Region with the absence of endemic rubella transmission for ≥12 months in the presence of a well-performing surveillance system. None Four verified (Bhutan, Maldives, Sri Lanka and Timor-Leste) Number of countries implementing national action plan or equivalent for measles and rubella elimination. None All 11 countries Number of countries in the SE Asia Region with ≥95% national coverage for two doses of measles and rubella-containing vaccine. Three Three (Bhutan, Maldives, Sri Lanka) Technical leadership and evidence-based policy: During the Thirteenth Meeting of the Immunization Technical Advisory Group (ITAG), country-specific recommendations were provided for 2021–2022. Taking account of the severe impact of the COVID-19 pandemic on immunization services, Member States prioritized the restoration of measles and rubella immunization and surveillance-related activities. Setting norms and standards and promoting their implementation The South-East Asia Regional Verification Committee for measles and rubella elimination verified the sustaining of measles and rubella elimination from the Member States that have eliminated these diseases and verified two additional countries for elimination of endemic rubella. The Committee also reviewed the annual progress reports and monitored the implementation of norms and standards. Technical support for institutional capacity An immunity profile for measles and rubella was developed at the national level in all 11 Member States and at the subnational level in India and Indonesia. In addition, a programmatic risk assessment was carried out for measles and rubella in all countries and risk mitigation plans were developed accordingly. Monitoring and assessing transmission trends A weekly bulletin and a quarterly bulletin, with a focus on the “Big Six” countries (Bangladesh, India, Indonesia, Myanmar, Nepal, and Thailand)*, summarized weekly surveillance reports for each country and the Region as a whole. An independent external review of progress towards measles and rubella elimination in the Region was conducted during October - November 2021. It was observed that while progress has been made, greater political commitment and excellence in technical and operational deployment remain critical to achieve the 2023 target of measles and rubella elimination. Knowledge generation, translation and dissemination Several webinars and virtual sessions were conducted, along with a gap analysis, to develop a regional framework for cross-border VPD surveillance with focus on measles and rubella. * Based On Population Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 29 Shaping the research agenda A set of research priorities were identified during regional meetings in 2021. One of the key research activities supported by the Region was to develop locally available rapid diagnostic test kits (including point-of-care diagnostic kits) for measles and rubella. Other operational research planned include total system effectiveness (TSE) analysis for switch from 10 doses to 5 doses of measles and rubella-containing vaccine in selected countries, as well as a feasibility analysis of the use of measles and rubella micro-array patches (MAP). Country Year in which verified measles Year in which verified rubella Bhutan 2017 2023 DPR Korea 2018 2023 Maldives 2017 2020 Sri Lanka 2019 2020 Timor-Leste 2018 2023 Major impact As of September 2023, five countries have achieved the goal of measles and rubella elimination by 2023 and have also sustained the goal of elimination (Table 5). Coverage with the first dose of MR-containing vaccine (MRCV1) in the Region has improved from 86% in 2021 to 92% in 2022. The coverage of second dose of the MR-containing vaccine has increased from 78% in 2021 to 85% in 2022. The global coverage for MRCV1 is 83%, while that for MRCV2 is 74%. This means that the WHO SE Asia Region is way above the global average. Six countries in the Region (Bangladesh, Bhutan, India, Maldives, Sri Lanka and Thailand) have achieved an MRCV1 coverage of 95% or more during 2022, while three of these (Bhutan, Maldives and Sri Lanka) have achieved more than 95% coverage with the MRCV2 as well. Table 5. Measles and rubella elimination by the Member States of WHO SE Asia Region Now more than ever, we must pull together to achieve our vision of a Region in which no child suffers or dies from measles; where no pregnant woman loses her unborn baby due to rubella; and where no neonate is born with a heart ailment or loss of hearing owing due to in-utero rubella infection. Dr Poonam Khetrapal Singh at the Region Verification Commission for Measles and Rubella Elimination in September 2021 Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 30 Challenges Impact of COVID-19 pandemic Measles vaccination coverage has steadily declined since the beginning of the COVID-19 pandemic. The paradox of the pandemic is that while vaccines against COVID-19 were developed in record time and deployed in the largest vaccination campaign in history, routine immunization programmes were badly disrupted, and millions of children missed out on life-saving vaccinations against deadly diseases such as measles. Globally, in 2022, nearly 32.6 million children missed a measles vaccine dose: 21.9 million children missed their first dose and an additional 10.7 million children missed their second dose. The global vaccination coverage rates of the first dose of measles vaccination showed some progress compared to 2021 however still remains below the level of 2010, although coverage varies by country. COVID-19 undermined measles and rubella activities in the Region by delaying the implementation of mass vaccination campaigns for measles and rubella and related monitoring and evaluation activities. In 2021 the Region reported an 8% decline in MCV1 and 5% decline in MCV2 coverage compared with 2019 due to the consequences of the pandemic. Coverage of MCV1 declined from 94% in 2019 to Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 31 86% in 2021, and coverage of MCV2 declined from 83% in 2019 to 78% in 2021. Similarly, coverage of the rubella-containing vaccine (RCV) declined from 93% in 2019 to 86% in 2021. In 2022, the Region reported MCV1 and MCV2 coverage as 92% and 85% which shows significant improvement in coverage due to the extensive efforts made by the countries. Surveillance for vaccine-preventable diseases was affected by the pandemic due to various reasons but is gradually reviving. Around 142 349 suspected measles cases were reported in 2022 compared to 38553 suspected measles cases in 2021, 31 091 cases in 2020, and 68 929 cases in 2019. The COVID-19 pandemic had a significant and far-reaching impact on routine immunization and surveillance, which experienced substantial delays, with progress being pushed back by a minimum of 5 to 8 years. WHO / Jubair Bin Iqbal Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 32 The need to get the regional response on track An independent review commissioned to assess progress towards measles and rubella elimination by 2023 has cautioned that the Region is not on track to achieve the 2023 milestone. As a result, target dates for achievement of these public health aims need to be revised, in consultation with global and regional experts, partners and Member States. Measles outbreaks in India and Nepal underscored the importance of improving public health efforts. From 1 January to 10 December 2022, 18,643 measles cases and 117 measles related deaths were recorded in India, among which 78% had no measles vaccination, with the majority reported from seven States. Between 24 November 2022 and until 17 January 2023, 192 cases and 1 death were reported in 17 wards (palikas) of Nepalgunj Sub Metropolitan city (SMC) and the nearby Khajura Rural Municipality. Outbreak response immunization (ORI) began on 6 January 2023 in affected areas. Sensitivity of the surveillance for measles and rubella remains sub optimal in endemic countries, resulting in under reporting and underestimation of the disease burden. Each year, a significant number of children in the Region do not receive the first dose of a measles containing vaccine through the routine immunization programme. An additional funding requirement of US$ 0.19 per capita per year, in addition to current funding levels, will be needed to get the regional response on-track. This will demand joint financing by national governments and partners as well as optimized implementation. Ensuring optimal implementation of key elimination strategies at accelerated pace remains a huge challenge, more so now with the COVID-19 pandemic and COVID-19 recovery phase that is likely to last for a couple of years to come. WHO / Christine McNab Flagship I - Measles and rubella elimination by 2023 WHO South-East Asia 33 The way forward Countries in the WHO South-East Asia Region have developed strategic, operational and policy guidelines for reviving immunization and surveillance activities following the COVID-19 pandemic, and indicators are gradually showing upwards trends. It is critical to continue to regularly identify gaps in performance at national and sub-national levels following the COVID-19 pandemic and to develop tailored strategies to plug these gaps. To achieve timely elimination of measles and rubella, WHO will continue to provide support for accelerated implementation of the recommendations made by the Thirteenth Meeting of the ITAG, the Eighth Meeting of the Regional Verification Commission, and from the independent external regional review of the measles and rubella programme. Strategic Direction Sustain Sustain the interruption of transmission of endemic measles in Bhutan, DPR Korea, Maldives, Sri Lanka and Timor-Leste. Also ensure continued and robust functioning of the national vaccination schedule until global measles eradication is achieved. Accelerate Accelerate efforts to optimally implement the national strategic plan on measles and rubella elimination, with a focus on strengthening acute fever and maculopapular rash surveillance and bridging the immunity gaps against measles and rubella among the populations of all countries of the Region. Innovate Innovate to expand the reach of measles and rubella vaccines for everyone, everywhere despite the COVID-19 pandemic. Deploy innovative approaches to optimally implement the elimination strategies and revive case-based surveillance for fever and rash in all areas. Our Journey Together. Our Journey Ahead. WHO South-East Asia 34 Flagship Prevention and management of noncommunicable diseases through multisectoral policies and plans, with a focus on ‘best buys’ Our Journey Together. Our Journey Ahead. WHO South-East Asia 35 Our Journey Together. Our Journey Ahead. WHO South-East Asia 36 Our Journey Together. Our Journey Ahead. WHO South-East Asia 37 WHO / Florian Lang Flagship 2: Prevention and management of noncommunicable diseases through multisectoral policies and plans, with a focus on ‘best buys’ Overview Noncommunicable diseases (NCDs) are among the world’s greatest threats to health and development and impose a major and growing burden in the South-East Asia Region. NCDs principally include cardiovascular diseases, cancer, diabetes and chronic respiratory diseases. NCDs cause an estimated 9 million deaths annually in South-East Asia, or 69% of all deaths, with the majority (52%) of NCD-related deaths in the Region occurring among people aged less than 70 years. Besides being an enormous burden, NCDs have serious socioeconomic implications. They disproportionately affect the poor. Due to long-term treatment costs and high out-of-pocket costs, NCDs can result in catastrophic health expenditures and impoverishment. The WHO South-East Asia Region has elevated the fight against NDCs into a major regional priority. In 2013, the Regional NCDs Action Plan was developed, with 10 regional targets to be achieved by 2025. In 2014, preventing NCDs, with a specific focus on “best buys”, was launched as a Regional Flagship Priority Programme. The 28 “best buys” represent the most effective, feasible and cost-effective interventions to prevent and control NCDs. Through WHO-led advocacy and technical support, Member States across the Region have strengthened their implementation of best buys, including important strategic shifts since 2014. All Member States have developed national multisectoral NCD action plans, and nine of the 11 Member States have endorsed these by their highest constitutional authorities, spurring accelerated uptake of best buys. 38 FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia Every 1 in 4 adults have raised blood pressure and 1 in 10 adults have diabetes in the Region. FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 39 Progress and Results WHO South-East Asia provides strategic directions and tools with a view to prioritize and accelerate high-impact interventions that are feasible within the national context. It provides guidance for prevention and control of NCDs, including links and tools for easy access. Progress made in prevention and control of NCDs have been significant in the Region. Fig. 2. illustrates the progress that Member States have made in implementing best buy interventions. 0 2 4Number of countries 6 8 10 12 Advertising bans or comprehensive restrictions on alcohol Availability of Mortality data Conduct of Risk factor surveys Increased excise taxes and prices on tobacco Tobacco demand reduction-Large graphic health warnings/plain packaging Bans on advertising, promotion and sponsorship of tobacco Mass media campaigns for tobacco demand reduction* Presence of Smoke-free policies* Reductions on physical availability of alcohol Increase excise taxes on alcohol* Salt/sodium policies Saturated fatty acids and trans-fats policies Regulation of Marketing to children-restrictions Marketing of breast milk substitutes restrictions* Public education and awareness campaign on physical activity National integrated NCD policy/strategy/action plan Drafted Guidelines for management of cancer, CVD, diabetes and CRD Drug therapy/counselling to prevent heart attacks and strokes* Setting of National NCD targets Fully achieved Partially achieved Fully achieved Partially achieved 2015 2021 Fig. 2. Progress in implementation of NCD policies and best buy interventions across counties in South- East Asia Region by year (2015, 2021) FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 40 The Seventy-fifth Session of the Regional Committee in 2022 in Paro, Bhutan, endorsed the “Implementation Roadmap for the prevention and control of NCDs in South-East Asia 2022–2030”. A regional “NCD Conclave – Advancing NCD prevention and control in South-East Asia” attempted to build and enhance the capacity of WHO regional and country office NCD teams to effectively support countries in implementing actions endorsed in the Roadmap. An NCD impact simulation tool supports countries in prioritizing NCD prevention and control measures by gauging the cost-effectiveness of different interventions and by estimating reductions in premature mortality associated with specific actions. Several interventions have been implemented at the country level to support action on different components of the NCD agenda. SEAHEARTS initiative serves as a platform to bring together tobacco control, salt reduction, and elimination of trans-fatty acids along with improved hypertension and diabetes coverage and control through primary health care. Bangladesh, Bhutan, India, Nepal, and Timor Leste have set-up national targets to scale up hypertension and diabetes management in primary health care by 2025 aligned to the SEAHEARTS initiative, and expected to cover 80 million people with hypertension or diabetes with standard protocol. ‘Dhaka Call to Action: Accelerating the control of cardiovascular diseases in a quarter of the world’s population’ founded on the SEAHEARTS initiative NCD management FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 41 (https://www.who.int/southeastasia/activities/ seahearts-for-accelerating-cvd-control) provides a strategic roadmap to achieve four interim milestones by 2025 (i) 100 million people with hypertension and/or diabetes are placed on protocol-based management, (ii) One billion people are covered by at least three WHO MPOWER measures for tobacco control, (iii) One billion people are covered with at least one of the WHO SHAKE package measures for reducing salt intake, (iv) Two billion people are protected from the harmful effects of trans-fatty acids through best practices or complementary policy measures of WHO REPLACE. The regional NCD Network was established with the participation of more than 62 academic and research institutes working in the fields of cardiovascular disease, stroke, NCD capacity- building, childhood cancer, oral health, palliative care and cancer registry. The network synergizes efforts by these different institutions and supports cross-learning and collaboration. The Regional Committee Session in 2022 also endorsed the Regional Action Plan for Oral Health 2022–2030 to guide the Member States towards universal health coverage for oral health, with a subsequent regional meeting convened to support countries in adapting and implementing the plan. Over 4000 children with cancer received improved care through WHO collaborating centres across the Region. WHO has now established, with the Tata Memorial Hospital, Mumbai, India, a WHO collaborating centre, the South-East Asia Cancer Network (SEACanNet) to facilitate improvement in the quality of cancer care. WHO / Marcus Perkins FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 42 WHO supported five countries in South-East Asia to conduct population-based surveys for NCDs and NCD risk factors, informing national decision- making and enabling countries to tailor policies and interventions to the country context. The SEARO NCD dashboard was launched in August 2023, providing data visualization to support strategic decision-making on NCD prevention and control. Bhutan, Indonesia, Nepal, Sri Lanka and Timor-Leste were supported on cancer registries through the International Agency for Research on Cancer regional hub for South, East, and South-Eastern Asia which is based in Tata memorial center, Mumbai, India. In partnership with the NORAD, WHO supported the expansion of integrated NCD care delivery in India, Myanmar and Nepal . The project is implemented in over 34 districts/ townships in the three countries covering more than 33 million persons. The key intervention is to improve effective coverage of hypertension and diabetes. Maldives designed the “Primary Health Care Demonstration Site” in Faafu Atoll with NCD service delivery as a major component. The India Hypertension Control Initiative has now more than 6 million people with hypertension or diabetes placed on standard care with control rates recorded through digital solutions. WHO also supported the design of national cancer control policies in Maldives and Nepal as well as the improvement of stroke care and surveillance in Maldives, Sri Lanka and Timor-Leste. NCD surveillance Fig. 3. WHO SEARO NCD dashboard FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 43 The Mental Health Action Plan for WHO South-East Asia 2023-2030 was developed and published to enable operationalization of the Paro Declaration. This plan contains 16 indicators to track progress in the Region, for which baselines from the Member States have been obtained. It also contains indicators that can be used at country level to track progress within countries. Country context reports on mental health outlining the current status and the challenges in all 11 Member States were published in 2022, and are available online (https://www.who.int/southeastasia/ health-topics/mental-health). The Report “Mental Health Conditions in WHO South-East Asia” launched in June 2023, summarizes the prevalence and burden associated with mental, neurological and substance use disorders as well as self-harm. An interactive dashboard containing Regional and Country epidemiological and burden data was also published in 2023, which is also available on the website above. The WHO Special Initiative for Mental Health (SIMH) is being implemented in Bangladesh and Nepal, for strengthening community mental health services. WHO estimates that more than 10 million people have now got access to mental health services in the Region through this Initiative. The “Regional Meeting on Expanding community mental health services (CMHS) in the WHO South- East Asia Region: scaling-up care for impact”, in Colombo, Sri Lanka in June 2023, at which mental health experts, government focal points and WHO Addressing mental health and substance use disorders Fig. 4. WHO SEARO Regional mental health dashboard FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 44 country office focal points participated. Many aspects related to expansion and strengthening community mental health were discussed and ideas exchanged. Documenting the learnings from policy responses for alcohol and tobacco, WHO published the report “Policy response to alcohol consumption and tobacco use during the COVID-19 pandemic in the WHO South-East Asia Region: preparedness for future pandemic events” was published in 2022. WHO built regional capacity to address mental health issues. It hosted a series of webinar for strengthening suicide prevention in Members States, with each webinar dealing with a specific measure to address suicide. The project “Strengthening the SE Asia regional response to mental health and psychosocial support in the context of COVID-19 recovery” helped bolster integration of mental health and psychosocial support services (MHPSS) into the country climate change mitigation and response. Aiming to build climate-resilient health systems and communities, the project helped develop a training package on multisectoral, community- based approaches for MHPSS; an integration manual and corpus of reference materials; and tools to support community-based approaches. One training using this material was conducted for country focal points and stakeholders. The process of in-depth implementation of the SAFER technical package for alcohol control in Bangladesh, Bhutan, Nepal, Thailand, Sri Lanka and Timor-Leste, commenced in 2023. In the WHO South-East Asia Region, the estimated prevalence of mental health conditions is 13.2%, equivalent to 260 million people living with some form of mental health condition. Mental health conditions are the leading cause of years of healthy life lost to disability. WHO / Florian Lang FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 45 Tobacco is the world’s leading cause of preventable death and major risk factor for NCDs, killing nearly 8 million people every year globally, including 1.6 million in the South-East Asia Region. The Region is also among the largest producers and consumers of tobacco products. WHO supported national World No Tobacco Day campaigns, including through the production and distribution of the video “tobacco – a threat to our environment” and other advocacy material. Support was provided to Member States to address the growing use of new and emerging nicotine products such as electronic nicotine delivery systems (ENDS) among youth by sharing updated evidence and best practices through an expert group consultation. Countries are stepping up to the challenge of tobacco control. Indonesia and Timor-Leste raised taxes on tobacco, in 2022 while Indonesia developed a “smoke-free dashboard” for monitoring smoke-free regulations at the subnational level. WHO supported countries in further strengthening tobacco cessation services including as part of the implementation of WHO package of essential non-communicable (PEN) disease interventions at the primary health care level. The first-ever “WHO quit tobacco” mobile app was developed. In addition to strengthening tobacco control policies, countries across the Region have also taken steps to improve tobacco surveillance and monitoring. WHO supported the development and review of reports for the first round of the Global Adult Tobacco Survey (GATS) in Sri Lanka and the second round of GATS in Indonesia. WHO assisted Thailand in carrying out the Global Youth Tobacco Survey. Inputs from all countries were provided for the next edition of the Global Tobacco Control Report (IX GTCR) in coordination with WHO country offices. WHO supported the Global Tobacco Surveillance System (GTSS) to strengthen tobacco surveillance in the Region in coordination with the US Centers for Disease Control and Prevention (US CDC), Atlanta. Unhealthy diet and physical inactivity Tobacco control Tackling NCD risk factors WHO prioritized efforts to address upstream factors that increase the NCD burden. The South-East Asia Region confronts a huge double burden of malnutrition, with stagnating undernutrition occurring even as levels of overweight/obesity are increasing. Among children under age five years living in the Region, an estimated 50 million children are stunted, 25 million experience wasting and 6.3 are million overweight. Overweight in children aged 5–19 years is estimated at 7.4% of the population. Approximately 15% adults and 74% of adolescents do not meet the standard minimum recommendations for physical activity. WHO supported efforts to generate strategic information to guide decision-making on improve nutrition status. WHO collaborated with UN partners (FAO, UNICEF and WFP) on the biennial FAO-led initiative to develop and publish the advocacy report titled Status of Food Security in Asia and the Pacific which in 2022 focused on urban food systems and rising food insecurity.. WHO is driving efforts across the Region to improve healthy diets and increase physical activity. With support from the WHO Regional Office, four countries, including Sri Lanka have now enacted trans fatty acid regulations. Indonesia also has complementary policies to reduce TFA developed Countries are also making progress on reducing population salt intake. In 2023, Sri Lanka reported a reduction in mean population salt intake. In India, the WHO Regional and country office provided advocacy and technical support to the Food Standards and Safety Authority of India (FSSAI), supporting the Authority’s decision FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 46 The WHO scorecard on health and environment for Bangladesh, India, Indonesia, Sri Lanka, Thailand and Timor-Leste provided a snapshot of the status of national efforts to manage major environmental threats to health. The scorecard lists the most urgent environmental health issues at country level, the health impacts of falling short of targets, and the policies that are, or should be, in place to tackle the issues identified. Environmental and occupational health, air pollution, chemical safety and climate change to produce regulations mandating front-of-pack nutritional labelling for high fact, sugar and salt in packaged processed food. Timor Leste, in 2022.23 implemented several measures to promote healthy diets. They implemented a tax on sugary beverages, increasing the number of countries in the Region with SSB taxes to five. They also legislated the Code of marketing of Breast milk substitutes (BMS) - The Region now has nine out of eleven countries with BMS Code Legislation. The Regional Office is also developing and disseminating supportive tools. An online e-learning module to enhance country capacity on regulatory actions to support healthy diets had over 4000 enrolled learners as of mid 2023. The RO has also developed a sodium score card to increase national accountability to sodium reduction, and Regional sodium benchmarks which are being disseminated to Member States to promote food reformulation with lower sodium. In response to the Global Obesity Acceleration Plan approved by the Seventy-fifth World Health Assembly, WHO held an intercountry advocacy and technical workshop to support countries to reduce child obesity. FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 47 Climate Change and WASH The Seventy-fifth Session of the Regional Committee extended the Male’ Declaration on Building Health Systems Resilience to Climate Change and the current Regional Framework for Action in building health systems resilient to climate change (2017– 2022) through 2027. The first regional expert group on environmental determinants of health and climate change was established in 2022 and had its first meeting in March 2023. A regional meeting on climate-resilient water and sanitation safety plans and audit was conducted in July 2023 in Nepal. A capacity-building and regional knowledge exchange workshop on WASH and climate-resilient and environmentally sustainable health-care facilities was held in Bangladesh. WHO developed an online WASH and climate resilience scorecard, along with a toolkit for integrating gender equality, disability and social inclusion (GEDSI) into plans and programmes for WASH in health-care facilities. SEARO also developed a knowledge catalogue for countries in the Region for improving hand hygiene in schools, health-care facilities and public places in the context of COVID-19. A regional benchmarking assessment was conducted, including the identification of lessons learned on COVID-19 medical waste management. SEARO developed sectoral briefs to mobilize multisectoral support for health-climate action. A social and behaviour change communication (SBCC) toolkit for community-level campaigns on climate change and health was initiated, highlighting lessons learned on building climate-resilient communities and providing psychosocial services during crises. WHO / Atul Loke, Panos Pictures FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 48 Air Pollution Almost a quarter of all deaths in the Region are attributable to the health impacts of environmental hazards. Air pollution accounts for the largest combined burden of disease of all environmental risks and is a leading contributor to the NCD epidemic. For people who live in cities across the Region, 99% breathe air that falls well short of WHO guidelines. Around 63% of households in the Region are still using solid fuels and are exposed to unacceptable levels of household air pollution. The draft Regional Roadmap for accelerating action towards reducing air pollution was discussed at the Regional Meeting on Air Pollution and Health in March 2023 in New Delhi. The WHO Regional Office published SDG3 and beyond: healthier environments for healthier populations in the SDG. The WHO scorecards on health and environment summarizes where countries in the Region stand on managing major environmental threats to health. Scorecards are in place in Bangladesh, India, Indonesia, Sri Lanka, Thailand and Timor-Leste. Air pollution accounts for the largest combined burden of disease of all environmental risks and is a leading contributor to the NCD epidemic. WHO / Patrick Brown FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 49 Chemical Safety Occupational Health WHO is working closely with its collaborating centres in the Region to establish or strengthen poison centres as strategic entry points to support Member States in relation to (i) prevention, (ii) diagnosis, and (iii) management of chemical poisoning, including toxicological services or clinical treatment in a chemical emergency situation. The Regional Meeting on Marine Pollution and Health in March 2023 discussed a draft white paper on marine pollution with special focus on microplastics and its impact on health. WHO and ILO published the first WHO/ILO joint estimates on the work-related burden of disease and injury, quantifying the number of people exposed to occupational risk factors and health losses from exposures to various occupational hazards. WHO and ILO published the first WHO/ ILO joint estimates on the work-related burden of disease and injury, quantifying the number of people exposed to occupational risk factors and health losses from exposures to various occupational hazards. Prior to the COVID-19 pandemic, countries in the Region such as India, Sri Lanka, Thailand and Bangladesh have showed progress in occupational health including integration of occupational health in health surveillance, training of occupational health professionals; and research on occupational health issues. A Regional Workshop to Strengthen Basic Occupational Health was in Colombo Sri Lanka from 19-22 September 2023. WHO / Vismita Gupta-Smith FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 50 ImplementationUpstream Impact Multiple measurements, too many indicators Commercial determinants Lack of commitment from non health sectors NCD and MH are the weakest links in PHC Patchy implementation Competition among health areas Investment in NCD management is not adequate Multiple domains The COVID-19 pandemic slowed this momentum, highlighting the continued inadequacy of implementation of NCD best buys, enforcement of regulations pertaining to NCD risk factors, multisectoral engagement, and NCD-related research and information. Country-level implementation challenges for best buys and other strategic NCD control interventions include inadequate resources (financial and human), health system bottlenecks and weaknesses, divergent sectoral mandates, industry interference, political pressure and a lack of clarity regarding roles and responsibilities. Persistently high out-of-pocket and catastrophic health expenditures due to NCDs demonstrate that the essential NCD package is insufficiently covered under UHC benefit packages. As a result, access to NCD medicines and diagnostics remains far too limited (Fig. 5). Challenges Fig. 5. Challenges FLAGSHIP 2: Prevention and management of noncommunicable diseases WHO South-East Asia 51 The way forward The “Implementation Roadmap for the prevention and control of noncommunicable diseases in South- East Asia 2022–2030” has outlined a clear route for countries to sustain, prioritize and accelerate actions with accountability. There is potential to harness the private sector in the prevention and management of NCDs, including digital solutions and technologies that improved disease outcomes and preserved service access during COVID-19. These technological innovations warrant scale-up with increased investments in public health and primary health care. The Paro Declaration represents a solid foundation for advancing the mental health agenda in the South-East Asia Region. The Regional Mental Health Action Plan of 2022 provides clear guidance on how to translate the Paro Declaration into concrete actions and offers specific indicators to monitor the progress. In addressing the double burden of malnutrition, attention must focus on mitigating the effects of food insecurity through the essential nutrition interventions, consolidating gains made in undernutrition reduction to date, and promoting a healthy food environment. Preventing child obesity must also be prioritized, including through technical support to countries and collaboration between partners. Tobacco control and surveillance need to be mainstreamed in the post COVID-19 era. The Regional Office will continue supporting countries to implement best buys to reduce demand for and supply of tobacco. WHO will support countries to further strengthen policies for tackling new and emerging nicotine and tobacco products and protection of the youth. The Regional Office will continue to provide technical support to countries as per the Male’ Declaration on building health systems resilience to climate change and the Regional Framework for Action. Further support will be guided through the implementation of the Action Plan for implementing the WHO Global Strategy for Health, Environment and Climate Change. Priority will be given to ensuring regional and national capacity to promote climate resilient and environmentally sustainable health-care facilities in the Region and supporting countries to improve drinking water quality surveillance and WASH services in health-care facilities. WHO will work closely with and provide technical supports to Member States in the Region in addressing the major environmental hazards which affect health. A roadmap to accelerate and scale up actions to reduce the impact of air pollution on health in the South-East Asia Region will be finalized. The Roadmap will focus on scaling up primary prevention; building cross-sectoral action, governance, and political support; strengthening the health sector; and enhancing the evidence base and risk communication. The draft white paper on microplastics in the ocean and its impacts to health and a practical way forward will be finalized. Strategic Directions: Implementation roadmap for accelerating the prevention and control of NCDs in South-East Asia 2022–2030 Sustain Sustain and strengthen national policies and programmes for NCDs Prioritize and accelerate Prioritize and accelerate implementation of prioritized interventions with innovation to achieve coverage and impact Account Promote accountability through timely and reliable data FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 52 Flagship Accelerate reduction of maternal, neonatal and under-five mortality FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 53 FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 54 FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 55 WHO / Shehzad Noorani Flagship 3: Accelerate reduction of maternal, neonatal and under-five mortality Overview The SDG 3 targets aim to end preventable deaths of newborns and children under 5 years of age and reduce maternal mortality. Regional commitment to the health and well-being of newborns, children and their mothers is evidenced by the designation of this area as one of the Regional Flagships. In addition to contributing to the achievement of SDG 3 targets, regional efforts on behalf of newborns, children and their mothers also advance the strategic objective of “one billion more people benefiting from universal health coverage” and “one billion more people enjoying better health and well-being”. Member States in the Region have achieved significant progress in reducing newborn and child mortality over the last two decades, including success in reaching the Millennium Development Goal target of a two-thirds reduction in under-five mortality in 2016. These gains have continued during the SDG era, with five countries in the Region having already achieved the 2030 target of under-five and the newborn mortality. At present, the Region is on track to reach the 2030 target for under-five mortality and the newborn mortality target. The second and third waves of the COVID-19 pandemic in 2021 severely interrupted plans to sustain these gains and accelerate progress in ending preventable maternal, newborn and child deaths across the Region. Due to the continuous mitigation efforts of Member States in 2022 and early 2023, most of services for reproductive, maternal, newborn, child and adolescent health (RMNCAH) have recovered, with most settings having reached pre-COVID levels. 56 FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia The 2030 target for U5MR is 25 or less under-5 deaths per 1000 live births. while for NMR is 12 or less newborn deaths per 1000 live births. FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 57 Bhutan Bangladesh DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SE Asia Region 38 47 102 68 130 74 84 93 27 28 108 73 MMR 2030 projection** 16 15 8 19 11 4 22 16 4 5 22 17 NMR 2021(deaths per 1000 LB) 9 11 5 12 8 2 17 11 3 3 19 10 NMR projection # 27 27 15 31 22 6 42 27 7 8 51 29 U5MR 2021 (deaths per 1000 LB) 17 19 10 18 16 3 30 18 5 6 38 18 U5MR 2030 projection # 15 7 6 8 7 3 13 12 5 4 13 9 SBR 2030 projection ## 21 9 8 12 9 5 15 16 6 6 14 13 SBR 2021 (deaths per 1000 total births) 123 107 103 173 57 179 174 29 29 204 117 MMR 2020* (death per 100000 LB) 60 Achieved country SDG global target for NMR or U5MR in the reported year and ENAP SB targets for 2030 Expected to achieve country MMR target or the SDG global target for NMR or U5MR by 2030 Countries are below the upper level of MMR in 2030 (no country should me more than 140/100000 LB) Need to increase efforts to achieve country MMR targets or the SDG global target for NMR or U5MR by 2030 Trends in maternal mortality 2000 to 2020 The MMR 2030 projection have been made using the annual rate of reduction between 2016-2020 and applied to 2020-2030 The NMR, and U5MR 2030 projection have been made using the annual rate of reduction between 2016-2021 and applied to 2021-2030 Progress and Results Table 6. Reduction in maternal, newborn and under-five mortality and stillbirth WHO South East Asia’s overarching goal is that all women and newborns will have access to skilled care services during pregnancy, childbirth and the postpartum and newborn periods, thereby minimizing maternal, perinatal and newborn morbidity and mortality. In this view, significant progress has been made in the Region. During the last decade, the region has achieved maximum reduction in all the three mortality indicators (maternal, newborn and under-5) compared to the other regions and the global reduction rates. FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 58 Four countries (Bangladesh, Myanmar, Nepal and Timor-Leste) are on track to achieve the 2030 target for maternal mortality rate (MMR), and seven countries are below the upper MMR limit for 2030 (140/100 000 live births). For the Region, MMR in 2020 was 117 per 100 000 live births (Table 1). Five countries (DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand) have already achieved the SDG 2030 targets for both the newborn mortality and under-five mortality rates. Four additional countries (Bangladesh, Bhutan, India and Nepal) are currently on track to achieve these 2030 targets. During the last decade, the region has achieved maximum reduction in all the three mortality indicators (maternal, newborn and under-5) compared to the other regions and the global reduction rates. Progress in South-East Asia in reducing maternal mortality has outpaced global gains. Globally, the South-East Asia Region achieved the largest decline in MMR from 2000 to 2020 (a 68.5% reduction compared to an average global reduction of 34.3%). During this period, the Region reported the greatest annual rate reduction in maternal mortality (5.8%). The total number of maternal deaths declined by 74.2% in the Region in 2000-2020, the biggest reduction among all WHO regions. Reductions in MMR since 2000 have occurred among all Member States in the Region, with eight Member States having reduced MMR by more than 50% (Fig. 6). However, at least eight countries in the Region need to accelerate the annual rate of reduction to sustain the momentum. WHO / Bernardino Soares, UNMIT FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 59 Fig. 6. Reduction in NMR, U5MR and MMR in SE Asia Region is close to double of the global reduction. *deaths per 1000 live births *deaths per 100 000 live births *deaths per 1000 total births *deaths per 1000 live births NMR 2010 2021 Data source: UN inter-Agency estimates:Levels and trends in Child Mortality Reports U5MR 2010 2021 0 10 20 30 40 50 60 0 5 10 15 20 25 30 Global SEAR 18% reduction 39%reduction 18 17 28 22 0 100 200 300 400 MMR 2000 2020 Global SEAR 34% reduction 69% reduction 223 117 372339 Global SEAR 25% reduction 45% reduction 38 29 5351 STILLBIRTHS 2000 2021 Global SEAR 35% reduction 54% reduction 14 13 28 21 0 5 10 15 20 25 30 Reduction in NMR, U5MR and MMR in SE Asia Region is close to double of the global reduction. FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 60 The Region has the second-highest reduction among WHO regions in the rate of stillbirth (55.8% from 2010 to 2021). Seven countries (Bhutan, DPR Korea, India, Indonesia, Maldives, Sri Lanka and Thailand) have achieved the 2030 stillbirth rate (SBR) target of 12 or less per 1000 total births. Assuming that the annual rate of reduction for 2010– 2021 continues through 2030, the Region is on track to achieve the ENAP targets for stillbirths, although three countries (Bangladesh, Myanmar, and Timor-Leste) will need to increase their efforts to achieve the stillbirth target by 2030. Coverage of evidence-based interventions has improved in recent years, but remains short of the goal of universal coverage. Eight of 11 countries (Bhutan, DPR Korea, Indonesia, Maldives, Nepal, Sri Lanka, Thailand and Timor-Leste) have achieved at least 75% coverage for at least four antenatal clinic visits and skilled birth attendance. Seven countries (DPR Korea, India, Maldives, Nepal, Sri Lanka, Thailand and Timor-Leste) have achieved >75% coverage for institutional deliveries (Fig. 7). Nearly two-thirds of women (65%) have postnatal contact with a healthcare provider within two days after birth while newborns with postnatal contact within two days is 78%. Less than two-thirds of infants less than 6 month of age are exclusively breastfed and 76% of children fully immunized. The coverage of oral rehydration salts for children with diarrhea is 55% and close to 64% of children with suspected pneumonia are taken to an appropriate health provider. Seven countries from WHO SE Asia Region have already achieved the 2030 stillbirth rate target of 12 or less per 1000 total births. Further, the Region is on track to achieve the ENAP targets for stillbirths. FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 61 0 20 40 60 80 100 GPW 13 2025 target achieved Bangladesh Maldives Myanmar Bhutan Nepal DPR Korea Sri Lanka India Thailand Indonesia Timor-Leste SEAR 63 87 82 86 66 79 45 61 76 59 63 87 Deman d satisfied for FP(%) Childern with suspected pneumoni a taken to facility (%) Childern with diarrhoea given ORS (%) Childern with all basic vaccination s (%) Exclusiv e breast feeding 6 months (%) Breast feeding initiated within one hour (%) Postnatal care newborns (2 days) (%) Postnat al care mothers (2 days) (%) Births attended by skilled health personne l (%) Births in health facility (%) ANC by skilled provider (%) ANC 4 visits (%) Fig. 7. Coverage of selected RMNCAH interventions in SE Asia Region WHO / Rinzi Om Dorji FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 62 In 2022, the WHO Regional Office convened a regional meeting on improving intrapartum and postpartum care to accelerate reductions in maternal and newborn mortality and stillbirths. Participants included nine Member States, implementing partners, professional associations and WHO collaborating centres. As part of the planning process for the Regional Meeting, a pre-workshop assessment was undertaken by WHO SEARO for the policy and programmatic environment and current implementation of recommendations on antenatal care, intrapartum care, postpartum care, non-health intervention on prevention of congenital syphilis, and labour care. Bangladesh updated its national Every Newborn Action Plan and its Ending Preventable Maternal Mortality Acceleration Plan. Nepal and Sri Lanka are updating their national plans to identify areas for priority action. Strengthening maternal newborn health FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 63 The Maternal Death Surveillance and Response (MDSR) training package has been expanded to include the review and response of stillbirths and early neonatal deaths, becoming the maternal, perinatal death surveillance and response (MPDSR). In 2022, capacity- building for MPDSR was completed for nine Member States, and a pool of facilitators was established to continue capacity-building at the national level. In 2022, WHO aided in the initiation of pilot projects in collaboration with the South Asia Federation of Obstetrics and Gynecologists (SAFOG), Johns Hopkins Program for International Education in Gynecology and Obstetrics (Jhpiego) and national obstetric societies of Bangladesh, India, Nepal and Sri Lanka. These projects aim to further strengthen capacity for maternal and perinatal death surveillance and response, focusing on the quality of review and response in selected health facilities. WHO supported Timor-Leste in developing the national MPDSR training manual and scaling up capacity-building at the municipal level. The WHO Regional Office is supporting country readiness for incorporate self-care interventions in maternal care programmes. Technical support was provided to Nepal for conducting an MPDSR evaluation study on maternal, perinatal death surveillance and response and for including maternal mortality in the census report of 2022. The evaluation results and census report are expected to provide future directions for Nepal to achieve its SDG targets. Maternal Perinatal Death Surveillance and Response (MPDSR) WHO / Christine McNab FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 64 In 2022, WHO built the capacity to support health- care teams in countries across the Region, developing new training modules and providing opportunities for collaborative learning in improving the quality of care. WHO SEARO supported e-training on the Point of Care Continuous Quality Improvement (POCQI) model. A regional training of trainers (ToT) workshop was conducted to develop a pool of master trainers for four countries (Bhutan, India, Indonesia and Maldives), while two regional workshops on POCQI were conducted for participants from six countries (Bangladesh, Bhutan, India, Indonesia, Maldives and Nepal). In addition, WHO supported the Maldives Health Ministry for national-level training on POCQI. POCQI-plus modules are being developed to include additional topics on patient safety and quality assurance in health facilities. Additionally, a pre-service training module for medical students is being developed to orient MBBS students in quality improvement. WHO organized a regional webinar on the Lancet 2022 series on Optimizing Child and Adolescent Health and Well-being, focusing on the implications of the latest evidence for countries in the Region. WHO is developing implementation guidance on the recent WHO recommendations on universal screening of neonatal conditions (neonatal hyperbilirubinemia, hearing impairment, eye abnormalities) to support the introduction of policy and scale-up across the Region. The WHO Regional Office is facilitating and coordinating an RMNCAH policy survey to identify the gaps in RMNCAH policies in Member States. The Regional Office is also investing in further capacity-building through a regional training on RMNCAH programme management, specifically at the subnational level. Strengthening Newborn and child health WHO / Maren Shapiro FLAGSHIP 3: Accelerate reduction of maternal, neonatal and under-five mortality WHO South-East Asia 65 The COVID-19 pandemic, both directly and indirectly, has caused severe disruption in RMNCAH services in the Region. The disruption of efforts related to access, demand and utilization of services was significantly high for RMNCAH services in the Region’s countries and could have adverse impact on maternal and child mortality. In the long run, this could potentially interfere with achieving the related SDG 2030 targets. Unless the annual reduction rate is accelerated, the Region is likely to miss a number of SDG 3 indicators by 2030. To accelerate progress, the coverage of several evidence-based, life-saving interventions across the RMNCAH life course must reach universal coverage. Coverage has been especially low among poor and vulnerable populations. In addition to low and uneven coverage, quality of care for maternal, newborn and child health has been inadequate, slowing the rate of mortality reduction. In several countries, progress has been slowed by an inadequate number of health workers and the required skill mix for RMNCAH, gaps in health-care infrastructure across the RMNCAH life-course, and issues related to essential supplies and equipment. Countries need to augment the overall financial allocation for RMNCAH services. As many national economies across the Region have yet to recover from economic setbacks during the pandemic, countries face challenges in sustaining the existing low levels of health financing. At the same time, out-of-pocket costs for health services remain high. These dynamics are causing regression or stagnation of progress towards the SDGs, including impeding efforts to achieve high coverage of key life- saving evidence-based interventions. Countries must keep RMNCAH at the centre of UHC initiatives – to sustain gains made to date and accelerate progress towards the full array of SDGs. Member States will need to increase domestic financing and scale up coverage of effective, well- characterized and relatively inexpensive evidence- based interventions to prevent newborn and child mortality. These essential services must be delivered across the life course continuum of RMNCAH and at all levels of care from home and community to first- level to referral-level health facilities linked through a functional referral system. Strategic Direction Sustain Catalyze government partnerships and sustain coordination with the UN partners, such as the H6 partnership in the region for harmonized support to Member States in programme implementation. Continue strategic and technical support to mitigate the risks on account of the COVID-19 pandemic through country support plans. Accelerate Accelerate the annual reduction rate in maternal, newborn, stillbirth mortality by implementing high-impact strategies, equitably scaling up the coverage of life-saving interventions and leaving no one behind. Improve RMNCAH programme governance by establishing National Technical Advisory Groups at the country level for more effective planning and implementation of national programmes to accelerate progress. Innovate Adopt innovative methods for strengthening health system actions for increased domestic financing and addressing human resources issues (e.g. midwives). Effectively apply digital health technologies for service delivery and programme monitoring as a key opportunity that must be leveraged. Challenges The way forward 66 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Flagship Continue progressing towards universal health coverage with a focus on human resources for health and essential medicines 67 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia 68 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia 69 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia WHO / Shobhan Singh 70 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Flagship 4: Continue progressing towards universal health coverage with a focus on human resources for health and essential medicines 71 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Overview Universal health coverage (UHC) requires that all people receive the health care they need, of sufficient quality and without suffering financial hardship (Fig. 8). UHC is central to the Sustainable Development Goal 3 to ensure healthy lives and promote well-being for all at all ages. UHC requires a strong, efficient, and equitable health system; an equitable and sustainable system for financing health services; a system for reliable and timely health information; access to essential medicines and technologies; and well- trained and motivated health workers. Primary health care (PHC) is the cornerstone of UHC. One of the three targets in WHO’s Thirteenth General Programme of Work (GPW13) is to ensure that “1 billion more people benefit from UHC by 2023”. UHC has been a Regional Flagship Priority Programme since 2014, with a focus on the health workforce and access to essential medicines. The Region is committed to the “Decade for strengthening human resources for health in the South- East Asia Region 2015–2024”. In 2018, Member States at the Regional Committee also endorsed the Delhi Declaration on improving access to essential medical products in the South-East Asia Region and beyond. In the SDG monitoring framework, UHC has two dimensions: provision of essential health services, as measured by the UHC service coverage index (indicator 3.8.1); and financial protection, as measured by catastrophic health expenditure (indicator 3.8.2). The South-East Asia Region has witnessed an increase in the service coverage index – from 47 in 2010 to 62% in 2021 and a sustainable value of 62 in 2021, although the pace of improvement is inadequate to achieve the minimum essential service coverage index of 80 by 2030. The latest regional estimates show that catastrophic health spending (measured by the population spending more than 10% of their total household total expenditure [income or consumption] on health) has increased from 13.1% in 2010 to 15% in 2017, with a further slight increase to 16.1% in 2019. The Region continues to have higher catastrophic health spending at 10% and 25% of total household spending compared to global average (16.1% vs. 13.5% at 10% household spending and 3.8% vs. 5.9% at 25% household spending). On a more positive note, indicator on impoverishing health spending which is defined as the total population impoverished due to OOP health spending (living with less than PPP $ 2.15 a day per person) decreased drastically in the Region from almost 29% in 2000 to about 4.7% in 2019. Despite this progress, the overall number of people with impoverishing health spending in the Region remained high (96 million in 2019) making it the second highest compared to other WHO regions. WHO / Christine McNab, UN Foundation 72 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Fig. 8. Three Dimensions to consider when moving towards universal health coverage Progress and Results Building on momentum from 2021, the year 2022 saw focused attention at the regional and country level to advance a PHC-oriented transformation of health systems, including convening and leveraging partner capacities towards key Member State priorities. A progress report on comprehensive primary health care (CPHC) was presented to the Seventy-fifth Session of the Regional Committee, which adopted resolution SEA/RC75/R3 on “Enhancing social participation in support of primary health care and universal health coverage”. The resolution formally endorsed the Regional PHC Strategy; urged Member States to strengthen comprehensive primary care and its monitoring; and called on the Regional Director to provide technical support and establish a regional knowledge and experience sharing mechanism for CPHC through mobilizing expertise from development, implementation and academic partners. Responding to Member States’ requests, WHO held three regional meetings in 2022; two virtually and third in-person. The first regional meeting sensitized Member States and partners regarding the regional PHC Strategy. A second regional meeting sought inputs on the content and governance of a regional forum to systematically capture PHC implementation-focused learning and enable partner synergy. The third, in-person, regional workshop enabled cross-country learning on innovations and challenges on PHC across the Region, with launch of the South-East Asia Regional Forum for Primary Health Care-oriented Health Systems (SEAR PHC Forum). Supporting PHC-oriented health system transformation Reduce cost sharing and fees Direct costs: proportion of the costs covered Services: which services are covered? Population: who is covered? Current pooled funds Extend to non-covered Include other services 73 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia At the Regional Workshop, Member States identified 7 areas of operational challenge, with associated commitment from Member States and partners to collective document operational innovation and learning as initial activity for the SE Asia Regional PHC Forum. In 2023, following virtual convenings of the thematic working groups, a three-day workshop of the SEAR PHC Forum-Thematic Working Groups was convened in Dhaka, Bangladesh in June 2023 with focus on capturing and translating innovations in the Region, including in the context of Bangladesh. A robust primary health care (PHC)-oriented health system is the most equitable and efficient approach for achieving universal health coverage and health security. To accelerate PHC-oriented transformation of health systems, Member countries of WHO South-East Asia Region, WHO, and Partners today launched the South-East Asia Regional Forum for Primary Health Care-Oriented Health Systems. Our challenges are immense, and our glass is half full. While the last few years have witnessed unprecedented energy and innovation in health, we must grasp these and other opportunities to accelerate transformation across our Region and do so in a manner that is coordinated, aligned with national priorities, and which avoids duplication and fragmentation. Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia, addressing participants at the launch of the PHC forum 74 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia WHO, through Country and Regional Office, further supported Member States to strengthen PHC- oriented health systems, including through the development of service and staffing standards in Bangladesh, Bhutan and Timor-Leste; a PHC revitalization pilot in Maldives; PHC-focused health labour market assessments in India; reviews of service delivery and human resources for health in Sri Lanka; and support to the High Level Event on Accelerating Universal Health Coverage for Smart Bangladesh in May 2023 and the National Launch of Primary Health Care, Integration in Indonesia in June 2023. To support Member States, the Regional Office also conducted regional reviews on service packages and associated service standards and a landscape analysis of PHC monitoring indicators and approaches. As part of the three-level WHO PHC Implementation Solutions initiative, and through engagement of Thailand’s International Health Policy Programme, success factors that contributed to Thailand’s strengthening of its’ district health system to deliver UHC has been documented; with learning to serve as resource for the region and globally. Finally, based on a self-reported survey and information from WHO, the Regional Office prepared the first progress report on the Ministerial Declaration adopted at the Seventy-fourth Regional Committee (SEA/RC74/R1) to be presented to the Seventy-Sixth Session of the Regional Committee. WHO also supported the key agenda item ‘Strengthening primary health care as a key element towards achieving universal health coverage’ for deliberation at the Seventy-sixth Session of the WHO Regional Committee. 75 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Strengthening the health workforce (pandemic and beyond) Health workers are central to improving health services and attaining UHC. The fourth Progress Report on the Decade of Strengthening Human Resources for Health, presented to the Seventy- fifth Session of the Regional Committee in September 2022, summarized the latest data from national health workforce accounts, including key initiatives on transformative education, rural retention and international migration of health workers across the Region. As highlighted in the Progress Report, the regional average density of doctors, nurses and midwives stands at 28.05 per 10 000 population. This represents a 30.5% increase since the start of the regional Decade of Strengthening Human Resources for Health in 2014. As of July 2022, nine Member States in the Region have surpassed the 2006 World Health Report- identified threshold of 22.8 doctors, nurses and midwives per 10 000 population (Fig. 9). Moreover, three Member States have surpassed the 2016 Global Strategy on Human Resources for Health-identified threshold of 44.5 doctors, nurses and midwives to achieve the SDGs. WHO / Christine McNab 76 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Fig. 9. Trends in the availability of doctors, nurses and midwives in South-East Asia Region countries, 2014–2020 2014 or before 2015 or 2016 2018 2019 or 2020 0 20 40 60 80 100 120 44.5/10000: Global Strategy on HRH 2016 22.8/10000: World Health Report 2006 Bangladesh*India* MyanmarTimor-LesteBhutanSri LankaThailand*Nepal*Indonnesia*MaldivesDPR Korea De ns ity o f h ea lth w or ke rs (d oc to rs , n ur se s, m id w ive s) pe r 1 00 00 p op ul at io n Source: Country data reported to WHO through the NHWA online platform (MoH & professional councils) as on 22 June 2022 77 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia For the first time, progress with respect to the UHC service coverage index (SDG 3.8.1) was mapped alongside the density of doctors, nurses and midwives. Mapping the two shows that the relationship between the UHC service coverage index and the density of doctors, nurses and midwives in several countries is not necessarily linear, as countries with relatively lower density of doctors, nurses and midwives nevertheless have opportunities to significantly improve service coverage through health system organization, including the important role of additional health workers. In addition to sufficient aggregate densities of doctors, nurses and midwives, critical factors for progress towards UHC include models of service delivery, and their efficiency and quality; financing and governance of the public and private sectors; availability and distribution of infrastructure, health workers and medical products across geographical areas, levels of health-care facilities and the public and private sectors; mechanisms for community engagement; and the role of additional occupations in health service delivery teams (including mid- level health workers, community health workers, traditional health workers, and other allied and paramedical staff). Through its regional and country offices, WHO is increasingly focusing its support on strengthening WHO / Tatiana Almeida For the first time in 2022, progress with respect to the UHC service coverage index (SDG 3.8.1) was mapped alongside the density of doctors, nurses and midwives. Mapping the two shows that the relationship between the UHC service coverage index and the density of doctors, nurses and midwives in several countries is not necessarily linear. 78 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia primary health care teams, including ongoing work in Bangladesh, India and Sri Lanka. WHO additionally supported a range of efforts including launch of the first ever Medical Education Bulletin and Community Health Worker Programme Review in Bangladesh; ongoing health labour market assessments in Assam and Gujarat states in India (with focus on PHC workforce); a review of human resources for health for strengthening PHC in Sri Lanka; development of methodology and projection of medical specialist requirements in Timor-Leste; as well as a regional reviews on lessons from use of the WHO Workload Indicators of Staffing Needs (WISN) tool; on the role of medical humanities to strengthen people-; and on opportunity to establish a regional network of health professional regulators. Notably, a Regional Human Resources for Health Meeting was held in July 2023, with aim to both inform a formative evaluation of the SE Asia Regional Decade for Human Resources for Health Strengthening and to discuss potential role of medical humanities in advancing people-centered care across the SE Asia Region. Regional Workshop Evaluation of the SEAR decade for HRH strengthening & Integration of medical humanities into HRH edu- cation and development, held on 10-12 July, 2023, Colombo, Sri Lanka Important country work was also supported with respect to reviewing and updating human resources for health strategies and associated policy dialogues, as well as supporting ministries of health in leveraging the WHO Global Code to lead and/or engage in government-to-government agreements on international health worker migration (in the case of India and Nepal). Improving access to essential medicines and health products To improve equitable access to medical products, WHO supported Member States in a range of areas. These include developing a national medicines policy in Nepal, developing medicines pricing policies in Maldives, strengthening procurement and supply chain management in Sri Lanka and Timor- Leste, and promoting rational use of medicines and combating antimicrobial resistance. A training workshop for a regional initiative for coordinated antidotes procurement (iCAPS) was held on 30–31 March 2022 virtually and face- to-face on 13–15 December 2022 in Bangkok, Thailand. iCAPS, which was launched in 2018, supports collaborative procurement of essential antidotes for several common causes of poisoning. This systematic approach is expected 79 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia to improve procurement efficiency by aggregating demand, reducing costs and coordinating quality assurance. An assessment of WHO Model Quality Assurance System for Procurement Agencies (MQAS) was conducted in Bhutan, India (Gujarat and Tamil Nadu states), Indonesia, Nepal and Timor-Leste. Quality standards and specifications for medical products procurement by government agencies are often not well defined, and compliance with quality assurance principles for procurement vary greatly across the Region. Such gaps pose health risks and lead to wastage. The assessment identified strengths and gaps in the system and supported countries to develop institutional plans to strengthen procurement and supply chain systems. The unaffordability of medicines poses a major barrier to access to effective, safe and quality medicines in low- and middle-income countries. In response, countries have adopted various mechanisms to control prices. WHO published and disseminated a technical brief on pharmaceutical pricing policies in the Region, reviewing various policy recommendations from WHO and summarizing policies currently in place across the Region. Technical brief 1 Pharmaceutical pricing policy and universal health coverage Affordable access to safe and quality pharmaceutical products is at the core of achieving universal health coverage. However, governments struggle with high pharmaceutical prices when trying to provide population-wide access to life-saving medical products for people in need, especially for people living with chronic diseases. Every year, out-of-pocket expenditure for medicines forces millions of people into poverty or further into poverty around the world and is especially a challenge in the WHO South-East Asia Region where public health spending is limited in many of the Member States (1) and medicines are the main component of out-of-pocket expenditure on health in the Region (2). Worst of all, several patients do not have access to potentially life-saving pharmaceutical products even many years after the discovery of these products, as their prices are unaffordable. While lowering pharmaceutical prices alone is unlikely to be sufficient to increase financial protection or reduce out-of-pocket expenditure, it decreases the economic burden on patients and increases value for money for purchasing organizations. Pharmaceutical pricing policies are interventions for managing the prices of pharmaceutical products adopted by a public institution such as the Ministry of Health and Ministry of Finance, a group of purchasing organizations or individual health service providers. The overall objectives of pricing policies should explicitly focus on achieving affordable and equitable access to quality-assured pharmaceutical products for patients and health systems, which should ensure value for money based on improved health outcomes at the population level, as well as maintaining supply security of high-quality products. Types of pharmaceutical pricing policies and recommendations from WHO The WHO Guideline Development Group, which consisted of international experts with experience in research and implementation of pharmaceutical pricing policies in countries, appraised the evidence and synthesized in a systematic review commissioned by WHO and provides the following recommendations on formulating and implementing policies relating to price management of pharmaceutical products. Interventions How it works Considerations Strong recommendation Promoting the use of quality- assured generic and biosimilar medicines This policy refers to strategies directed at patients, prescribers or pharmacists to encourage the use of quality-assured generic medicines or similar biological medicines (i.e. biosimilar medicines). Enable early market entry of generic and biosimilar medicines through legislative and administrative measures, with a view to encouraging early submission of regulatory applications, allowing for prompt and effective review, and ensuring that these products are safe, efficacious and quality assured. 1 Access to medical products in the South-East Asia Region, 2021: review of progress. New Delhi: World Health Organization, Regional Office for South-East Asia; 2021. 2 Hui W, Torres LV, Travis P. Financial protection analysis in eight countries in the WHO South-East Asia Region. Bull World Health Organ. 2018;96(9):610–20E. Technical brief Access to essential medicines Pharmaceutical pricing policy Access to safe blood and blood products is a vital part of the quest to achieve UHC and the SDGs. The availability of safe Blood is an integral part of strong health system. The WHO Action Framework to ensure uniform access to safe blood and blood products provides guidance to member states in establishing quality assured blood transfusion services. Regional workshop on quality assurance for blood and blood products, 18-20 July, Colombo, Sri Lanka was organised to listen to the countries about their current status of Blood Transfusion Services and provide guidance or insight on scaling up the implementation of the WHO action framework on the availability of safe blood and blood products and ensuring quality assurance in all aspects of NBTS through lectures, site visits, and sharing best practices. 80 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Strengthening medical products’ regulatory systems Robust regulatory systems are required to ensure access to safe, effective and quality medical products. These systems play a critical role in achieving UHC. WHO has continued supporting countries in strengthening their regulatory systems through the use of the Global Benchmarking Tool (GBT) for medicines and vaccines. The GBT assesses national regulatory system performance, provides recommendations in institutional development plans (IDPs), and monitors progress over time. In 2022 and 2023, WHO undertook GBT-related activities in Bangladesh, Bhutan, Indonesia, Maldives, Nepal, Sri Lanka and Timor-Leste. WHO also helped strengthen regulatory frameworks for traditional and complementary medicine products. Capacity-building was provided through training in laboratory-based quality control methods to Bhutan, India, Indonesia, Maldives, Nepal, Sri Lanka, Thailand and Timor-Leste. At the regional level, the South-East Asia Regulatory Network (SEARN) has been effectively revitalized following a meeting of its Assembly in June 2022 in New Delhi. During the meeting of the Assembly of the members in July 2023 in Jakarta, Indonesia, the heads of the National Regulatory Authorities (NRA) and their representative adopted the outputs of 14 action points (the summaries can be found on the website), established a Coalition of Interested Parties (CIP) at the regional level to further support the activities of the Network through close collaboration with the development partners, and adopted the new workplan. Especially, the Assembly adopted a strategy to strengthen information sharing, which included a declaration from the Members of SEARN to facilitate information sharing. WHO / Christine McNab 81 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Traditional medicine in the South-East Asia Region In 2022, WHO also established a multidisciplinary technical group (MTG) to review, evaluate and interpret all available safety data related to ocular adverse events associated with the use of miltefosine, an oral anti-infective medicine with established efficacy in the treatment of some forms of leishmaniasis. This work, supported by the German National Regulatory Authority (BfArM) and the Uppsala Monitoring Centre (UMC), provided the basis for recommendations adopted in December 2022 by the Advisory Committee on Safety of Medicinal Products (ACSoMP) on measures to minimize the identified risks [see https://www.who. int/news/item/12-04-2023-acsomp-miltefosine]. Furthermore, a regional workshop on ‘Ensuring the Quality of Medicines from Contaminated Substances’ was conducted in Jakarta, Indonesia, on 2–4 May 2023, in collaboration with the Therapeutics Goods and Administration (TGA) and the United States Pharmacopeia (USP), to support Member States in protecting public health from contaminated medicines. This workshop allowed to discuss how to best address the issue of contaminated products and develop tailored solutions in the region. These discussions further fed the South-East Asia Regulatory Network (SEARN) regional strategy to ensure the integrity of excipients, which was adopted by the Assembly during its meeting on 26-27 July 2023 (please see above). Traditional medicine has been an important part of health care all over the world, with 170 WHO Member States reporting its use. Nearly all WHO Member States have in place national policies on traditional medicine, and nine have formal training and education systems for traditional medicine practitioners. Aligned with the WHO Traditional Medicine Strategy 2014–2023, the WHO Regional Office developed a Regional Action Plan in 2015 with four priority areas: i) system performance monitoring; ii) safety monitoring for traditional medical products; iii) research capacity- building; and iv) integration of traditional medicines into the health-care delivery system. Progress has been made under each priority area of the Regional Action Plan. For data and analytics on the performance of the traditional medicine system, the Regional Office developed a monitoring framework, including the standard core and reference indicators and their metadata. The Regional Office organized South-East Asia Regulatory Network is a pathbreaking initiative which it is hoped will enhance information sharing and collaboration, and lead to convergence of regulatory practices across the region. Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia 82 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Advancing international trade and health Member States agreed at the Seventy-fourth World Health Assembly to strengthen implementation of the Global Strategy and Plan of Action on public health, innovation and intellectual property (GSPA), taking into account national contexts. It was agreed that the Secretariat, through informal consultations, would identify and share best practices in GSPA every two years. WHO prepared the Regulations and Laws promoting health and well-being goals (SDG3) in WHO South- East Asian countries” with the aim of advancing health-related legal support for UHC and GSPA. This seminal document is the only one of its kind that identifies country laws that support the 2030 Agenda for Sustainable Development as well as key country decisions, covenants and best practices for achieving health goals. a regional consultation on traditional medicine data, monitoring framework and indicators with metadata. The Regional Office drafted a dashboard to support Member States in monitoring the traditional medicine system performance. A DHIS2- based traditional medicine data collection tool was developed and made available on the WHO regional public domain website. To strengthen safety monitoring for traditional medicine products, the Regional Office organized training workshops on pharmacovigilance. Recognizing that conventional research methods are not always applicable to traditional medicine, the Regional Office is also developing guidelines at the regional level for traditional medicine research. The guideline highlights the need and the “innovative” wherewithal to conduct research based on designs specific to traditional medicine. Other activities by WHO in this domain include the introduction of an M-Yoga mobile application, developed through collaboration between WHO headquarters and the Regional Office. Given the importance of traditional medicine, WHO has established the Global Centre for Traditional Medicine in Jamnagar, in the state of Gujarat in India, with support from the Government. This centre will help promote traditional medicine and its integration into prevention, wellness and health promotion, and health-care delivery in the Region. Under the aegis of the GCTM, the first WHO Traditional medicine Global Summit took place at Gandhinagar, India on 17-18 August 2023. The “Gujarat Declaration” is one of the major outcomes of this global event [see https://cdn.who.int/media/ docs/default-source/traditional-medicine/who_ tm_summit_meeting_report_gujarat_declaration. pdf?sfvrsn=4a816abb_1&download=true] 83 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Increasing health financing and financial protection The WHO Regional Office released the financial protection chapter within the 2022 UHC Monitoring Report. The report provides a comprehensive overview of the financial protection situation in the Region, the implications of COVID-19 and policy recommendations to reduce financial hardship. New national health accounts (NHA) studies have been conducted, with Bhutan, Indonesia, Maldives, Nepal, Thailand and Timor-Leste having completed the NHA reports with their 2019–2020 estimates. Studies include health expenditures mapped by disease and conditions, health-care functions and health-care providers, which allow to further estimates regarding policy-relevant indicators such as COVID-19 and primary health care spending. As a result of the COVID-19 pandemic, countries continued efforts to broaden health financing strategies and reforms. In this context, WHO has provided technical assistance and guidance through evidence-based policy dialogues, aiding countries in unpacking the likely economic impact, and best possible avenues to mitigate the negative consequences of the crisis. WHO organized the Sixth Biregional Workshop on Health Financing for UHC in Asia and the Pacific, with a specific focus on lessons learned from COVID-19 and opportunities for health financing reform. The workshop brought together health, finance and insurance authorities to explore joint efforts towards ensuring high-performing health systems for health security and UHC. Jointly with the Organization for Economic Co-operation, WHO also convened the “Annual Asia-Pacific National Health Accounts Experts’ Meeting”, which included technical discussions regarding COVID-19, PHC expenditure tracking and strengthening the institutional capacity to produce national health accounts. WHO / Calixte Hessou 84 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia Challenges Although marked progress has been made across the Region in advancing towards UHC, important challenges persist: Health system governance: Key health governance issues in the Region include the low levels of public spending and investment in several countries, the lack of integration of programmes, the challenge of ensuring access to 24X7 quality care and essential medical products, and weak health information systems. Human resources for health: While aggregate numbers of health workers are increasing, the inequitable distribution of skilled human resources (geographic and by level of care), competency and performance remain key constraints. Sustaining human resources in rural settings poses a particular challenge. People-centred primary health care: Major improves are needed to increase capacity and competence on PHC, including PHC workforce teams and medicine; integration of programs/ comprehensive PHC to match with community demand and evolving population health needs (e.g. non- communicable diseases, mental health, essential public health functions); quality and patient safety and trust; collaboration across sectors, including the private sector; and PHC in specific settings and populations, including urban settings. Access to essential medical commodities: Access is impeded by the increasing cost of newer and effective medicines; low access to essential medical devices and diagnostics; weak regulatory capacity; and inequitable access to and availability of medicines and other medical products. Generation of evidence Considerable improvements have been seen among countries in the Region with respect to the systematic tracking of health expenditure. Ten Member States regularly report health spending data through the Global Health Expenditure Database. Ten Member States have produced at least one health expenditure study and have all transitioned to the global standard accounting framework (System of Healht Accounts - SHA, 2011), which in turn has enabled cross-country comparisons and increased the reliability of national estimates. Seven countries have produced at least one estimate on PHC expenditure based on the globally comparable definition. Four countries have produced disease-specific health expenditures. Gains have also been made the tracking of pharmaceutical expenditure through additional data and methodological understanding. Among WHO regions, the South-East Asia Region has taken a leading role in this regard. Improved pharmaceutical expenditure tracking helps answer critical policy questions on how to reduce OOP spending, which is significantly driven by outlays on medicines, and improve financial protection. National capacity to adjust health financing systems in response to crisis has improved. Improved capacity stems from evidence generated during COVID-19 and from technical support and other capacity-building efforts undertaken by WHO. WHO’s work in this area has highlighted the need to mobilize additional revenues for the health sector, including for the financing of COVID-19 vaccines. But at the same time, the COVID-19 crisis has also offered opportunities to introduce reforms to enhance the efficiency of resources allocated to the sector – such as promoting and strengthening primary health care – and ensure that vulnerable and poor populations are prioritized. Countries learned lessons from other countries through different policy meetings and webinars organized to inform responses and adjustments and implications of COVID-19 vaccine financing. WHO has also better-equipped country office focal points with up-to-date evidence and policy messages to advocate (in concert with partners) for the protection of health spending in the context of the fiscal constraints and promote more efficient and equitable health disbursements. 85 FLAGSHIP 4: Continue progressing towards universal health coverage WHO South-East Asia The way forward A central focus during the period ahead, as emphasized in the Declaration by the Ministers of Health at the Seventy-fourth session of the Regional Committee in 2021, will be to guide, support and monitor ongoing PHC- oriented health system transformation in the Region, including through operationalization of the South-East Asia Regional Strategy for Primary Health Care. As the Region recovers from the impact of COVID-19, it is more imperative than ever to increase public investment in PHC-oriented health systems including human resources for health and access to essential medical products at the primary care level. Strategic Direction Sustain Ensure health system resilience to continue provision of essential health services and conduct essential public health functions. Continue supporting all national regulatory authorities (NRAs) in the Region and further strengthen their regulatory systems for all health-care products, using the Global Benchmarking Tool and developing tailored solutions. Commitment to strengthening universal health coverage in the Region, with focus on human resources for health and access to medicines Accelerate Replicate progress seen on the list of essential medicines with respect to diagnostics, medical devices and assistive products lists. Ensure adequate post-market safety monitoring, reliable medical device equipment maintenance protocols, training of users and technicians in maintenance of diagnostic equipment, and expansion of the range and use of point-of-care diagnostics, especially with screening for noncommunicable diseases. Progress on improved health workforce availability in the Region, with attention to ensuring alignment with national health goals. Innovate Improve the efficiency of health spending, including PHC financing, public financial management and strategic purchasing arrangements for health services. Optimize the strategic use of digital technologies, including interoperable digital health ecosystems, which have the potential to transform health care and ensure continuity of essential health services Strengthen system of knowledge management at national and regional level, with focus on implementation-related learning, to support PHC-oriented reforms in the Region. WHO / Florian Lang 86 FLAGSHIP 5: Building national capacity WHO South-East Asia Flagship Building national capacity for preventing and combating antimicrobial resistance 87 FLAGSHIP 5: Building national capacity WHO South-East Asia 88 FLAGSHIP 5: Building national capacity WHO South-East Asia 89 FLAGSHIP 5: Building national capacity WHO South-East Asia WHO / Vismita Gupta-Smith 90 FLAGSHIP 5: Building national capacity WHO South-East Asia Flagship 5: Building national capacity for preventing and combating antimicrobial resistance Overview Antimicrobial agents have played a critical role in reducing the burden of communicable diseases across the world. The South-East Asia Region is no exception. Antimicrobial drugs, including antibiotics, have generally been cheap, accessible and highly efficacious across the Region. It is with good reason that many have long considered them to be “wonder drugs”. The emergence of antimicrobial resistance (AMR) is creating “superbugs” that make treating common infections difficult (and in some cases impossible) and make organ transplant and surgery risky. And though the emergence of resistance in micro- organisms is a continuous biological phenomenon, its amplification and spread are the result of primarily human behaviour. The WHO South-East Asia Region is particularly affected. As WHO-conducted risk assessments have shown, the Region is likely the most at-risk part of the world for the rise and spread of antimicrobial resistance. Not only does AMR affect the health and well-being of people, it also has ramifications on public health and well-being more broadly. As recent developments demonstrate – and as this chapter highlights – in our interconnected world the potential for superbugs to adversely impact travel is real, escalating the issue to one of immense global significance. The Region has been pro-active in combating the problem. As early as 2011 the Region’s health ministers called for concerted action against AMR via the Jaipur Declaration on Antimicrobial Resistance at the Sixty-fourth Regional Committee session. In 2014 the battle against AMR was made a Flagship Priority Programme by the Regional Director. And in 2015 the Regional Committee passed a key resolution on the prevention and control of AMR. WHO has continued to support countries in strengthening AMR prevention and control and accelerating progress towards realization of these regional commitments. 91 FLAGSHIP 5: Building national capacity WHO South-East Asia Progress and Results National Action Plan All countries in the South-East Asia Region have developed and endorsed national action plans (NAPs) for AMR in line with the Global Action Plan on antimicrobial resistance. Compared with 2018, all 11 Member States of the Region had by 2021 made notable progress towards implementing their AMR NAPs. Countries are using domestic or external resources to implement these national plans. The COVID-19 pandemic has underscored the importance of intensifying implementation of NAPs within the priority health agendas of national governments. Preserving the effectiveness of antimicrobial agents is essential to help mitigate pandemics in the future. Eight Member States updated their NAPs as their initial tenure had ended by 2022. WHO provided countries with consultant/expert support in updating their NAPs as well as with capacity-building assistance on costing and budgeting tool utilization. Direct financial contributions helped countries finalize and disseminate their national action plans to relevant stakeholders. WHO / Marcus Perkins 92 FLAGSHIP 5: Building national capacity WHO South-East Asia Since 2017, WHO and its partner organizations the Food and Agriculture Organization of the United Nations and the World Organisation for Animal Health has had in place a monitoring system for the implementation of NAPs. The annual Tripartite AMR country self-assessment survey (TrACSS) is a component of a broader approach for monitoring and evaluating the Global Action Plan. The Tripartite partnership for One Health formally became the Quadripartite following the signing of a memorandum of understanding with the United Nations Environment Programme (UNEP). The Quadripartite group developed a Joint Plan of Action on One Health, proposing a set of activities to enable countries to advance and sustainably scale up “One Health” to manage health threats to humans, animals, plants and the environment. In the SE Asia Region, a regional system exists to monitor every two years the progress of the implementation of NAPs with the “One Health” approach. This monitoring exercise assesses implementation phases, notes implementation gaps or bottlenecks, and identifies the necessary remedial action. The first situational analysis of AMR was undertaken in 2016 and the second in 2018. The Third One Health Situational Analysis of AMR, due to be implemented in 2020, was undertaken only in 2021 on account of delays due to the COVID-19 pandemic. The third progress analysis of the implementation of antimicrobial resistance national action plans in the WHO South-East Asia Region was published in 2022. Launched at the Seventy-fifth session of the Regional Committee for South-East Asia in Bhutan, the third progress analysis report highlighted important strides made by the 11 Member States in implementing their NAPs. However, progress in the animal and agricultural sectors was found to be lagging compared with that in the human sector, while the least progress had been registered in the environmental sector. The third progress report documented considerable variations among the Member States. For all countries in the Region, the third situational analysis found that 64% of indicators had a median implementation status of 3 or above – much higher than the second (40%) and first (16%) situational analyses. Compared with the second analysis, none of the countries had regressed in their implementation status in 2021 (Fig. 10). Monitoring the implementation of NAPs 93 FLAGSHIP 5: Building national capacity WHO South-East Asia WHO 94 FLAGSHIP 5: Building national capacity WHO South-East Asia 0 10 20 30 40 50 60 70 80 90 100 Timor-LesteThailandSri LankaNepalMyanmarMaldivesIndonnesiaIndiaDPR KoreaBhutanBangladesh 00 19.319.319.3 129.6 2625 3026.6 12.9 54.8 64 41.9 83 77 45 64 41.9 67 29 32.2 29 58 61 16 16 80.6 61.2 71 90 48.3 Phase 2016 Phase 2018 Phase 2021 Fig. 10. Proportion of indicators with implementation phase 3 or above in each country from 2016 to 2021 WHO 95 FLAGSHIP 5: Building national capacity WHO South-East Asia Global Antimicrobial Resistance and Use Surveillance System (GLASS) The 2021 situational analysis observed progress across all eight focus areas and indicators (national AMR plan and governance, raising awareness, national AMR surveillance system, rational use of antimicrobials and surveillance of use/sale including and AMS, IPC, research and innovation, One Health engagement and overarching coordination mechanisms for One Health engagement. However, no progress was observed in AMR awareness generation and education on AMR in the environmental sector. The countries with the highest percentage of indicators with implementation status 3 or above were Thailand (90%), Bhutan (83%) and DPR Korea (77%). Two countries reached this implementation with less than half of the indicators – Maldives (32%) and Timor-Leste (48%). All 11 Member States from WHO South-East Asia Region are enrolled in GLASS-Antimicrobial Resistance (AMR). Globally, 115 Member States, including 11 in South-East Asia are enrolled in GLASS- AMR and 77 Member States from around the globe, including 6 in South-East Asia (Bangladesh, Bhutan, Indonesia, Maldives, Nepal and Timor-Leste) are enrolled in GLASS - antimicrobial consumption (AMC). The WHO regional office is developing a report analyzing the situation of fungal pathogens in the Region. In following up on the WHO Fungal Priority Pathogens List (FPPL) published in 2022, the regional office aims to enable countries to develop and/or strengthen their capacity for surveillance and research on fungal pathogens. This requires a stepwise approach, starting with knowing and understanding the situation of fungal pathogens in countries, where this information will be used as baseline information to initiate a regional programme on fungal pathogens. WHO 96 FLAGSHIP 5: Building national capacity WHO South-East Asia Fig. 11. Total consumption by antimicrobial classes in WHO SE Asia Region in 2020, expressed as Defined Daily Dose (DDD) per 1000 inhabitants per day In Bhutan, Maldives and Nepal, the median value of the overall consumption of antibacterial is 15.3 [range, 9.5- 57.4]). Available data demonstrate considerable fluctuation among countries, suggesting significant variations in the use of antimicrobial drugs (Figure 11). 0 20 40 60 0 20 0 20 0 20 0 20 Bhutane Maldivesb Nepala NR NR NR NR NR NR NR NR South-East Asia Region Antibacterials for systemic use Antimycotics and antifungals for systemic use Antivirals for systemic use Drugs for the treatment of tuberculosis Anti- malarials aData from 2018 bData from 2019 cOnly public sector reported dOnly community consumption reported eOnly hospital counsumption reported NR: Not reported The regional office organized a regional training that strengthened the capacity of Member States to build sustainable surveillance of antimicrobial consumption (AMC). Until currently, countries were at different phases of development on monitoring AMC. Reasons for this variation in AMC monitoring include the use of different methodologies, lack of support, lack of dedicated staff, and lack of information on AMC surveillance. GLASS provides a standardized approach to the collection, analysis, interpretation and sharing of data by countries. It promotes a shift from surveillance approaches based solely on laboratory data to a system that includes epidemiological, clinical and population-level data. With advocacy and technical support by WHO, by the beginning of 2022, all Member States had enrolled in GLASS and commenced entering data and information on AMR through national AMR surveillance systems. 97 FLAGSHIP 5: Building national capacity WHO South-East Asia Fig. 12. National antimicrobial resistance (AMR) surveillance systems coordination capacity The WHO Regional Office facilitated a training workshop on AMC data assessment in Indonesia. This training aided the Ministry of Health in assessing potential data sources for AMC surveillance and to build the capacity of stakeholders to support the establishment of a national AMC surveillance system. In 2022, WHO continued technical support to Indonesia and Nepal to implement extended- spectrum beta-lactamase (ESBL) E. coli integrated surveillance. Indonesia has completed WP1-3 data collection and analysis and is finalizing on WP-4 molecular characterization (sequencing). Nepal has recently completed sample collection and testing from all three sectors (human health, animal health and environment) and is now undertaking data analysis. Coordination (Data are reported as of August 2020) Region No. of countries, territories and areas No. of countries, territories and areas enrolledin GLASS No. of countries, territories and areas that reported information from the national surveillance system to GLASS African Americas/PAHO Eastern Mediterranean European[2] South-East Asia Western Pacific Total 78 9 9 23 16 6 15 94 9 11 25 20 6 23 196 27 11 54 22 35 47 Overview [1] At the end of the 2020 data call – 31st August 2020. [2] Kosovo included: all references to Kosovo in this document should be understood to be in the context of UnitedN Na�ons Security Council resolu�on 1244 (1999). 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Proportion of countries and territories (by region and year) African Region 2020 2019 2018 2017 Eastern Mediterranean Region 2020 2019 2018 2017 European Region 2020 2019 2018 2017 Region of the Americas/Pan American Health Organization 2020 2019 2018 2017 South-East Asia Region 2020 2019 2018 2017 Western Pacific Region 2020 2019 2018 2017 Establishment of national coordinating centre (NCC) in GLASS enrolled countries, territories and areas, by region and year 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Proportion of countries and territories (by region and year) African Region 2020 2019 2018 2017 Eastern Mediterranean Region 2020 2019 2018 2017 European Region 2020 2019 2018 2017 Region of the Americas/Pan American Health Organization 2020 2019 2018 2017 South-East Asia Region 2020 2019 2018 2017 Western Pacific Region 2020 2019 2018 2017 Establishment of national reference laboratory (NRL) in GLASS enrolled countries, territories and areas, by region and year Established Establishment in progress Not established Not reported Not enrolled in GLASS 98 FLAGSHIP 5: Building national capacity WHO South-East Asia AMR stewardship AMR awareness Research One health policy Antimicrobial stewardship (AMS) is an organizational or system-wide healthcare strategy at the country level to promote the appropriate use of antimicrobials through the implementation of evidence-based interventions is established. WHO conducted 10 monthly webinars covering various AMS-related topics in 2022. AMS plans are being implemented across the Region. Eight countries (Bhutan, DPR Korea, India, Indonesia, Myanmar, Nepal, Thailand and Timor-Leste) have implemented AMS in health-care settings. This represents a substantial improvement compared to the situation in 2018 (two) or 2016 (three). The Regional Office conducted a national training of trainers (ToT) AMS in Bhutan for Ministry of Health and WHO country office staff who are responsible for antimicrobial stewardship. The training developed improved understanding and skills on how to set up and scale up national and healthcare facility-level AMS programme, including the development and enforcement of policies and regulations. Support was also provided for a national AMS situational analysis using the standard WHO AMS. The WHO Regional and country offices organized a series of events on 18–24 November 2022 to harness momentum around tackling AMR and galvanizing behaviour change. The awareness initiative included talk shows, webinars, social media events, campaigns, including the “Go Blue Campaign” and community events at schools, universities and other locations. Government agencies, health institutions and other stakeholders also took part. In collaboration with WHO TDR at headquarters and partner Regional Antimicrobial resistance Data Analysis for Advocacy, Response and policy (RADAAR) – Evidence-informed Policy Network (EVIPNet), a series of webinars were organized on translating AMR data and evidence into effective policies. These webinars aim to build capacity to support the development of policies to optimize antimicrobial use in human health. There are promising developments on the policy front. Both Bangladesh and Nepal are in the process of drafting policies addressing the irrational use of antimicrobials. Member States have established or are in the process of establishing a national One Health coordination mechanism to address zoonoses, food safety and AMR. In coordination with the Food and Agriculture Organization of the United Nations (FAO) and the World Organization of Animal Health (WOAH), WHO supported the development of a One Health policy and strategy in several countries including Bangladesh, Bhutan, Indonesia, Myanmar, Nepal and Timor-Leste. 99 FLAGSHIP 5: Building national capacity WHO South-East Asia AWaRe classification Regulatory networks Bangladesh, Bhutan, Indonesia, Maldives and Nepal have adopted or are in the process of adopting the AWaRe categorization of antibiotics into their national lists of essential medicines. Other countries are planning to do so. Member States in the Region are taking steps to improve the affordability of medicines. India and Sri Lanka have set ceiling prices on selected essential medicines and devices, while the Maldives standardized the price of essential medicines across the country. The South-East Asia Regulatory Network (SEARN) continues to be responsible for the regulation of medical products, including medicines, vaccines, medical devices and diagnostics across the Region. In 2022, SEARN continued to play a more active role in surveillance, detection and regulatory action on substandard and falsified antimicrobials. WHO / Karen Reidy 100 FLAGSHIP 5: Building national capacity WHO South-East Asia Challenges Although all countries in the Region have a NAP and 91% are in the process of implementing them, only 36% of countries have a costed and budgeted operational plan, with monitoring indicators and systems in place. Even when these NAPs enjoy strong political support, factors that impede their effective implementation include limited technical capacity within some ministries of health and related sectors; persistent over-the-counter sales of reserve classes of antimicrobials; and irrational use of antimicrobials. Surveillance, detection and regulatory action on substandard and falsified antimicrobials need to be strengthened across member states. COVID-19 significantly impeded the progress of countries towards the implementation of AMR national action plans. Ongoing responses for multiple health emergencies hinder the regular work on AMR, particularly on strengthening the surveillance systems. In addition, the risk remains that the ongoing COVID-19 pandemic could drive inappropriate (instead of rational) use of antimicrobials, thus leading to an increase in AMR. Efforts are needed to improve data quality and AMR surveillance, including building country capacity to expand sentinel surveillance sites and utilize AMR/ 101 FLAGSHIP 5: Building national capacity WHO South-East Asia AMC data at both the facility and national levels. Further steps are needed to strengthen the multisectoral steering committees that have been established in most Member States. Action is needed to bolster research and development, as most Member States in 2022 were not generating strategic evidence on AMR due to limited funding or capacity. AMR investments are essential to health and well- being. Findings from independent AMR evaluations need to be taken on board in planning and implementing essential interventions. National AMR action plans need to finance and incorporate into regular government budgets as well as linked with other existing plans/strategies, including Global Patient Safety Action Plan, IPC, WASH, Patient Safety, Strategy and others. Strategic action is needed to increase AMR awareness and engagement in the environmental sector. WHO / Angeliki Antonia Balayannis 102 FLAGSHIP 5: Building national capacity WHO South-East Asia The way forward If the spread of pan-resistant microorganisms is not impeded or halted globally, we may well soon enter the post-antibiotic era. We cannot count on biomedical innovation to solve this looming crisis, as the development of new antibiotics is cost-intensive and misuse/overuse leads to a short shelf life. Global leaders have recognized that AMR has serious implications not only on human health but also on the economy, food security and overall human development. Significant achievements have been made in efforts to address AMR. The issue is now recognized as a priority by Member States, WHO and other stakeholders, necessitating urgent and sustained interventions. The momentum created during the past decade needs to be sustained and accelerated to reap greater benefits. It is essential to have multisectoral, multidisciplinary and multi-institutional efforts to control the burgeoning problem of AMR that threatens human development. WHO will continue its advocacy to ensure that AMR is tackled as a pressing concern of Member States. WHO will support countries to ensure that NAPs are prioritized, cost and financed and that NAPs prioritize integration with primary health care and health emergency preparedness and response strategies. WHO will continue to strengthen the coordination and cooperation between sectors, including monitoring and evaluation of progress in different sectors. WHO will actively work with other partners and agencies to strengthen collaboration on the One Health agenda. WHO will also continue its technical support to countries on AMR. WHO will work to strengthen national regulatory capacity and frameworks on the prescription and sale of antimicrobials for human use and also support the adoption of the AWaRe categorization. WHO will strengthen the evidence base for action by supporting enrolment and reporting to GLASS-AMR and GLASS-AMC. WHO will continue to support countries in strengthening surveillance, including technical assistance to expand AMR sentinel sites. 103 FLAGSHIP 5: Building national capacity WHO South-East Asia Strategic Direction Sustain Continue support to Member States on NAP implementation and monitoring. Sustain and expand AMR surveillance, building on the successful efforts made thus far. Accelerate Implement multisectoral actions to combat antimicrobial action. Support Member States in sharing AMR and AMC data with GLASS and taking up a standardized approach for the collection and analysis of AMR data at global and regional levels, as well as utilize those data for informed policy decisions. Develop a practical package of essential AMR interventions that can be adapted to specific country needs. Innovate Prioritize collaborations to develop new antibiotics and vaccines and reduce the need for antibiotics and make new therapeutic advances in the Region. Further implement the Structured Operational Research and Training Initiative (or SORT IT), pioneered by TDR at WHO headquarters. Incorporate relevant findings of independent AMR evaluations (centrally and regionally) when developing interventions, and build operational research into AMR interventions to optimize use of resources and impact. WHO 104 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Flagship Scaling up capacity development in emergency risk management in Member States 105 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia 106 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia 107 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia WHO 108 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Flagship 6: Scaling up capacity development in emergency risk management in Member States Overview The Region continues to be vulnerable to diverse types of natural hazards, outbreaks, adverse climate change, air pollution and related health emergencies. During the COVID-19 pandemic, the increasing occurrence of emerging and re-emerging diseases, including but not limited to zoonotic diseases, has further accentuated pre-existing inequalities and vulnerabilities in diverse populations. As the Global Health Security (GHS) Index 2021 confirmed, countries across the world remain dangerously unprepared to meet future epidemic and pandemic threats. This is certainly true for the WHO South-East Asia Region, where most countries fall in the bottom two of the five tiers of GHS Index results. Strengthening health emergency preparedness and response has been an important WHO priority for the Region. Scaling up capacity development in emergency risk management in countries is a Regional Flagship Priority Programme that was endorsed by Member State health ministers through the Delhi Declaration on Emergency Preparedness in the South-East Asia Region at the Seventy-second session of the WHO Regional Committee in 2019. 109 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Progress and results Infectious Hazard Management In 2022, the Regional Office screened 1500 media articles daily for information on health hazards and triaged 1432 articles for further investigation. Of the 54 events monitored in 2022, 36 (67%) were due to infectious hazards (e.g. COVID-19, dengue, cholera, measles, mpox, circulating-vaccine-derived poliovirus), six (11%) were due to natural disasters (e.g. earthquakes, floods, landslides, tropical cyclones, and volcanic eruptions), another six (11%) were societal (e.g. armed conflicts and humanitarian crises), five (9%) were of undetermined cause (e.g. acute hepatitis of unknown cause), and one (2 %) was a product safety event (Fig. 13). The Regional Office coordinated six rapid risk assessments (RRA) for key public health events in the Region, in addition to contributing to eight global RRAs. Virtual training on RRA was provided to WHO regional and country workforce across the region, which improved the contributions of country offices on RRA. Fig. 13. Acute public health events in WHO South-East Asia Region (1 January – 31 December 2022) Hazards InfectiousHazards Societal N=6, 11% (unknown) N=4, 11% Disaster N=6, 11% Acute Fever and Rash Syndrome N=6, 17% Acute Flaccid Paralysis (AFP) N=1, 3% Infectious N=36, 67% Product safety N=1, 2% Undetermined N=5, 9% Acute Respiratory Syndrome N=13, 36% Acute Watery Diarrhoeal Acute Febrile 110 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Drawing from recommendations of the expert consultation in 2019, the Regional Office drafted a Regional Strategy and Roadmap for the prevention and control of Nipah virus. The Strategy is based on the one health approach and emergency framework. Additionally, in collaboration with National Institute of Virology (NIV) Pune, a draft has also been prepared for the regional manual on standard operational procedures on laboratory diagnosis of Nipah virus in the Region. The World Health Emergencies (WHE) Programme held a regional consultation to identify priority surveillance needs and objectives beyond sentinel surveillance in terms of respiratory pathogen pandemic preparedness, including influenza. WHO HQ in 2022 incorporated regional needs and surveillance objectives in the global guidance on “Crafting the Mosaic”, a framework for resilient surveillance for respiratory virus and epidemic and pandemic potential. Regional collaborative public health intelligence (PHI) activities were strengthened in 2022, with an increased number of signals monitored and events assessed systematically. WHO regularly produced information products to alert stakeholders and inform risk assessment. The WHO Regional Office introduced epidemic intelligence from open sources (EIOS) in Indonesia and Nepal, as part of the national surveillance systems to strengthen early warning functions. In support of risk assessment and readiness planning. The unit also produced analytics, information products on public health events and technical briefs, including international health regulations (IHR) products (event information sites and disease outbreak news online bulletins), weekly situation reports and a regional dashboard. WHO took steps to strengthen IHR event communication across the Region. In 2022, the WHO Health Emergencies (WHE) Department of the Regional Office established an IHR “duty officer” system, introduced a dedicated phone for regional IHR contact points, and rolled out a standard operating procedure to streamline the IHR event communication. A regional consultation informed the development of a Regional Strategic Framework for action for surveillance, risk assessment and field epidemiology, based on the Regional Strategic Roadmap on health security and health system resilience for emergencies 2023–2025. The meeting identified common priority actions, with outcomes and recommendations summarized in a meeting report. 111 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Public health laboratories At the Seventy-fifth session of the WHO Regional Committee for the South-East Asia Region, Member States adopted a Regional Roadmap for diagnostic preparedness, integrated laboratory networking and genomic surveillance. The regional referral mechanism for investigative and diagnostic confirmatory testing was successfully used to respond to acute emergency events such as mpox (monkeypox), acute viral hepatitis in children and hand-foot-and-mouth disease. An external quality assessment of laboratory functioning with respect to SARS-CoV2 covered over 1187 laboratories from nine countries. Overall, 93.5% of subnational laboratories in the Region achieved 100% correct results, which represents substantial improvement from the previous cycle (75%). WHO / Rahmat Ali 112 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Country health preparedness and IHR (2005) Country-level IHR Core Capacity was assessed and joint external evaluations (JEE) of IHR were conducted in Thailand (second) and Nepal (f irst JEE). Thailand became only the third of four countries globally, and the first in South-East Asia Region, to pilot the Universal Health and Preparedness Review to ensure national leadership and commitment on health security strengthening. A national bridging workshop on IHR-Performance of Veterinary Services (PVS) reviewed gaps in key technical areas and collaborative mechanisms. It resulted in the development of a joint roadmap to improve prevention, detection and control of zoonotic diseases. The Strategic Risk Assessment Tool (STAR) was used in Bangladesh for profiling infectious hazards with a pandemic or endemic potential, including particular attention to the most vulnerable displaced people in the camp setting of Cox’s Bazar. Staff working on emergencies at WHO headquarters and the Regional Office benefited from capacity-building initiatives on STAR and related tools. WHO convened regional webinars to sensitize national focal points (NFP) for IHR and other key stakeholders on the existing and newer tools of the monitoring and evaluation (M&E) framework. These sessions enhanced capacity with respect to dynamic preparedness metrics (DPM) and other tools recommended in the WHO National Action Plan for Health Security (NAPHS), aiding countries in determining their preparedness status and supporting planning, prioritization and implementation of critical health security interventions. The Seventy-fifth Regional Committee session adopted the Regional Strategic Roadmap on Health Security and Health System Resilience for Emergencies 2023–2027. The Roadmap aims to tangibly bolster health security capacity and build health systems that are resilient to emergencies through continued high-level political commitment, 113 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia sustainable financing, effective intersectoral collaboration and robust multisectoral partnerships. WHO provided technical support to build emergency response capacity in countries across the Region. Roll-out of the WHO Rapid Response Team (RRT) Training Implementation Package (TIP) in Nepal strengthened the capacity of a core group of national trainers and RRT managers. Steps were taken to strengthen disaster risk reduction (DRR) and operational readiness capacities in Cox’s Bazar, Bangladesh, through a contextualized and locally adapted tool for health facilities to assess safety and resilience. Fire safety assessment checklists were developed in Maldives and Nepal and a related training of trainers was conducted. These activities contributed to the finalization of the WHO global guide and checklist for operational readiness and the health emergency/disaster risk management priorities and plans. The WHO Regional Office successfully collaborated with the WHO Western Pacific Regional Office to conduct the biregional meeting of the Technical Advisory Group on the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (APSED III). This collaboration is contributing to the development of the next version of APSED. WHO supported Member States’ active engagement in the Working Group on IHR Amendment (WGIHR) and the Inter-governmental Negotiating Body (INB) to draft and negotiate a global framework for pandemic preparedness and response. To support country engagement, WHO facilitated meetings, prepared background documents, provided technical assistance to Member States and stakeholders, and provided technical inputs and regional implementation status on temporary recommendations to the Emergency Committee on COVID-19. WHO also released a flagship global publication on engagement with civil society organizations (CSO), with a chapter dedicated to the South-East Asia Region’s experience on engaging civil society organizations during the COVID-19 pandemic. WHO 114 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Health emergency information and risk assessment Regional collaborative public health intelligence (PHI) activities were strengthened in 2022, with an increased number of signals monitored and events assessed and communicated. WHO strengthened information dissemination on regional health emergencies, including the production of the weekly situation updates and weekly slide deck, in addition to daily updates via the COVID-19 dashboard and daily signal reports. WHO developed policy and technical briefs, including on readiness in mpox and risk-based approaches for COVID-19 responses. The WHO Regional Office consulted with Member States to identify regional priorities for surveillance, risk assessment and field epidemiology for the next five years, drawing on lessons learned from COVID-19 and the Regional Strategic Roadmap on health security and health system resilience. The report is available at https://www.who.int/ publications/i/item/strengthening-public-health- surveillance-and-risk-assessment-for-health- security-threats-in-the-who-south-east-asia-region. The Epidemic Intelligence from Open Sources (EIOS) was rolled out for the first time. The initial roll-out occurred in Nepal in September 2022 followed by Indonesia in November that year. EIOS is expected to strengthen countries’ event-based surveillance and early warning functions. The Epidemic Intelligence from Open Sources (EIOS) was rolled out for the first time in 2022. The initial roll-out occurred in Nepal and was followed by Indonesia. EIOS is expected to strengthen countries’ event-based surveillance and early warning functions. 115 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Emergency operations WHO / Mast Irham Nepal became the first country in the Region to advocate for and strengthen the Global Outbreak Alert and Response Network (GOARN). A GOARN roadshow in Nepal brought together GOARN network participants from beyond the Region, including participation of GOARN Steering Committee Chair and other members. Twenty-four participants from Bangladesh, Myanmar, Nepal and Sri Lanka attended the Region’s first health cluster training. A deployment-based training on GOARN Tier 2.0 trained 22 participants from partner institutions. The regional WHE Unit strengthened operational partnership for enhanced readiness across the Region. One avenue for enhancing scale-up capacity and coordination was scenario-based training programmes for GOARN and health clusters. Almost 50 participants from Member States and partner organizations participated in two intense scenario- based training programmes conducted with the support of experienced faculty from all three levels of WHO and partner institutions. WHO invested in health emergency operations centres (HEOC) as the heart of all readiness and response functions. To help consolidate and coordinate responses in the Region, WHO conducted tabletop and full-scale simulation exercises, drawing 100 participants in Nepal and 40 participants (from government, UN and NGOs) in an intensive three-day exercise in Bangladesh. WHO collaborated with the Association of South-East Asian Nations (ASEAN) under the ASEAN-EU Strategic Partnerships funding for the implementation of the ASEAN Strategic Framework for Public Health Emergencies, launched in late 2020. The Strategic Framework is intended to enhance ASEAN’s preparedness, detection, response and resilience to public health emergencies. It also aims to strengthen ASEAN’s cooperation in enhancing regional health security. 116 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia Implementation of the framework will take into account ASEAN mechanisms and tools under development, such as the ASEAN standard operating procedures for the coordination of emergency medical teams (EMT SOP), ASEAN Public Health Emergency Coordination System, Coordinating Centre for Animal Health and Zoonoses and the proposed ASEAN Centre for Public Health Emergencies and Emerging Diseases. The WHO Regional Office has established a functional project office to implement this collaboration in the countries that are also Member States of ASEAN, including Indonesia, Myanmar and Thailand. Implementation of the ASEAN Strategic Framework has helped to strengthen technical cooperation with ASEAN by sharing the latest WHO technical resources related to COVID-19 and monkeypox. Through webinars, WHO shared information with the ASEAN Secretariat and their networks on contemporary health issues (clinical management of monkeypox, laboratory, genome surveillance, One Health, human resources for refugees and migrants’ health). WHO technical teams, in collaboration with the ASEAN Emergency Operations Centre Network, ASEAN Risk Assessment and Risk Communication (ARARC), Regional Public Health Laboratory Network (RPHL), and ASEAN Plus Three Field Epidemiology Training Network (FETN), have developed concept notes to implement ASEAN- WHO collaborative activities to strengthen pandemic preparedness and response capacity, which will be implemented in 2023. The activities focus on emergency operations, risk communication and community engagement, laboratory capacity, and field epidemiology training capacity. WHO supported Maldives and Timor-Leste to submit a robust project proposal for strengthening food safety systems to the Codex Trust Fund, which was accepted. The WHO regional office negotiated with the organizer of the World One Health Congress in Singapore to facilitate sponsorship and participation of nine out of 11 countries in the region. The Regional Office facilitated a series of virtual and in-person technical workshops on leptospirosis diagnosis, surveillance and prevention, including rodent control to the Ministry of Health Indonesia, using experts from Global Leptospirosis Environmental Action Network (GLEAN). Zoonotic diseases, food safety and One Health WHO / Federica Maurizio 117 FLAGSHIP 6: Scaling up capacity development WHO South-East Asia The way forward Challenges Inadequate financial resources is among the most important challenges for emergency risk management across the Region. This includes the limited financial resource allocation to the WHE Programme within WHO offices and in Ministries of Health of Member States. Investments at national and subnational levels for identification of prevailing risks, hazards, vulnerabilities, and for risk prevention and operational readiness, have increased over last decade since the launch of the Flagship in 2014. However, investments are still not adequate to attend to the regional burden of natural hazards, disease outbreaks and emerging threats to health security. Existing technical and human resource capacity in the Region for dealing with emerging high-threat pathogens (known and unknown) remain inadequate. Further efforts are needed to leverage and build on the encouraging political commitment and increased investments of the Member States in the Region for enhancing genomic surveillance and sequencing capacity through expanding laboratory networks and regional and international partnerships. Although the aftershocks of COVID-19 continue to reverberate across the Region, the experience also provides new opportunities to engage with various partners to further strengthen health-care service delivery, expand access to care through telemedicine, scale up manufacturing of pandemic products and other emergency logistics and attract investment in innovations, research and development. The resilience of populations and health systems across the Region will be increased if the focus is shifted from responding to emergencies to disaster risk reduction, preparedness and operational readiness measures. Strategic Direction Sustain Strengthen emergency preparedness and response capabilities in health and related sectors. Consolidate and expand on existing partnerships (GOARN, EMTs, WHO Collaborating Centres, Global Health Cluster and StandBy Partners) and regional level operational partnership in health emergencies and disaster risk management (National Disaster Management Authorities, UNDRR-ROAP, UNOCHA, UNICEF-ROSA, ASEAN, SAARC, IFRC, ADPC, e-health Initiative and private sector corporates). Accelerate Invest in efforts to close critical gaps at national and subnational levels. Proactively implement the resource mobilization strategy at both WHO regional and country office levels, including regular interactions with the donor community during pre-emergency and post-emergency phases in addition to donor calls in acute emergency response times. Innovate Leverage innovation and research for continuous improvement of preparedness and response systems. 118 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Flagship Finishing the task of eliminating NTDs and other diseases on the verge of elimination 119 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia 120 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia 121 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia WHO / Risintha Premaratne 122 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Flagship 7: Finishing the task of eliminating NTDs and other diseases on the verge of elimination Overview Neglected tropical diseases (NTDs) are a diverse group of disease conditions that are most common in tropical and subtropical regions. These diseases most heavily affect people who lack access to adequate sanitation, basic infrastructure and health services. NTDs not only lead to significant morbidity and mortality, but also to stigma and discrimination in communities. Through a combination of proven public health interventions, the means exist to control, eliminate or eradicate all NTDs. NTD elimination and control efforts are recognized as one of the most cost-effective interventions in global health today. In 2014, the Regional Director names as one of the regional flagship priorities finishing the task of eliminating NTDs on the verge of elimination. The SDGs, endorsed the following year, also pledged Member States to end the epidemics of NTDs by 2030. The WHO South-East Asia Region bears the world’s highest burden of NTDs, with 15 NTDs continuing as sources of public health concern in the Region. In 2021, 856.8 million people in the Region required NTD-related interventions, accounting for 52% of the global burden of NTDs Since 2014-2015, WHO, its Member States and its partners in the Region have made tremendous progress towards NTD elimination. These efforts continued in 2022, despite the challenges posed by the COVID-19 pandemic. There is a vital need to consolidate these successes and further reduce the burden of NTDs for the health and well-being of all people across the South-East Asia Region. 123 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Progress and results Table 7. Endemic NTDs in WHO South-East Asia Region Bhutan Bangladesh DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste PVS MDA MDA PVS MDA MDA PVS PVS TAS LFCountry PVS PVS Sporadic VL・CL VL・CL Interventions Interventions Interventions Interventions Interventions Interventions Interventions Interventions Interventions Interventions Sporadic Sporadic VL PVS PVS Trachoma MDA MDA SCH Yaws Leprosy Priorities: Mapping Interventions Post-intervention surveillance Post-elimination In 2021, 52% out of 1.65 billion people requiring interventions against NTDs globally, were in the WHO South-East Asia Region. Although COVID-19 resulted in considerable disruption of services, countries began prioritizing the resumption of essential health services and community-based interventions from 2022. Countries that had previously been either validated or verified for eliminating some NTDs continued to maintain strong surveillance systems and thus were able to sustain elimination status. India sustained its yaw-free status while Maldives, Sri Lanka and Thailand maintained their lymphatic filariasis (LF) elimination status. Nepal and Myanmar also sustained its achievement of having eliminated trachoma. Regionwide, 69% of LF-endemic districts across nine endemic countries met the criteria and stopped mass drug administration (MDA). The number of new cases of kala-azar has fallen by 97% in the Region over the last seven years. Bhutan and Maldives continue to report fewer than 25 new leprosy cases annually since 2013. Between 2010 and 2020, the number of people requiring interventions against NTDs in the South-East Asia Region declined by 20%. At least one or more NTDs eliminated from seven countries of the WHO SE Asia Region Between 2010 and 2020, the number of people requiring interventions against NTDs in the SE Asia Region reduced by 20% 124 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Lymphatic filariasis (LF) Fig. 14. Proportion of the number of Implementation Units (IUs) in 9 LF-endemic countries that are under MDA or have stopped by the end of 2022 Bangladesh received WHO validation for having eliminated LF as a public health problem in May 2023. India, Indonesia and Nepal continued to scale up MDA using triple drug therapy (IDA) and transmission assessment surveys in endemic areas. Myanmar also conducted the first round of MDA using IDA in February 2023. By the end of 2022, 740 out of 1,072 implementation units in nine endemic countries (69%) passed at least one Transmission Assessment Survey (TAS) and stopped MDA (Figure 14). IUs stoppped MDA IUs under MDA 0% 20% 40% 60% 80% 100% 19 01 08 357 13 Timor-LesteThailandSri LankaNepalMyanmarMaldivesIndonesiaIndiaBangladesh 198 135 145 91 15 18 28 49 At its annual meeting in 2022, the Regional Programme Review Group (RPRG) recommended the adoption of the new impact assessment protocol in areas that have implemented MDA with IDA and in areas where the Brugia species is endemic. Following these recommendations, WHO is supporting India, Indonesia and Nepal in orientation and training on the new impact assessment protocols. India is developing a roadmap for LF elimination by 2027, three years ahead of global target. It is based on the recommendation of the Joint Monitoring Mission for the Lymphatic Filariasis Elimination Program, which was convened in 2022 in five high- burden states of the country. Likewise, Nepal is initiating development of a roadmap for LF elimination based on the recommendation of the Joint Malaria, Kala-azar, LF and Dengue Monitoring Mission convened by May 2023 with support of WHO. WHO regional office signed a new agreement with the U.S. Agency for International Development to collaborate in accelerating progress towards elimination of LF as a public health problem in the Region, starting from September 2022. 125 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Kala-azar (KA) In 2022, 1,201 new KA cases were reported in the South-East Asia Region, a 23% decline compare to 2021, when 1,560 cases were reported. The number of cases of post Kala-azar dermal leishmaniasis (PKDL) was 653, 20% fewer than in 2021 (Figure 15). By the end of 2022, the KA elimination target was achieved in all endemic upazilas of Bangladesh, 99.8% of all endemic blocks in India and 95% of endemic districts in Nepal (Fig 3). Bangladesh has sustained the target of less than one KA case per 10 000 population in all implementing units since 2017, and in 2022 initiated development of a dossier to claim achievement of elimination of KA as a public health problem. Country was validated for eliminating KA as a public health problem in October 2023. Bangladesh Nepal India Bhutan Sri Lanka Thailand 0 5000 10000 15000 20000 25000 30000 35000 40000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Fig. 15. The number of new kala-azar cases reported in the South-East Asia Region, 2010–2022 In last 7 years, new cases of kala-azar have been reduced by 97% across the Region, and by the end of 2022, the last 1% of the implementation units in the Indian subcontinent is left to achieve the target threshold for elimination as a public health problem. In October 2023, Bangladesh became the first country in the world to be validated by WHO for having eliminated kala-azar as a public health problem. 126 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Fig. 16. Progress of kala-azar elimination from Bangladesh, India and Nepal made by implementation units, 2022 100 0 200 300 400 500 600 700 Bangladesh 100 0 Nepal 40 2 1 India 632 IU did not achieve elimination target yetIU achieved elimination target In consultation with Member States, the WHO regional office launched a new Regional Strategic Framework for accelerating and sustaining KA elimination in the South-East Asia 2022-2026. It aims to achieve and sustain elimination of KA as a public health problem in the Region through optimizing, integrating and sustaining three strategic interventions: KA and PKDL surveillance, complete case management and integrated vector management.Bhutan developed a national guideline for the prevention, diagnosis and management of Leishmaniasis in April 2023. Sri Lanka also initiated development of the national strategic plan for KA elimination. The regional office signed a new three-year agreement in October 2022 with the Bill & Melinda Gates Foundation to collaborate towards accelerating elimination of kala- azar as a public health problem in South-East Asia. The agreement focuses particular attention on Bangladesh and Nepal, guided by the new Regional Strategic Framework 2022-2026. 127 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia WHO / Marcus Perkins WHO / Marcus Perkins 128 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Leprosy The Region accounted for 66.5% new cases of leprosy in 2021. Leprosy is endemic in 10 (out of 11) Member States of the Region, with DPR Korea reporting zero cases for over the last 10 years. Six countries in the Region (Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka) are identified among the 23 global priority countries. The reported number of new leprosy cases in the Region has slowly declined over the last 15 years, from 174,118 in 2006 to 143,787 in 2019, with India accounting for 80% of Regional burden. The proportion of children (<15 years of age) among new leprosy cases has also consistently declined, from 9.08% in 2015 to 7.41% in 2019 and 6.06% in 2021, indicating reduction in recent transmission of leprosy. COVID-19 has had important effects on leprosy control efforts. In 2020-2021, the reported number of new cases declined by 41% in 2020 (compared to the previous year) and by an additional 10% in 2021. These effects underscore the need for intensified catch-up efforts. In April 2023, the WHO regional office convened a regional Leprosy Programme Managers Meeting, five years after the last such regional meeting The meeting provided an opportunity for cross-learning and the sharing of experiences, challenges and innovative practices towards leprosy elimination. The WHO South-East Asia Region reduced grade-2 disabilities (G2D) among new leprosy cases by more than 50%, from almost 8000 in 2013 to below 3800 in 2022. Today, achieving a world with zero leprosy disease, zero leprosy disability, and zero leprosy stigma and discrimination is within our grasp. Together, let us eliminate this age-old disease in our time, on our watch. Dr Poonam Khetrapal Singh at the 19th Meeting of the Technical Advisory Group on Leprosy, Goa - 2023. 129 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Fig 17. Detection of new leprosy cases in SE Asia Region 0 100 200 300 400 500 600 700 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 20212000 Maldives Sri Lanka DPR Korea Timor-LesteNepal IndiaBangladesh Mayanmar Thailand Bhutan Indonesia WHO / Leonard Ortega 130 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Trachoma Trachoma is a public health problem in 44 countries and is responsible for causing blindness or visual impairment in almost 1.9 million people. Two of endemic countries have been validated for elimination as public health problem (Nepal and Myanmar). Nepal and Myanmar continue to sustain the elimination of trachoma as a public health problem from their respective countries. Trachoma elimination programmes in endemic countries are being implemented using the WHO- recommended SAFE strategy. This consists of: Surgery to treat the blinding stage; Antibiotics to clear infection, particularly mass drug administration (MDA) of the antibiotic azithromycin which is donated by the manufacturer through the International Trachoma Initiative; Facial cleanliness; and Environmental improvement, particularly improving access to water and sanitation. India remains the only country in the Region yet to eliminate trachoma. The country, however, reports that it has already achieved the elimination threshold for infective trachoma. India is completing a 24-month pre-validation survey throughout the country in 2023. Nepal and Myanmar have already eliminated trachoma in 2018 and 2020, respectively. India remains the only country in the Region yet to eliminate trachoma. The country, however, reports that it has already achieved the elimination threshold for infective trachoma. 131 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia Challenges Progress towards elimination of NTDs is undermined by the lack of sustained political commitment. Inadequate commitment is reflected in limited domestic funding, a large number of vacant NTD-related posts, frequent staff turnover and poor coordination across different levels within the health system. Case detection, surveillance and treatment coverage remains suboptimal. Access to diagnosis and treatment are especially limited in hard-to-reach rural areas, urban, ethnic and vulnerable populations, migrants and mobile population. Enhanced reporting is needed from private and informal sectors to ensure comprehensive data for NTD elimination efforts. Other challenges include declining expertise, knowledge and awareness among health professionals on prevention, control and clinical management of NTDs. Among affected communities, poor awareness and knowledge persist; for example, even after 20 years of MDAs, villagers in endemic areas often remain unaware of the connection between mosquitoes and LF. COVID-19 had particularly negative effects on the many community outreach activities recommended by WHO. This is largely due to the pandemic’s impact on case-finding activities and patients’ access to health care. Inevitably, this has pushed back the targeted milestone for the elimination of some of the diseases in some Member States. Regional intensification of efforts has led to substantial achievements but also to programmatic fatigue in many endemic countries. The presence of a substantial number of individuals who have never been treated during the decade of annual MDA is proof of this. These individuals act as a reservoir of transmission. Despite the gradual overall decline in leprosy burden in the Region, proportions of new leprosy cases and those with G2D in many countries remain relatively high, indicating late case detection and ongoing transmission. WHO / Marcus Perkins 132 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia The way forward As NTDs are diseases of those who are left behind, their elimination will be one more step towards achieving SDGs and implementation of Universal Health Coverage, helping create a more equitable world. The WHO South-East Asia Region has a unique opportunity to fundamentally change the global NTD landscape by demonstrating continued success in the control and elimination of NTDs. In 2021, WHO launched “Ending the Neglect to Attain the Sustainable Development Goals: A road map for neglected tropical diseases 2021–2030”, which set out updated global targets and milestones to prevent, control, eliminate or eradicate 20 diseases and disease groups. The roadmap also outlined cross-cutting targets aligned with the Sustainable Development Goals. Service integration is critical to improving the cost-effectiveness, community acceptance and sustainability of NTD elimination efforts. A regional integrated strategic framework for accelerating and sustaining the elimination of NTDs is currently in development. An integrated field entomology and vector management training is now being rolled out at regional and national levels, and a regional integrated skin NTD toolkit for health professionals and health workers is in development. An integrated programme for vector-borne diseases was convened in 2023 and a meeting on cross-border efforts to control vector-borne diseases is planned for later in the year. Integrated active case detection is increasingly being implemented in countries. Strategic Direction Sustain Sustain the elimination status in counties that have achieved elimination of an NTD as a public health problem, with a focus on integration of surveillance and response with other disease programmes and health systems, while accelerating research and development of new tools and strategies to make further progress. Sustain political commitment with respect to interventions to prevent and control NTDs, which are considered one of the “best buys” in global public health. Accelerate Establish a system for continued surveillance, case finding, outbreak response and targeted response post- validation for Kala-azar, LF and trachoma, which are presently targeted for elimination as a public health problem. Presently, there are no appropriate tools to achieve and/or verify interruption of transmission. Catalyse and accelerate multisectoral partnerships. The elimination and control of NTDs require the delivery of interventions by other programmes or sectors, encompassing vector control, water and sanitation, animal health, health education, disability and psychosocial care. Engage and empower communities in efforts to eliminate NTDs. NTDs remain prevalent due to persistent risk factors such as open defecation, poor housing and environmental hygiene. Access to appropriate treatment remains limited due to a lack of health-seeking behaviours. Effective health risk communication and community empowerment should be considered a cost-effective and sustainable solution to address the social determinants of health that contribute to the proliferation of NTDs. Innovate Generate the evidence needed to determine feasible, cost-effective and sustainable post-validation surveillance options for NTDs. This will require national leadership and the support of international donors and research and development partners. Although a post-validation strategy will be needed to maintain government and donor commitment, there is presently limited evidence for WHO to recommend any specific post-validation surveillance strategy. Encourage and support countries to analyse programmatic areas with suboptimal delivery of interventions and innovate to enhance programme reach and efficiency. Innovative delivery of programmatic actions and investment in innovation for better tools is necessary. These are achieved through partnerships and cooperation among Member States, WHO, academia, industry and public and private institutions. 133 FLAGSHIP 7: Finishing the task of eliminating NTDs and other diseases WHO South-East Asia WHO / Marcus Perkins 134 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia Flagship Accelerate Efforts to End TB by 2030 135 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia 136 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia 137 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia WHO / Gary Hampton 138 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (MTB) bacteria. Tuberculosis generally affects the lungs but can also affect other parts of the body. Most infections show no symptoms, in which case it is known as latent tuberculosis. About a quarter of the global population is estimated to have been infected with TB bacteria, but most people will not develop TB disease. Around 5–10% of patients infected with the TB bacillus have a lifetime risk of falling ill with the disease. Those with compromised immune systems, such as people living with HIV, undernutrition or diabetes, or people who use tobacco, have a higher risk of falling ill. The WHO South-East Asia Region has 26% of the world’s population but the highest burden of TB, accounting for more than 45% of 10.6 million global new TB cases in 2021 and half the 1.6 million global TB deaths. In 2021, an estimated 4.8 million people fell ill with TB in the Region and more than 760 000 succumbed to the disease (excluding TB-HIV deaths). The Region also accounts for more than 38% of the estimated global incidence of rifampicin-resistant (RR-TB) and multidrug-resistant TB (MDR-TB) cases, with approximately 172 000 cases emerging in 2021. Six of the 30 global high-TB-burden countries are in the South-East Asia Region: Bangladesh, DPR Korea, India, Indonesia, Myanmar and Thailand. Nepal has replaced Thailand on the high multidrug/rifampicin- resistant (MDR-TB/RR-TB) burden list. TB does not only cause morbidity and mortality but also propels families further into poverty. Patient cost surveys in the Region found that between 30–80% of TB-affected households bear catastrophic costs due to the disease, forcing families to sell their assets and even pull children out of school.For example, the poor and undernourished are four times as likely to get TB than those in the highest-income bracket. The COVID-19 pandemic provided a further tangible setback and reversed much of the progress made towards ending TB. The effects of COVID-19 were both direct (reduced case notifications) and indirect (exacerbating social determinants of the disease such as poverty, inequity and undernutrition). After years of steady progress, estimated TB and TB/HIV mortality in the Region increased to nearly 800 000 in 2021 compared to 650 000 in 2019. There were 2.56 million TB case notifications in 2020 and 3.1 million in 2021, compared to nearly 3.4 million in 2019. Flagship 8: Accelerate Efforts to End TB by 2030 Background Fig. 18. Disproportionate burden of TB in South-East Asia Region In 2021, SE Asia Region accounted for more than 45% of 10.6 million global new TB cases and half the 1.6 million global TB deaths. SEAR 139 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia Progress and results Prior to the COVID-19 pandemic, the Region had made commendable, albeit slow, progress towards ending TB. For example, Myanmar, a high-TB-burden country, had achieved the 2020 milestone for End TB targets by securing a 20% reduction in TB incidence compared with the 2015 baseline. Before COVID-19 emerged, Bangladesh, Myanmar and Thailand were on track to achieve TB mortality targets (Table 8). Table 8. South-East Asia Region performance against five priority performance indicators for monitoring the implementation of the End TB Strategy Indicator Baseline (2015) Progress (2021) Target (2025) TB treatment coverage 54% 62% ≥90% Treatment success rate among new and relapse TB cases 79% (2014) 86% (2020) ≥90% Percentage of TB-affected households that experience cata- strophic costs due to TB No data 42%* 0% Treatment coverage of latent TB infection Children aged <5 years who are household contacts People living with HIV (PLHIV) newly enrolled in HIV care 2% 9% 26% 4.9%** ≥90% Drug-susceptibility testing coverage of TB patients: New cases Previously treated cases 5% 57% 68% 70% 100% *Based on surveys conducted in four countries in the Region – Indonesia, Myanmar, Thailand and Timor-Leste **based on data available with the Global TB Programme However, following service disruptions associated with COVID-19, none of the targets endorsed by the UN High- Level Meeting on Tuberculosis (Fig. 19) would be achieved. The gap between targets and the achievement levels is especially pronounced for TB preventive treatment. In 2022, TB allocations in the Region reached US$ 1.4 billion, of which 60% was from domestic sources. However, for mission success, we need at least US$ 3 billion annually, which will also help maintain key social protection programmes, such as for nutritional support. Dr Poonam Khetrapal Singh at the high-level meeting to sustain, accelerate and innovate to end TB in the South-East Asia Region, Gujarat, India. 140 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia Fig. 19. South-East Regional progress prior to 2021 against UN High-Level Meeting 2018 commitments Target: 18 million 2018-2022 TB treatment (All ages) Target: 1.5 million 2018-2022 TB treatment (Children) treated in 2018-2021 12million (67%) treated in 2018-2021 0.84million (56%) Target: 0.5 million 2018-2022 MDR/RR-TB treatment (All ages) Target: 11 million 2018-2022 TB preventive treatment treated in 2018-2021 250000 (50%) treated in 2018-2021 2.1million (20%) By 2021, the South-East Asia Region had achieved 67% of its apportioned target for treatment overall, 56% of its apportioned target for treatment of children, 50% of its apportioned target for treatment of drug-resistant TB, and just 20% of its target for TB preventive treatment coverage. However, as a Region, on three of the four UNHLM targets, we outperformed the global average. 141 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia Strengthened political commitment towards ending TB The Region has continued to exhibit sustained political will towards ending TB, even in the face of the extraordinary challenges posed by COVID-19. Throughout 2020–2021 when the pandemic raged, WHO collaborated with partners, stakeholders and communities to provide TB-related technical support to Member States through virtual platforms and the use of digital technologies. Building on the virtual High-Level Meeting in 2021, TB was taken up as an Agenda item for the plenary discussions during the Seventy-fifth Session of the Regional Committee in Bhutan. Member States reiterated their commitment towards ending TB and praised the Regional Director for including TB as one of her Regional Flagship Priorities. Member States also commended WHO for continuing technical support to support the adoption on new guidelines and technologies in countries. The publication Act Now: End TB in the South-East Asia Region provides a snapshot of the current TB situation, progress towards High-Level Meeting targets, the impact of COVID-19 on TB control efforts, and the way forward for accelerating efforts towards ending TB in the Region. More recently, the Region saw successful conduct of a High-Level ministerial meeting “Sustain, Accelerate and Innovate to End TB in the South-East Asia Region” held on 16-17 August 2023, at Gandhinagar, Gujarat in India with an overall objective of reinvigorating the political commitment and as preparation towards WHO / Patrick Brown 142 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia UNHLM on TB on 22 September 2023. The meeting was attended by DG WHO, 6 health ministers in person and one virtually, Regional Directors of SEAR and EUR, senior representative from Global Fund and, several partners and experts from the SE Asia Region. This high-level ministerial meeting led to “Gandhinagar declaration” that calls for: • Formation of multisectoral coordination mechanisms that report to the highest political level for monitoring progress towards ending TB and priority communicable diseases. • Harness science and technology and improve access that is equitable and human rights-based through an integrated, primary health care approach. • Allocate necessary resources to meet TB service coverage targets and address social determinants to have multi-disease impact, achieve the targets of universal health coverage and promote pandemic preparedness. The declaration also calls for maintaining TB as a flagship priority over the coming years to achieve the desired progress towards ending TB. As a result of the political commitments, the budget for TB programmes across the Region for 2022 amounted to nearly US$ 1.4 million, with more than US$ 663 million coming from domestic sources. This is nearly two and a half times the budget for TB programmes in 2016, when less than one third came from domestic sources. A UN High-Level Meeting on TB was organised on 22 September 2023 at New York. The meeting led to a Political Declaration (PD). The PD in alignment with DG WHO’s Flagship Initiative to End TB calls for an ambitious coverage of services to meaningfully bend the TB epidemic curve. The Flagship Initiative calls for global investments for ending TB reaching US$22 billion annually by 2027 of which US $5 billion per year are for research. Gandhinagar Declaration 2023 WHO 143 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia WHO / Leonard Ortega 144 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia Technical support and capacity-building The WHO Regional Office hosted a workshop on strengthening the capacity of laboratory staff for second-line drug-susceptibility testing in 2022. In March 2023, a regional workshop on community capacity-building towards ending TB was held in Nepal, with the aim of strengthening community engagement and collaboration with national programmes in the planning and monitoring of TB control. The multisectoral gathering of clinicians, programme officers and TB survivors made for a unique opportunity for cross-learning, attracting the participation of stakeholders from Bangladesh, Bhutan, India, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. Seven in-country Regional Green Light Committee (rGLC) missions were conducted in 2022, some of them along with the joint monitoring missions, to review the progress of programmatic management of drug-resistant tuberculosis (PMDT). rGLC support to India’s National TB Elimination Programme was provided remotely, supporting implementation of newer TB regimens. Laboratory staff in Myanmar benefited from a virtual capacity-building workshop on infection control, phenotypic drug susceptibility testing and line probe assay. In 2023, comprehensive TB programme reviews were undertaken in Myanmar, Nepal and Timor-Leste in 2023 to support updating of the existing national strategic plans and to guide the development of Global Fund proposals. Together with WHO headquarters, the Regional Office conducted a capacity-building workshop for drug-resistant TB in April 2023. The workshop focused on accelerated implementation of new shorter, 6–9 months’ duration regimens for RR-MDR- TB. The Regional Office also hosted a webinar for dissemination of updated paediatric TB management guidelines in April 2022, including participants from national TB programmes, NGOs and WHO country 145 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia offices. In August 2022, WHO convened a meeting of national TB programme managers, stakeholders and donors for a review of the status of TB efforts across the Region and discussions on the way forward in the light of the impact of COVID-19. WHO also organized a workshop for all Member States to support development and peer review of Global Fund proposals for TB, HIV and malaria on 13–15 February 2023 in Bangkok. The workshop supported countries to review their Global Fund draft funding requests and provided inputs for their improvement. The WHO Regional Office convened a meeting of partners to explore strategies for supporting Maldives in its efforts to accelerate progress towards ending TB. A grant of 1000-person course of Rifapentine has already been mobilized from the Aurum Institute, and the Regional Office is facilitating another grant for the country through the Regional Research Platform. Learnings from the country could well be replicated in other countries, and Maldives could become the first country in the Region to end TB. Through the Joint Monitoring Mission (JMM) in 2022- 2023, technical assistance provided to Bangladesh, Bhutan, Indonesia, Myanmar, Nepal, Thailand and Timor-Leste. JMM findings are informing these countries’ preparation of Global Fund proposals. WHO / Gary Hampton 146 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia Enhancing partner collaboration Several partner consultations were organised in the Region for Regional approach to the UN High-Level Meeting on TB on 22 September 2023 in New York. The Regional Office convened a series of virtual meetings with members of the SE Asia Regional Strategic and Technical Advisory Group for TB (SEAR- STAG-TB) to brainstorm on SEAR high-level meeting in August 2023, ultimately targeting the UN High- Level Meeting on TB in September 2023 at New York. Similarly, a social listening webinar was organized with civil society and community representatives to get their feedback on expectations regarding the UN High-Level Meeting. The regional Green Light Committee (rGLC) which is a partnership platform of experts in drugresistant TB, was reconstituted in January 2023. The annual rGLC meeting was held on 27 April 2023 in Bangkok following the MDR-TB capacity-building workshop. Members of rGLC were equipped with new information to advocate and provide technical assistance in the transition to a 6–9 months’ oral RR-/MDR-TB regimen. There is an urgent need to intensify case notification and social protection efforts to overcome the effect of COVID-19. Due to COVID-19, an additional 7 million people in the Region are likely to develop TB and 1.5 million more will die due to TB between 2021 and 2025 unless urgent action is taken. The Region confronts a funding gap of more than US$ 1.5 billion for TB programmes to fully implement the strategies needed to end TB (as set out in the South- East Asia Regional Strategic Plan towards ending TB 2021–2025). The budget for TB programmes has risen from US$ 551 million in 2014 to US$ 1.4 billion in 2022, but the pace of this increase is insufficient to reinforce a firm edifice on which the elimination of TB across the Region can be achieved. The Region continues to face a longstanding challenge with respect to the availability of trained human resources and health infrastructure. The repurposing of staff from TB programmes to the COVID-19 response further compromised the availability of TB services. There are also gaps in the coverage of TB services because of multiplicity of the stakeholders providing health- care services. An estimated three quarters of all people in South-East Asia seek health care in the private and informal sector as their first point of contact, including those with tuberculosis. Ensuring a seamless, coordinated approach to TB service delivery is therefore essential. Challenges WHO / S B Rai 147 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia The way forward The follow-up UN High-Level Meeting on TB in September 2023 offers an opportunity to sustain and further strengthen the political commitment across the Region. In each country, an empowered country initiative must be operationalized, led by the highest possible political levels of authority and focused on accountability monitoring for reaching the High-Level Meeting targets. While COVID-19 has set back progress, substantial gains in the quest to end TB are still possible through multipronged action, multistakeholder engagement and a whole-of-society approach. Urgent planning is needed in the Region for catching up on the ground lost due to the COVID-19 pandemic and for commensurate investments for a comprehensive package that includes prevention, screening and rapid diagnosis, use of newer and shorter treatment regimens, and patient support including rehabilitative and palliative care. Increased investments in ending TB will not only avert new TB cases and deaths, but also avoid the loss of a projected 31 million disability-adjusted life years in the Region between 2021 and 2025. Traditional and innovative financing mechanisms must be explored. The highest attainable standards of rights- based, stigma-free, quality-assured, people-centric services must be ensured for every person in the target groups. Social and financial protection must be mainstreamed along with TB care. COVID-19 has underscored the critical importance of systematic provision of socioeconomic support to the patient and family. In all countries of the Region, social and economic support for TB patients must be enhanced, better integrated into social protection services, and delineated into measures that are TB-specific, TB- inclusive and TB-sensitive. An evidence base obtained through contextualized people-centric research and innovation that has wide local acceptance will provide significant impetus to TB prevention, diagnosis and cure. Strategic Direction Sustain Translate political momentum into on-the-ground action and results, and continue the expansion of coverage of TB services including engagement of the private sector. Sustain people-centric services that are gender sensitive and protect human rights. Accelerate Enhance social and economic support for TB patients, better integrate these interventions into social protection services, and delineate into measures that are TB-specific, TB-inclusive and TB-sensitive. Intensify community engagement in planning, monitoring and implementing national TB programmes. Accelerate coverage of TB preventive treatment needs to reach at least 90% of all high-risk groups to have the desired impact on incidence. Implement WHO guidelines by adapting newer drug regimens, which will increase adherence and improve the cure rate. Innovate Increase South-South collaboration for technology transfer and commodity support. Strengthen ongoing research, including clinical trials of a TB preventive vaccine for household contacts of TB patients, as well as a post-TB vaccine to prevent TB recurrence. Ensure in all Member States that GeneXpert/TrueNat, scaled up for COVID-19 testing, are used for TB, including for drug-resistant forms. Establish innovative funding mechanisms need to help close funding gaps. Our Journey Together. Our Journey Ahead. WHO South-East Asia 148 Reflection & Beyond Breaking new ground. Differently. Our Journey Together. Our Journey Ahead. WHO South-East Asia 149 Reflection & Beyond WHO 150 Reflection and Beyond Breaking new ground. Differently. All of WHO’s work aims to realize the goal set out in the WHO Constitution – “the attainment by all peoples of the highest possible level of health”. Regional offices extend WHO’s work across all parts of the globe, and country offices provide day-to-day support to country partners to advance health and well-being. Traditionally, the WHO Regional Office for South- East Asia, like its counterparts in other regions, has focused on critical functions – technical leadership, setting standards and norms, enunciating evidence- based policy options, and monitoring the health situation and assessing trends. These core functions remain pivotal to WHO’s work to improve health outcomes in South-East Asia, but over the past decade, the Regional Office has moved beyond these technical functions. Increasingly, the Regional Office is complementing its technical leadership with strategic efforts to support national health agendas, with the ultimate goal of improving health and human development in a part of the world that is home to one fourth of humanity. The Regional Office has taken steps to shape the research agenda, stimulating the generation, translation and dissemination of knowledge among countries in the Region. In seeking to further leverage its impact and influence, the Regional Office has relied on careful planning, clearly defined strategies and pathways, continuous political engagement, course correction based on feedback from external evaluations, promoting innovation and fostering the right partnerships and collaboration. Across its work, including the Flagship Priorities highlighted in this report, the Regional Office has endeavoured to empower country offices to optimize their strategic impact on the health agendas of the 11 Member States of the Region. Over the past decade, the Regional Office has continued the core functions it has long provided. But with the aim of accelerating health gains, it has also adopted new ways of working. Through enhanced focus, a clear vision and the pursuit of concrete targets and milestones, the Regional Office has attempted to break new ground and overcome key barriers. In addition to discussing challenges and vulnerabilities, the Regional Office has created platforms for celebrating achievements, infusing a sense of optimism and motivating Member States to strive for the best. Our Journey Together. Our Journey Ahead. WHO South-East Asia Our Journey Together. Our Journey Ahead. WHO South-East Asia 151 Breaking new ground. Differently. Setting priorities and targets Generating political commitment External evaluation for course correction Empowering country offices Focusing on vulnerable populations Fostering collaboration and partnerships Regional solidarity at the global level Knowledge generation and disseminatio Focus on gender, equity and human rights Clear vision and robust planning WHO’s work in the Region is inspired by the Regional Director’s “One in Four” vision and strategy for building a responsive, accountable and inclusive WHO in South-East Asia. This approach has prioritized four strategic imperatives: (1) addressing persistent and emerging epidemiological and demographic challenges; (2) promoting universal health coverage and building robust health systems; (3) strengthening emergency risk management for sustainable development, and (4) articulating a strong regional voice in the global health agenda. To realize the “One in Four” vision, the WHO Regional Office has pursued the Sustain. Accelerate. Innovate. approach in 2019 – sustaining achievements, accelerating progress to complete the unfinished agenda and chart bold advances, and harness the full power of innovation. A clear vision is the cornerstone of robust planning when it comes to implementing strategies in the Region. With a defined and comprehensive vision, WHO set targets on specific health-care goals and objectives, ensuring that its efforts are directed towards improving the health and well-being of the people in the Region. Evidenced by the notable increase in the creation of strategic documents Our Journey Together. Our Journey Ahead. WHO South-East Asia 152 Setting priorities and targets Generating political commitment Given the finite financial and technical resources, prioritization has been critical to drive progress across the Region, with particular attention to the needs of underserved and marginalized communities. The formulation of the Flagship Priorities, drawn through extensive input from stakeholders in all Member States, accelerated and galvanized a more intensive focus on key priority areas of health, in alignment with global health goals and targets. This prioritization has enabled Member States to make a concrete difference in people’s lives. In each of the Flagship Priorities, clear targets were established – to drive progress, unite diverse stakeholders around common goals, and enhance transparency and accountability. Through enhanced country cooperation, WHO worked closely with countries to clarify national priorities and translate regional targets into country-specific targets. Progress across the Flagship Priorities has benefited from robust political commitment, as reflected in marked improvements in health coverage, drastic reductions in the proportion of the regional population experiencing catastrophic health costs, and a 30% increase in health worker density. In addition to the many resolutions and declarations on Flagship Priorities that have emerged from the Regional Committees, additional ministerial-level dialogues and roundtables have helped to build political commitment for action to reach the regional health goals. From the 22 ministerial meetings organized by the Regional Office over the past decade, 18 ministerial declarations have been on the Flagship Programmes. Ministerial meetings helped to translate commitment into concrete targets and spurred action by Member States. The Regional Office organized several ministerial meetings on specific areas so that Member State commitments could be further reinforced to achieve critical health goals. Ministerial roundtables were organized during the Regional Committee meetings to facilitate in-depth deliberations and thrash out important issues. Regional Committee meetings increasingly focused on the Flagship Priorities, adopting resolutions and declarations on specific areas that needed urgent attention and action. The continuous engagement with health and political leadership in Member States yielded the desired results – increased national funding for critical programmes such as tuberculosis (TB). It was due to the galvanized political commitment at regional and country levels that the budgetary allocation for TB in the Region rose from US$ 550 million in 2014 to around US$ 1.4 billion in 2021. and national action plans since the introduction of the Flagship Priorities, these efforts have wielded substantial influence on a global scale. To illustrate, the South-East Asia Region has assumed a strategic leadership role and significantly contributed to shaping worldwide directives aimed at eliminating diseases such as tuberculosis, leprosy, and various neglected tropical diseases (NTDs). From 2014 onwards, the Region has seen the development and dissemination of more than 60 strategies and 72 guiding documents. Additionally, among the 38 technical resolutions and decisions endorsed by the Regional Committee, an impressive 78% have pertained directly to the areas designated as Flagship Priorities, underscoring the Region’s profound impact on shaping international health-care agendas. Our Journey Together. Our Journey Ahead. WHO South-East Asia 153 External evaluation for course correction Since 2014, the Regional Office has progressively nurtured a culture of assessment and worked to embed this practice within the South-East Asia Region. In 2017, the WHO South-East Asia Regional Framework for enhancing evaluation for learning and advancement was established with the goal of standardizing evaluation procedures throughout the Region. This Framework was revised in 2022, integrating valuable lessons learned from the execution of planned evaluations. The Framework actively sought external independent evaluation, enabling rapid and effective course correction. External evaluations covered both specific programmes for individual countries as well as Regionwide progress. For instance, a 2019 independent assessment of the kala-azar elimination programme in India, pivotal to kala-azar elimination in the Region, identified bottlenecks and challenges in the last mile of elimination, informing country efforts to improve results. Similar country-specific studies evaluated WHO’s role in viral hepatitis control in India, strengthening health information systems in Nepal, supporting NCD control and health systems strengthening in Sri Lanka, strengthening community-based services in Bangladesh and improving nutrition outcomes in Sri Lanka. Regionwide evaluations included a review of adaptation and use of WHO guidelines on reproductive, maternal and newborn health, a 10-year assessment of the South-East Asia Regional Health Emergency Fund (SEARHEF), and evaluations of tobacco control policies and programmes, including implementation of the WHO MPOWER technical package, and of national immunization technical advisory groups. An external evaluation assessed the relevance, effectiveness and efficiency of WHO’s role in the Regional Flagship Priorities from 2014 to 2018, with the aim of promoting learning, enhancing accountability and guiding future actions of WHO at the regional and country levels as well as stakeholders in ministries of health in Member States. The evaluation made seven recommendations for the WHO Secretariat and four for the ministries of health. To take the Flagship Priorities forward, these recommendations were carefully considered and accepted by the WHO management, while those meant for Member States were communicated to high-level officials at the regional governing body meetings. WHO-SEAROCOX Bazaar Our Journey Together. Our Journey Ahead. WHO South-East Asia 154 Empowering country offices WHO takes into account the diversity of health challenges and strategies across the Region, tailoring its health leadership and technical support to the needs of individual Member States. WHO country offices ensure technical cooperation with health ministries and provide leadership in the health sector, mainly through policy advice and technical support, knowledge dissemination and advocacy. New demands, including complex emergencies and disasters, have necessitated rapid adjustments to WHO support, in all cases placing country offices at the centre of WHO’s work in the Region. Consistent with the Regional Director’s vision and the regional emphasis on achieving tangible outcomes at the country level, over the past ten years, more than 70% of the Region’s total financial resources have been allocated to WHO country offices. This proportion has consistently been on the rise, notably increasing from the 2016–2017 biennium and steadily approaching 80% over the last two bienniums (Fig. 20). The proportion of total WHO resources flowing to the country offices was about 90% during the pandemic years. Fig. 20. Resource allocation to the Regional Office and WHO country offices in the SE Asia Region another example of this country focus is the South-East Asia Regional Health Emergency Fund (SEARHEF), which was established in 2007 as a funding mechanism that allows for a rapid response to disasters from natural and human-generated hazards. The Fund enables countries to carry out life-saving activities and lay the foundation for an adequate response to health needs in the first phase of a response operation. During the COVID-19 pandemic, the WHO Regional Office ensured that adequate resources were made available to country offices for extending timely technical advice to national health ministries. 2016-17 78% 24% 2018-19 78% 22% 2014-15 74% 26% 2012-13 76% 24% 2022-23 80% 20% 2020-21 83% 17% Regional Office WHO Country Office Our Journey Together. Our Journey Ahead. WHO South-East Asia 155 Focusing on vulnerable populations Maximizing health impact and fulfilling the SDG pledge of “no one left behind” require focusing on vulnerable and marginalized communities at the subnational level and responding to the health needs of migrants and the homeless. Given the enormous impact of NTDs on marginalized communities, WHO and its stakeholders across the Region have continually devised and adjusted interventions to advance towards elimination of NTDs such as kala-azar, leprosy, lymphatic filariasis, schistosomiasis, trachoma and yaws, which affect some of the most marginalized communities in the Region. The inclusion of TB as a Regional Flagship Priority in 2017 boosted regional commitment to fight TB, enhanced strategic partnerships and encouraged greater focus on key and vulnerable populations at greatest risk. The Rohingya crisis in Bangladesh also posed new challenges, as nearly a million people reached Cox Bazar in Bangladesh and needed urgent medical help and health care. The Regional Office and WHO Country Office in Bangladesh worked closely with the Bangladesh Ministry of Health as well as international agencies to provide timely help to the Rohingyas. WHO-SEARO Anuradha Sarup Our Journey Together. Our Journey Ahead. WHO South-East Asia 156 Fostering collaboration and partnerships WHO’s collaborations and partnerships in the Region are wide-ranging. They are central to WHO’s work in the Region and a hallmark of the tenure of the Regional Director. WHO’s many collaborations have generated a synergistic impact, aided in the mobilization of additional resources for health efforts and given the Region a much stronger collective voice on key health issues. The network of close to 100 WHO collaborating centres in the Region has helped to generate the necessary knowledge and information for effective implementation of the Flagship Priorities and other programmes across the Region. Working with the Association of Sutheast Asian Nations (ASEAN), the Regional Office has set in motion the South-East Asia Health Pandemic Response and Preparedness project in eight ASEAN countries. With the Asian Development Bank (ADB), WHO is collaborating at the country level through country-tailored grants, including COVID-19 grants to Bangladesh, India, Maldives and Nepal as well as technical collaboration among ministries of health and finance. The Regional Office has also established a partnership with the European Union and provided resources to support the COVID-19 response in nine countries. While ministries of health remain at the centre of the action on health, WHO engages across government departments and society, helping to catalyse the whole-of-government, whole-of- society approaches needed to achieve the SDGs. During the COVID-19 pandemic, the Regional Director also supported strong interdisciplinary collaboration among the 11 Member States, convening a series of meetings of regional partners to share best practices and lessons learnt as well as discuss strategic engagement among Members States and partners. Such exercises helped to identify areas of collaboration to address the challenges posed by COVID-19. They were attended by more than 200 partners, including representatives of the ministries of health, partner/donor countries, multilateral institutions, development agencies, international financial institutions, UN agencies, philanthropic organizations, international and national NGOs, research and academia. These discussions informed the development of a regional roadmap to strengthen health security in the Region. WHO has actively worked to engage non-State Actors in efforts to improve health and well-being, with particular attention to the most vulnerable communities and remote areas. These efforts galvanized support for migrants to have access to information, treatment and vaccination (DISHA, India), inclusion for people with disabilities (National Federation for Disabled, Nepal), access for those with mental health needs due to COVID-19 (KOSHISH, Nepal), sensitization of faith leaders, local government councillors and transport workers (ADAB, Bangladesh), support for youth during COVID-19 (Alcohol and Drugs Information Centre, Sri Lanka) and community surveillance and support for COVID-19 (The Foundation for Health Promotion). WHO has actively worked to engage non-State Actors in efforts to improve health and well-being, with particular attention to the most vulnerable communities and remote areas. Our Journey Together. Our Journey Ahead. WHO South-East Asia 157 Regional solidarity at the global level The era of the Flagship Priorities has coincided with a remarkable elevation in the visibility, stature and influence of the Region in the global health agenda. Envisioning a strong regional voice in the global health agenda, the Regional Director has emphasized Regional One Voice statements by Member States at global governing body meetings. In another first, all Member States now regularly collaborate on the development of Regional One Voice statements at the World Health Assembly and Executive Board meetings. The Working Group on Sustainable Financing (WGSF) has spurred informal discussions across the Region, resulting in Regional One Voice statements on financing issues in meetings of the WHO Executive Board. Knowledge generation and dissemination The WHO South-East Asia Region places strong emphasis on knowledge generation and sharing of evidence, as evidenced by the release of more than 415 diverse documents between 2014 and 2023. These documents cover a wide range of categories, such as advocacy, guidance, meeting reports, situational analyses, evaluation studies, research papers, strategies, and awareness materials. Notably, the largest proportion, approximately 35%, focused on communicable diseases, with noncommunicable diseases closely following at 23%. Moreover, 32% of the documents served as guidance or strategy materials, while another 35% were dedicated to publications advocating for improved health outcomes. The Regional Office has issued numerous technical and advocacy documents, including SDG health profiles for various countries, regional progress reports on specific SDGs, and records of technical meetings, along with guidance materials addressing specific SDG-related issues. These achievements, such as substantial improvements in maternal and child health indicators and the successful elimination of several NTDs and vaccine-preventable illnesses in the Region, have been meticulously documented and widely disseminated both within the Region and to a global audience. Collaborating with Member countries during health emergencies is a crucial area of engagement in the Region, given its susceptibility to natural disasters such as floods and earthquakes, as well as other crises. Strengthening capacities for emergency preparedness and operational readiness has been a top priority in the South-East Asia Region and a Flagship Priority since 2014. The collection of publications related to health emergencies encompasses materials generated in response to significant public health crises, such as the 2015 Nepal earthquake and the 2017 Rohingya crisis. These documents have played a pivotal role in highlighting a spectrum of best practices, innovations, and outcomes. As an illustration, a regional report titled Towards a safer future: insights from a decade of public health emergencies in the South-East Asia Region, published in 2021, chronicles the Region’s experiences in managing health emergencies. The Regional Director has emphasized Regional One Voice statements by Member States at global governing body meetings. In another first, all Member States now regularly collaborate on the development of Regional One Voice statements at the World Health Assembly and Executive Board meetings. Our Journey Together. Our Journey Ahead. WHO South-East Asia 158 Focus on gender, equity and human rights Over the past decade, a focus on gender, equity and human rights (GER) has increasingly guided WHO’s work. This emphasis recognizes that the goals of universal health coverage and primary health care will be realized only if gender- and human rights-related barriers to health service access and optimal, equitable health outcomes are effectively addressed. To advance the GER agenda, WHO has provided country-focused technical support; built the capacity of national stakeholders and WHO staff; strengthened the evidence base; and strengthened policy advocacy and partnerships. An output scorecard now provides transparent reporting on WHO outputs that include the integration of issues relating to gender, equity, human rights and disability. The Regional Office helped Member States align their national programmes with GER requirements, especially those relating to the sexual health of adolescents and mental health policies. WHO shared the INNOV8 methodology to facilitate capacity-building of programme managers and health professionals to integrate equity and social determinants of health across strategies, plans and actions meant for the health of women, children and adolescents. In addition, the Health Equity Assessment Toolkit (HEAT Plus) was made available to address inequalities at national and subnational levels, and support provided for the development of advocacy materials on mainstreaming GER in health programmes. During the COVID-19 pandemic, Member States were supported to include GER issues in their national responses. Scaling new heights: achievements Prioritization yields results Prioritization is a cornerstone of success in the WHO South-East Asia Region, where careful selection and focus on key technical areas have yielded remarkable results. The concrete, transformative successes of the Flagship Programmes over the past decade, documented in the preceding chapters, definitively demonstrates that prioritization yields powerful results for people living in the Region. Since their launch in 2014, the Flagship Priority Programmes have helped channel WHO’s technical and financial support to Member States in identified areas and programmes, bringing a much stronger focus on results, transparency and accountability. The Flagship Programmes have inspired sustainable and results- oriented efforts at the national level, tailored to individual country contexts. Prioritization is a cornerstone of success in the WHO South-East Asia Region, where careful selection and focus on key technical areas have yielded remarkable results. The concrete, transformative successes of the Flagship Programmes over the past decade, documented in the preceding chapters, definitively demonstrates that prioritization yields powerful results for people living in the Region. Our Journey Together. Our Journey Ahead. WHO South-East Asia 159 The South-East Asia Region: the hub for disease elimination Ahead in the race towards the 2030 goal on maternal and child health The SDGs shifted the global health paradigm – from disease control to disease elimination. The South-East Asia Region actually foreshadowed this paradigm shift, prioritizing disease elimination in its Flagship Priorities, launched the year prior to endorsement of the SDGs. The Region as a whole has been certified polio-free and as having eliminated maternal and neonatal tetanus. It is the only Region with more than 20 disease eliminations in one or more Member States (Table 9). This includes some of the first eliminations in the SDG period – including malaria, prevention of mother-to-child transmission of HIV and syphilis in high-burden settings, and elimination of yaws and trachoma. With the wind in its sails, the Region is committed to eliminating NTDs ahead of the agreed global timelines. By 2022, five countries (DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand) had already achieved the global under-five mortality rate target of fewer than 25 deaths per 1000 live births, and Bangladesh, Bhutan, India and Nepal are expected to achieve the target by 2030 if they continue with their current trajectories. Four countries (DPR Korea, Maldives, Sri Lanka and Thailand) have already achieved the global SDG target for a neonatal mortality rate of fewer than 12 deaths per 1000 live births and four other countries (Bangladesh, Bhutan, Indonesia and Nepal) are expected to reach the target by 2030. Table 9. Disease eliminations in WHO South-East Asia Lymphatic Filariasis Yaws Trachoma Kala-azar EMTCT Malaria Measles Rubella Bangladesh 2023 2023 Bhutan 2017 2023 DPR Korea 2018 2023 India 2016 Indonesia Maldives 2016 2019 2015 2017 2020 Myanmar 2020 Nepal 2018 Sri Lanka 2016 2019 2016 2019 2020 Thailand 2017 2016 Timor-Leste 2023 2018 2023 Source: WHO SEARO Our Journey Together. Our Journey Ahead. WHO South-East Asia 160 Towards achieving universal health coverage Combating noncommunicable diseases Boosting the response to communicable diseases The Region is a pathfinder in the global quest to achieve universal health coverage (UHC), ensuring that UHC remains the bedrock of the health policy architecture in all countries. UHC is a central element of all the Flagship Programmes. The Region’s health service coverage index is now 62% (2021) as compared with 47% (2010) a decade ago, although there are substantial disparities that need to be closed – Maldives, Sri Lanka and Thailand have achieved relatively high levels of service coverage and low levels of catastrophic health spending, while Bangladesh, India and Myanmar continue to experience high levels of catastrophic health spending and relatively less service coverage. The density of health workers has substantially increased. Nine countries are now above the WHO threshold of 22.8 health workers per 10 000 population, compared with six in 2014. The availability of doctors, nurses, and midwives improved by 30.6% from 2014 to 2020. Five Member States report 100% birth registration coverage, while six Member States register more than 70% of deaths in their countries.1 Between 2000 and 2019, the total population in the Region impoverished and further impoverished due to OOP health spending has substantially decreased, from almost 29% to about 5%, respectively. As the global toll from noncommunicable diseases continues to increase, the Region is rising to meet the challenge, markedly expanding the reach of NCD services. In 2019, Thailand became the first country in the Region and the second in Asia to introduce plain packaging of tobacco products. Ten Member States have introduced pictorial warnings on tobacco packs. Thailand has also introduced legislation that bans trans-fats in food. Regionally, the proportion of the population using tobacco declined from 50.4% in 2000 to 29% in 2020. Five countries have implemented a ban on electronic nicotine delivery systems. India and Thailand have scaled up hypertension control activities. The India Hypertension Control Initiative (IHCI), a nationwide primary health care intervention under the National Health Mission, was honoured with the 2022 UN Interagency Task Force and the WHO Special Programme on Primary Health Care Award. In 2015, the Region was credited with halting and reversing the HIV, TB and malaria epidemics, fulfilling the Millennium Development Goal (MDG) targets. The burden of TB, however, remained high in the Region at the beginning of the SDG era. The identification of TB as one the Flagship Priorities in 2016 accelerated the ongoing work in TB at the national level and boosted activities for a strategic shift in approach from controlling to ending TB. Recognition of TB as a Flagship Priority galvanized significant political commitment at regional and country levels, resulting in enhanced budget allocation from US$ 550 million in 2014 to around US$ 1.4 billion in 2021. 1 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2022 update. New Delhi: World Health Organization, Regional Office for South-East Asia; 2022. Our Journey Together. Our Journey Ahead. WHO South-East Asia 161 Tackling emergencies Flagship Programmes’ success propels non-Flagship areas As recent history has vividly underscored, the Region is vulnerable to different types of emergencies and natural disasters, including floods, cyclones, earthquakes, tsunamis, landslides and volcanic eruptions, as well as outbreaks and epidemics of common infectious diseases and emerging or re-emerging diseases. Identifying “Scaling up capacity development in emergency risk management” as a Flagship Priority provided strategic support for improved management of emergencies through advocacy, preparedness and response, information management, technical and operational support and partnership. The Region has made notable progress in the preparedness and management of health emergencies, and the Flagship Priority Programme has led to increased efforts by Member States to secure resources through government as well as donor partners. The Regional Programme established SEARHEF, an operational fund to provide financial support to a Member State for the first three months following a disaster in a Member State. SEARHEF has supported 43 emergencies in 10 countries and disbursed over US$ 6.77 million. In 2016, the Fund was expanded to cover the preparedness stream as well. The benefits of the Flagship Priorities are not limited to these areas alone, as spillover effects have generated marked progress in non-Flagship areas as well. The success achieved in the elimination of polio, measles and various NTDs in the Region stimulated momentum towards the elimination of diseases that were on the verge of elimination. Measles and rubella flagship priority supported the efforts for strengthening other aspects of routine immunization. The coverage rate for DPT3, third dose of diphtheria, pertussis and tetanus vaccines which is used globally to assess vaccination rates, recovered to pre-pandemic 91% in WHO South-East Asia Region, a sharp increase from 82% recorded in 2021. The elimination of malaria and mother-to-child transmission of HIV and syphilis (EMTCT) in Maldives and Sri Lanka are shining examples of the positive impact that the Flagship Priorities have had in areas not directly covered under them. Additionally, malaria, which has been already eliminated from Sri Lanka and Maldives, has shown a sharp declining trend with 62% reduction in malaria incidence between the period of 2015 and 2021. It is on track to reach the 2030 SDG goals. In the same way, the progress made in achieving UHC goals as part of the Flagship Priorities helped to address diseases both within and outside the Flagship Priorities. UHC is considered to be an essential mean to achieve all public health agenda. The Flagship Priority on UHC, with a focus on HRH and access to medicines, underscores the importance of an integrated, appropriately resourced and effective health system, to achieving UHC and the health- related SDGs. The flagship priority on health emergencies preparedness in WHO South-East Asia is dedicated to fostering the development of a robust and resilient health system. This system is not only geared to address the specific diseases outlined in the flagship but also to effectively manage any health emergency and challenge that may arise beyond the flagship’s scope. This comprehensive approach ensures that the region is better equipped to protect the health and well-being of its population in the face of a wide range of challenges and uncertainties, including upcoming issues such as climate change and air pollution. The success of the Flagship Programmes in measles, TB and antimicrobial resistance has demonstrated to policy-makers that major public health problems can be tackled with the right level of political commitment, strategic focus and financial support. Our Journey Together. Our Journey Ahead. WHO South-East Asia 162 Leveraging innovation and digital health to accelerate progress Low public health spending At a time of unprecedented innovation and technological change, the Regional Director has advanced the “Sustain. Accelerate. Innovate” maxim by prioritizing research, innovation and the use of affordable health technologies. The intensified focus aims to identify, disseminate and scale up innovative practices and technologies in the Region so that Member States can learn from each other and benefit from health innovations. Digital innovations are transforming our world, and health delivery in South-East Asia is no exception. The COVID-19 pandemic accelerated uptake of digital health innovations such as telehealth, digitized health information systems, and use of social media for dissemination of health information. The Asia e-Health Information Network serves as a platform for peer-to-peer assistance in adopting, scaling up and fully capitalizing on digital innovations to improve health service access and outcomes. Leveraging India’s presidency of the G20, the Regional Office and the Government of India in 2023 hosted a global conference on strategies for leveraging digital innovations to accelerate progress towards UHC. Regionally, total health expenditure as a percentage of GDP is lower in South-East Asia than in any other WHO region, as four countries allocate public health spending at nearly 1% of their GDP, while a total of six countries dedicate public health expenditure as a share of their GDP that is less than 2%. As a result, Out-of-pocket expenditure (OOPE) as a proportion of total health expenditure is higher (40% in 2018) than the global average in the Region (Fig. 21), placing tremendous financial burden on individuals and families and potentially driving the vulnerable into poverty or deepening poverty among the already impoverished, especially in the case of NCDs and other chronic diseases. The latest estimates show that catastrophic health spending has increased from 13.1% in 2010 to 15% in 2017, with a further slight increase to 16.1% in 2019.2 Although the past decade has seen remarkable, historic gains in the health and well-being of the Region’s people, important challenges persist. Challenges The scope of the Flagship Priorities transcended the Flagship areas. In fact, the scope of the Flagship Programmes went infinitely beyond any particular disease or programme related initiative. Flagship programmes, directly or indirectly, propelled many of the diseases specific programmes which were not included in the flagships. Our Journey Together. Our Journey Ahead. WHO South-East Asia 163 Impact of COVID-19 In each of the preceding Flagship-specific chapters, the substantial and continuing impact of COVID-19 has been described. Progress towards numerous vital targets have been slowed, in some cases throwing the momentum to achieve the targets completely off track. COVID-19 pushed the progress of routine immunization and surveillance activities back by 5–8 years in some cases. TB mortality has increased and is now back at 2015 levels due to reduced access to TB diagnosis and treatment. During the pandemic, the Region witnessed an increase in the levels of obesity and hypertension, adversely affecting the targets for the NCD-related Flagship Priority Programme. While the pandemic highlighted the importance of environmental determinants such as water, sanitation and hygiene (WASH), the implementation of strategies and programmes to improve access to clean drinking water and sanitation were hampered as a result of the pandemic, which in turn undermined progress in the Flagship Programme on communicable diseases. The disruption of essential health services due to the pandemic also delayed timelines for attainment of the UHC targets. Fig. 21. Out of pocket expenditure as % of total health expenditure in Member States of WHO South-East Asia (2020) Source: WHO global data observatory There are also signs of a health financing transition, with a decline in donor financing as a proportion of current health expenditure in most countries of the Region. The Regional Office continues to encourage Member States to develop innovative policies for increasing domestic heath financing, reducing OOPE, and increasing the availability and affordability of essential medicines and diagnostics, which are major sources of OOPE. 2 WHO global data observatory 0 20 10 30 40 50 70 60 80 Timor-LesteThailandSri LankaNepalMyanmarMaldivesIndonesiaIndiaBhutanBangladesh 54 0717 32 51 15 74 73 47 11 Our Journey Together. Our Journey Ahead. WHO South-East Asia 164 Implementation challenges Vulnerability to disasters In some areas of concern, such as antimicrobial resistance, policies are in place but implementation lags behind. While all Member States have developed national multisectoral action plans, they depend on WHO and donor partners to move forward in areas such as human resources, technical expertise and funding support. At the country level, significant challenges exist to implementing “best buys” and other strategic interventions to control NCDs. These include suboptimal financial and human resources, inadequate capacity, heath system bottlenecks and weaknesses, divergent sectoral mandates, industry interference and lack of clarity regarding the roles of different actors and stakeholders. The Region is prone to natural disasters, such as earthquakes, cyclones, floods and droughts, and these risks have been accentuated by climate change. Such disasters have the potential to undo the gains made to date. A regional scientific risk profiling study showed that existing capacities in the Region did not match the prevailing and ever-increasing threats. The inadequate capacity of International Health Regulations (IHR) national focal points (NFPs), paucity of trained personnel, gaps in intersectoral coordination, insufficient uptake and adaptation of technical guidelines, limited contingency funds for response and funding for preparedness activities, and inadequate risk communication capacity are some of the limitations. WHO Vismita Gupta-Smith Our Journey Together. Our Journey Ahead. WHO South-East Asia 165 Plateauing of certain trends – missing the targets Other health system challenges In some areas, such as premature mortality due to NCDs, coverage of essential services index and new HIV infections, progress has plateaued, underscoring the need to accelerate gains. In the absence of substantially stronger efforts, the Region is likely to miss a number of the 2030 targets, such as those related to ending TB, expanding essential service coverage, reaching maternal mortality rate, NCD targets etc. Health system challenges such as Health financing and Health service coverage has already been discussed earlier. However, the health system presents additional complexities. Firstly, the diversity in health system organization across the region is noteworthy. Larger countries such as India, Indonesia, and Bangladesh exhibit a prominent private sector presence, while nations like Bhutan, DPR Korea, and Thailand have a predominantly public sector orientation. This diversity introduces intricacies in managing and delivering healthcare services. Moreover, regional patterns favor decentralized healthcare management through subnational government bodies, posing considerable hurdles in developing local government capacity for healthcare service management and financing. The availability of a skilled and well distributed health workforce also persists as a challenge. While the Region experienced an increase in the average density of doctors, nurses and midwives, the average density across the Region stands at 28 per 10 000 population. Only three countries are above the WHO threshold of 44.5 health workers per 10 000 population. Inequalities in distribution, as well as challenges related to the quality of education and practice, skills mix, policy dilemmas in handling traditional and informal practitioners, productivity, and performance, are also prominent within countries3 Although timely and reliable data are essential for guiding formulation and implementation of public health policies, prioritizing and allocating resources, and accelerating implementation, important gaps and weaknesses in data systems persist in the Region. The Region faces an ongoing challenge in effectively and practically tracking progress towards the health-related SDGs and UHC service coverage. This challenge is primarily attributed to the absence of a robust routine information system capable of generating timely and dependable data. To measure progress in achieving UHC and meeting the health-related SDGs, it’s essential to go beyond evaluating the availability and utilization of healthcare services. It’s equally critical to assess these aspects for various population segments and ensure high-quality care. Consequently, countries must enhance their Health Information Systems (HIS) to generate health data outcomes and outputs that are broken down by factors such as income, gender, age, race, ethnicity, disability, geographic location, and migratory status. This disaggregation is vital for identifying and addressing inherent health inequities. Critical attention is needed to improve regular data availability on financial protection to monitor the impact of UHC policies and programmes in reducing financial hardship and take timely corrective actions as for most countries in the Region, the latest data on financial protection dates to 2016–2017, and for one country it is before 2016. It is also critical to measure and monitor unmet needs including forgone care. Availability and affordability of essential medicines, vaccines, diagnostics and devices is also a challenge, with expenditure by households on these components being the main driver of financial hardship related to health in the South-East Asia Region. 3 South-East Asia Regional Strategy for Primary Health Care: 2022-2030. New Delhi: World Health Organization, Regional Office for South-East Asia; 2021. Our Journey Together. Our Journey Ahead. WHO South-East Asia 166 Although persistent challenges are real and concerning, there are important achievements and substantial momentum on which the Region can build to improve the health and well-being of its people. Renewed vigour and a clear vision will be essential – to catalyse a whole-of-society and whole-of- government approach to health, strengthen primary health care, develop resilient health systems, and accelerate collaboration and innovation, including the use of digital technologies and data. The success of the Flagship Priority Programmes has demonstrated that prioritization is critical and powerfully effective. Future efforts will need to build upon this experience and focus on certain specific areas – reaching vulnerable and marginalized groups to leave no one behind; using community- based, decentralized models to adapt health delivery to the needs of the people; strengthening health systems through enhanced domestic financing and expanding coverage of essential health services; scaling up evidence-based, high-impact interventions, including digital health products and solutions; and tracking epidemics and diseases at national, subnational and local levels through data, disaggregated where possible (Fig. 22). The way forward Fig. 22. The way forward Pr om ot e re se ar ch a nd in no va tio n. Ca tc h up o n th e gr ou nd lo st d ue to th e C O VI D- 19 Focus on vulnerable populations - leave no one behind. Thus, bringing programmes to the center of universsal health coverage Adapt health delivery to the needs of people: invest in decentralized community health system by strenghtening the community - based approches Strengthen health system actions like appropriate domestic financing and addressingHR issue including coverage of essential health services Scaling up of evidence-based high impact inteventions, inclluding through digital health and other innovations Know your epidemic & know your response at local level. Timely, reliable and sustained national and subnational data with possible disaggregation Ensure adequate preparedness and response to disease | Develope and sustain a sensitive and timely surveillance system Strengthening multisectoral coordination and collaboration beyond health sector | Develope and maintain a proficient laboratory network Our Journey Together. Our Journey Ahead. WHO South-East Asia 167 Advocacy is needed to increase even further the visibility of the Flagship Priorities at country level and to mobilize greater political support. Doing so will help consolidate the important gains made over the past decade and sustain and extend them in future years. Future success depends on strengthening the capacity for evidence-based research at country level and enhancing multisectoral collaboration with the non-health sectors. Collaboration will be essential. Further efforts will be needed to strengthen and effectively leverage WHO collaborating centres, multidisciplinary partnerships and key regional networks and collaborations (including but not limited to tripartite monitoring of national action plans for antimicrobial resistance, the India-based global Centre for Traditional Medicine, and technical advisory groups in different Flagship Priority areas). Opportunities must also be sought and enhanced for peer-to-peer collaboration among Member States, such as meetings of national regulatory authorities and regional information-sharing on primary health-care expansion. Building robust, resilient health systems is key to progress across the Flagship Priorities and in the quest to achieve UHC. Increasing public spending on health is essential – the key that unlocks the door to regional achievement of the SDGs. Taking on board lessons learned during COVID-19, the Region must also further build its capacity for disease surveillance and early warning and expand the use of digital tools to enable people-centred services to be available during future emergencies. After reviewing progress across the Flagship Priority Programmes, the 75th meeting of the Regional Committee endorsed further strategic action to advance gains towards the Flagship targets. The eight Flagship Priority Programmes will continue to support the extension of Thirteenth Global Programme of Work through 2025. Particular attention will be required to address the needs of the most vulnerable populations and leave no one behind, intensify support for community-based approaches, strengthen health systems, focus on scaling up evidence-based and high-impact interventions, and fully leverage national and subnational data to guide strategic action. Moving forward on the path to good health is both a challenge and an opportunity for countries in the Region. Experience with the Flagship Programmes shows that transformative progress is achievable. Now is the time to build on the gains of the past 10 years to lay the foundation for good health and well-being for all. Indonesia, 2017 Our Journey Together. Our Journey Ahead. WHO South-East Asia 168 Achievements in the Flagship Priority Areas Measles and rubella elimination Five countries – Bhutan, DPR Korea, Maldives, Sri Lanka and Timor-Leste – have achieved the regional goal of measles and rubella elimination Measles incidence declined by 86% and rubella by 78% between 2014 and 2021. Reduce of maternal, neonatal and under five mortality Five countries – DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand – have already achieved the SDG 2030 targets for both the newborn mortality and under-five mortality rates From 2010 to 2021, there was a substantial decrease of 39% in the NMR and 45% reduction in the U5MR. Similarly, MMR declined by an impres- sive 69% between 2000 and 2020. Notably, the reductions in NMR, U5MR and MMR in the South-East Asia Region are nearly double the global reduction rates. Progress towards universal health coverage Universal health coverage index increased from 47 to 62 in 2010–2021 Availability of doctors, nurses and midwives increased by over 30.6% since 2014 The total population in the Region impoverished and further impoverished due to OOP health spending has substantially decreased, from almost 32% (2000) to about 7% (2019) - at $ 2.15 a day per person. Prevent and control noncommunicable diseases Sharp decline in tobacco use from 50.4% in 2000 to 29% 2020 Over 10 million people with hypertension and/or diabetes put on protocol-based management with improved control rates More than 4500 children with cancer received improved care through the SEARO Childhood Cancer Network Strategic shift in the way Member States responded to NCDs before and after 2014, which illustrates strong political commitment, will and leadership for multisectoral engagement and partnerships Probability of dying from NCDs declined from 23.4% in 2010 to 21.6% in 2019. Prevent and combat antimicrobial resistance All 11 countries in the South-East Asia Region have developed and endorsed respective national action plans (NAPs) in line with the Global Action Plan. Eight Member States have updated their NAPs by 2022. The progress in the implementation of NAPs was 64% in 2021, compared with 40% in 2018 and 16% in 2016 By Sept 2022, all Member States were enrolled in the Global AMR Surveillance System (GLASS) and 6 Member States enrolled in GLASS–antimicrobial consumption (AMC). Emergency risk management The South-East Asia Regional Health Emergency Fund, or SEARHEF, has supported over 43 emergencies in 10 countries. SEARHEF mandate was expanded in 2016 to include strengthening preparedness Countries strengthened International Health Regulations (2005) core capacities and committed to health security Lessons from COVID-19 pandemic are guiding the Regional Strategy Roadmap on Health Security and Health System Resilience for Emergencies 2023–2027. Eliminate neglected tropical diseases Lymphatic filariasis eliminated in Maldives and Sri Lanka in 2016 and in Thailand in 2017 India verified yaws-free in 2016 Trachoma eliminated by Nepal in 2018 and Myanmar in 2020 Bangladesh eliminated lymphatic filariasis and kala azar in 2023. End TB by 2030 There has been a marked increase in political commitment at both the regional and country levels to combat tuberculosis, resulting in a significant budget allocation rise, from US$ 550 million in 2014 to US$1.4 billion in 2021 Sustained political commitment led Member States to rebound in improving TB services access and coverage post-COVID-19, reaching more patients than ever in the Region. Our Journey Together. Our Journey Ahead. WHO South-East Asia 169 Achievements in the Flagship Priority Areas Measles and rubella elimination Five countries – Bhutan, DPR Korea, Maldives, Sri Lanka and Timor-Leste – have achieved the regional goal of measles and rubella elimination Measles incidence declined by 86% and rubella by 78% between 2014 and 2021. Reduce of maternal, neonatal and under five mortality Five countries – DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand – have already achieved the SDG 2030 targets for both the newborn mortality and under-five mortality rates From 2010 to 2021, there was a substantial decrease of 39% in the NMR and 45% reduction in the U5MR. Similarly, MMR declined by an impres- sive 69% between 2000 and 2020. Notably, the reductions in NMR, U5MR and MMR in the South-East Asia Region are nearly double the global reduction rates. Progress towards universal health coverage Universal health coverage index increased from 47 to 62 in 2010–2021 Availability of doctors, nurses and midwives increased by over 30.6% since 2014 The total population in the Region impoverished and further impoverished due to OOP health spending has substantially decreased, from almost 32% (2000) to about 7% (2019) - at $ 2.15 a day per person. Prevent and control noncommunicable diseases Sharp decline in tobacco use from 50.4% in 2000 to 29% 2020 Over 10 million people with hypertension and/or diabetes put on protocol-based management with improved control rates More than 4500 children with cancer received improved care through the SEARO Childhood Cancer Network Strategic shift in the way Member States responded to NCDs before and after 2014, which illustrates strong political commitment, will and leadership for multisectoral engagement and partnerships Probability of dying from NCDs declined from 23.4% in 2010 to 21.6% in 2019. Prevent and combat antimicrobial resistance All 11 countries in the South-East Asia Region have developed and endorsed respective national action plans (NAPs) in line with the Global Action Plan. Eight Member States have updated their NAPs by 2022. The progress in the implementation of NAPs was 64% in 2021, compared with 40% in 2018 and 16% in 2016 By Sept 2022, all Member States were enrolled in the Global AMR Surveillance System (GLASS) and 6 Member States enrolled in GLASS–antimicrobial consumption (AMC). Emergency risk management The South-East Asia Regional Health Emergency Fund, or SEARHEF, has supported over 43 emergencies in 10 countries. SEARHEF mandate was expanded in 2016 to include strengthening preparedness Countries strengthened International Health Regulations (2005) core capacities and committed to health security Lessons from COVID-19 pandemic are guiding the Regional Strategy Roadmap on Health Security and Health System Resilience for Emergencies 2023–2027. Eliminate neglected tropical diseases Lymphatic filariasis eliminated in Maldives and Sri Lanka in 2016 and in Thailand in 2017 India verified yaws-free in 2016 Trachoma eliminated by Nepal in 2018 and Myanmar in 2020 Bangladesh eliminated lymphatic filariasis and kala azar in 2023. End TB by 2030 There has been a marked increase in political commitment at both the regional and country levels to combat tuberculosis, resulting in a significant budget allocation rise, from US$ 550 million in 2014 to US$1.4 billion in 2021 Sustained political commitment led Member States to rebound in improving TB services access and coverage post-COVID-19, reaching more patients than ever in the Region. 170 FLAGSHIP 8: Accelerate Efforts to End TB by 2030 WHO South-East Asia