Changing the game: strengthening health and well-being through sport events

Changing the game Strengthening health and well-being through sport events

Changing the game Strengthening health and well-being through sport events Changing the game: strengthening health and well-being through sport events ISBN 978-92-4-010135-7 (electronic version) ISBN 978-92-4-010136-4 (print version) © World Health Organization 2024 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. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Changing the game: strengthening health and well-being through sport events. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at https://iris.who.int/. Sales, rights and licensing. To purchase WHO publications, see https://www.who.int/ publications/book-orders. To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/copyright. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Cover page: Scenes from the FIFA World Cup Qatar 2022: packed stadiums, emergency teams on standby, vibrant fan zones, and the iconic World Cup trophy display. Cover photos taken by ©Supreme Committee for Delivery and Legacy, Hamad Medical Corporation, and Generation Amazing Foundation The design of this report has been prepared by Lee Ellis and Laura Mingozzi-Marsh

Contents i. Foreword 4 ii. Acknowledgements 7 iii. Abbreviations 8 iv. Executive summary 10 1. Introduction: the Healthy FIFA World Cup Qatar 2022 – Creating a legacy for Sport for Health 19 2. Methodology: how this report was developed 22 3. The Sport for Health vision: using sports events to improve public health 24 4. Background 26 4.1 Context 27 4.1.1 Delivering the FIFA World Cup Qatar 2022 during a global pandemic 28 4.1.2 FIFA Arab Cup: an event to prepare for the big one 30 4.1.3 How Qatar’s health system works 32 5. Partnering for Sport for Health 34 5.1 Governance of the partnership 36 5.2 Operational governance for the FIFA World Cup Qatar 2022 37 5.2.1 Event governance 38 6. Protecting health 46 6.1 Public health system 50 6.1.1 Surveillance 50 6.1.2 Other monitoring activities 62 6.1.3 Surveillance: reflections 68 6.1.4 Issues, challenges and responses 68 6.1.5 Considerations for future events 69 6.1.6 Example: social listening and RCCE 71 6.1.7 Summary 76 7. Providing health 78 7.1 Health care system 80 7.1.1 Predictive modelling 84 7.1.2 Access to health care 86 7.1.3 Key services 94 7.1.4 The FIFA World Cup Qatar 2022 daily situational report 100 7.1.5 Incident readiness and response 108 7.1.6 Example: real time information for real time response 113 7.1.7 Health care: reflections 114 7.1.8 Issues, challenges and responses 114 7.1.9 Considerations for future events 117 7.1.10 Summary 120 2 Strengthening health and well-being through sport events Changing the game 8. Promoting health 122 8.1 Physical activity 130 8.1.1 Promoting physical activity in community settings, stadiums and fan zones 132 8.1.2 Promoting active transport: walking, cycling and public transport 134 8.1.3 Strengthening national governance, capacity and partnerships 137 8.1.4 Implementation of a global active video game – GenMove 138 8.1.5 Box 5: the first Sport for Health conference, 2022 141 8.1.6 Box 6: the 2022 World Innovation Summit for Health 142 8.1.7 Physical activity: reflections 143 8.1.8 Issues, challenges and responses 143 8.1.9 Considerations for future events 144 8.1.10 Example: Generation Amazing Foundation 146 8.2 Nutrition: healthier food and healthier food environments 150 8.2.1 Nutrition: reflections 154 8.2.2 Issues, challenges and responses 154 8.2.3 Considerations for future events 155 8.2.4 Example: alcohol free stadiums 158 8.3 Tobacco control 160 8.3.1 Main activities 161 8.3.2 Tobacco control: reflections 163 8.4 Mental health 165 8.4.1 Example: friendship benches 166 8.5 Accessibility 168 9. Advocating for health 172 9.1.1 Advocating for health: reflections 174 9.1.2 Issues, challenges and responses 174 9.1.3 Considerations for future events 175 9.1.4 Example: #BringtheMoves 176 9.1.5 Example: Fides 179 9.1.6 Why is the Fides project needed? 180 9.1.7 Goals and achievements 180 9.1.8 Example: health through my lens photography exhibition 182 9.1.9 Example: health in focus filmmaking workshops 183 9.1.10 Summary 184 10. Building a global movement for Sport for Health 186 10.1.1 Resolution WHA77.12 of the Seventy-seventh World Health Assembly 187 11. References 188 3Contents Foreword The Sport and Health Project, spanning from 2021 to 2024, represents a pioneering collaboration between Qatar, the World Health Organization (WHO) and FIFA. This tripartite partnership aimed to ensure a healthy and safe FIFA World Cup Qatar 2022 while creating a lasting legacy for public health and social well-being. Under the banner of “Healthy FIFA World Cup 2022 – Creating a Legacy for Sport and Health,” the project achieved remarkable milestones across several key areas: health promotion, physical activity, nutrition, health security, and overall well-being. Our primary objective was to protect the health of all participants—spectators and event staff alike—while using the World Cup as a platform to advocate for healthier lifestyles through a sustainable model for future large-scale events. The report, “Changing the Game: Strengthening Health and Well-Being through Sport Events,” comprehensively documents the outcomes and impact of this ambitious project. Through efforts in communication and advocacy, initiatives to promote physical activity and better nutrition, and enhanced health security measures—including risk assessments and preparedness strategies—the project has demonstrated the powerful synergy between sport and public health. Building on insights gained during the FIFA World Cup Qatar 2022, the Seventy-seventh World Health Assembly adopted a resolution in May 2024 on “Strengthening Health and Well-Being through Sport Events.” This resolution, co-sponsored by several Member States, emphasizes evidence-based actions, cross-sector collaboration, evaluation of health impacts, and increased accessibility to sports. Its adoption marks a significant step in embedding health and well-being into the fabric of global sports events. Looking ahead, the path forward is clear: replicating the successes of this project, sharing knowledge, monitoring and evaluating outcomes, and fostering a lasting legacy. These lessons need to be translated into actionable guidance to be shared through global platforms in order to sustain the momentum and systematically integrate public health into sports. As the Sport for Health Project concludes, it leaves a lasting legacy— not just in Qatar, but as a global model for future sporting events. This collaboration between Qatar, WHO, FIFA, and other partners highlights the potential of uniting sport and health for the benefit of global well-being. Dr. Hanan Mohamed Al Kuwari Minister of Public Health Qatar Dr. Tedros Adhanom Ghebreyesus Director-General World Health Organization 4 Strengthening health and well-being through sport events Changing the game Statement from FIFA As the governing body of the world’s most popular sport, FIFA uses football’s power to improve people’s lives, and one area where football can make a tangible difference is in public health. The “Healthy FIFA World Cup Qatar 2022 - Creating Legacy for Sport and Health” initiative we launched with the World Health Organization (WHO) and the Ministry of Public Health of Qatar in 2021 proved invaluable in this respect. It enabled us to promote the importance of a healthy lifestyle among the five billion people who engaged with the FIFA World Cup Qatar 2022. In a divided world, football stands for unity, and it does so by forging alliances with important stakeholders from the political sphere. Football is a synonym of joy, happiness, passion, love and peace. It is also a synonym of unity. Football Unites the World. Supported by FIFA Legends and active players as well as WHO Goodwill Ambassadors for Sport and Health, Football Unites the World is a global movement that aims to inspire and to unite through football. In so doing, FIFA delivers various important social messages via powerful campaigns around relevant causes in partnership with global institutions, thus maximising positive impact by joining forces during FIFA events which command global audiences. The FIFA World Cup is one such global event – and the biggest one on the planet. Our initiative aimed at protecting the health of all those involved in the FIFA World Cup Qatar 2022, at using the FIFA World Cup Qatar 2022 as a platform to promote healthy lifestyles and at creating a blueprint to protect and promote health at future mass gatherings. Our actions aimed at tackling each of these points. During the tournament, our specific commitment to health was evident via the #BeActive campaign which encouraged people to get off the couch and get moving, a response to data provided by the WHO that shows some 80% of youngsters globally are not getting enough daily exercise. We also followed WHO criteria in ensuring that close to 30% of the food on offer at concessions inside FIFA World Cup stadiums in Qatar were considered healthy, and we also implemented a tobacco-free policy at all 64 matches during the final tournament in 2022. This report identifies that we took important steps with the WHO and the Ministry of Public Health of Qatar to change the game by strengthening health and well-being through sport events, as that is our collective role. In 2022, therefore, we ensured that the “Healthy FIFA World Cup initiative” was an excellent example of how we can use football’s popularity to make a positive impact on society, because we need health for football, and we need football for health. Gianni Infantino FIFA President 5i. Foreword Statement from the Supreme Committee for Delivery and Legacy Ensuring the health and safety of every participant, visitor and fan during the FIFA World Cup Qatar 2022 was a top priority for us. Ever since we began working on hosting the first edition of this tournament in the Middle East, ensuring health and safe experiences for all was front of mind – whether on construction, office, or tournament official and non-official sites. Set against the context of COVID-19, our commitment to health and safety only grew in strength, and we worked hard with local and international stakeholders including the Ministry of Public Health, FIFA and the World Health Organization to host the world in a restrictions-free public gathering for the first time since the pandemic. The approach we adopted ensured that the experience we provided for every visitor during the FIFA World Cup Qatar 2022 applied the best of international practices against the local context and standards. The result was a safe and healthy experience for all, with no major health and safety issues during the tournament. Our successes and learnings have since been refined and applied to host sporting events that Qatar has hosted since the FIFA World Cup Qatar 2022, marking an important part of the tournament’s legacy – an area that has been of utmost focus of ours since we began bidding for the tournament. We have long realized the potential of sports and related events as a tool for positive development and have utilized the FIFA World Cup Qatar 2022 to introduce innovations and initiatives that not only benefitted the tournament and its visitors, but will continue to benefit the residents of Qatar, future visitors to the country and the region as a whole. This report is another important part of this legacy. It details how Qatar and its partners delivered a healthy and safe FIFA World Cup Qatar 2022 during a global pandemic, the positive impacts of our approach locally and globally, promotion of and advocacy for health and safety, and how we utilized sport to enhance wellbeing. It also shares the successes and lessons learned during Qatar’s hosting of the tournament, which was delivered to the highest of international standards and through an innovative collaborative approach that guaranteed the health and safety of all visitors and participants. Our hope is that the report acts as a guide not only for the health and safety industry, but the sport industry as well as future hosts of sporting and non-sport mega-events, and inspires similar collaborative and innovative approaches when delivering future events of a similar size and magnitude. Hassan Al Thawadi Secretary-General 6 Strengthening health and well-being through sport events Changing the game Acknowledgements Leadership and coordination This report was prepared under the leadership of the Joint Editorial Board: Salih Al Marri (Ministry of Public Health, Qatar); Roberto Bertollini (Ministry of Public Health, Qatar); Gaudenz Silberschmidt (WHO headquarters, Switzerland); Rayana Ahmad Bou Hakka (WHO Country Representative, Qatar); Ahmed Al-Mohammed (Hamad Medical Corporation, Qatar); and Rana Hajjeh (WHO Eastern Mediterranean Region Office, Egypt). Dr. Hanan Mohamed Al Kuwari, Minister of Public Health for Qatar, provided strategic direction and input to the report. WHO thanks the Health in All Policies Unit, Ministry of Public Health, Qatar, in particular Maya Al Akkawi, Maysoon El-Hamarnah, Sara Khalife, Raghad Nazzal, Hatoun Saeb and Rayan Sheik for their coordination and technical input. WHO contributors and reviewers Many WHO colleagues contributed to the technical development and review of this report. WHO headquarters: Elena Altieri, Darryl Barrett, Maria Borodina, Fiona Bull, Luz De Regil, Kaia Engesveen, Paul David Garwood, Amaia Artazcoz Glaria, Katrina Lundberg, Lama Mattar, Giulia Oggero, Andrew Pattison, Camila Philbert Lajolo, Vinayak Mohan Prasad, Dalia Samhouri, Kerstin Schotte, Ninglan Wang, Manami Yanagawa. WHO Eastern Mediterranean Region: Mona Aly Yassin, Tara Rose Ansley , Fatima Arifi, Samar Elfeky, Peggy Hanna, Safaa Ahmed Moussa, Khalid Saeed, Mahmoud Sadek. Technical writing Mark Nunn, Highbury Editorial, the United Kingdom of Great Britain and Northern Ireland Institutional contributions Numerous technical inputs and feedback to this report were received from experts of the Ministry of Public Health, Qatar, the Supreme Committee for Delivery and Legacy; Hamad Medical Corporation and Primary Health Care Corporation. They are too numerous to be named but WHO thanks all of them for their invaluable and essential contribution. In addition, the following institutions in Qatar contributed by providing data analysis and synthesis support: WHO Collaborating Centre for Disease Epidemiology Analytics on HIV/ AIDS, Sexually Transmitted Infections, and Viral Hepatitis at Weill Cornell Medicine- Qatar; College of Health Science at Qatar University; Pathology Sciences Department at Sidra Medicine; Qatar Environment and Energy Research Institute; the Office of the CEO and WISH at Qatar Foundation; Global Health Strategies; and Doha Film Institute. WHO is grateful to the different teams on the ground who supported the implementation and monitoring of Healthy FIFA World Cup Qatar 2022. Financial contributions WHO gratefully acknowledges the financial contributions of Qatar towards the development and publishing of this report. Conflict of interest All external experts acting in their individual capacity submitted to WHO a declaration of interest disclosing potential conflicts of interest that might affect, or might reasonably be perceived to affect, their objectivity and independence in relation to the subject matter of the report. WHO reviewed each of the declarations and concluded that none could give rise to a potential or reasonably perceived conflict of interest related to the subjects covered by the report. Contribution of non- governmental institutions to the report was assessed through the WHO Framework of Engagement of Non-State Actors. 7ii. Acknowledgements Abbreviations AAR after-action review AI artificial intelligence AQHI air quality health index AR augmented reality CBRN chemical, biological, and/or or radionuclear CDC Hamad Medical Corporation Communicable Diseases Centre CEO chief executive officer COVID-19 SARS-CoV-2 virus DFI Doha Film Institute EBS event-based surveillance ECDC European Centre for Disease Prevention and Control EIOS Epidemic Intelligence from Open Sources ERG Event Review Group F4D Football for Development FCTC (2003) Framework Convention on Tobacco Control (2003) FIFA Fédération Internationale de Football Association FIM Football is Medicine GA Generation Amazing Foundation GACC Generation Amazing Community Clubs GCC Gulf Cooperation Council HED Health Emergency Department HBKU Hamad Bin Khalifa University HiAP Health in All Policies team, Ministry of Public Health HMC Hamad Medical Corporation HP health promotion IAAF International Association of Athletics Federations IBS indicator-based surveillance ICU intensive care unit IOC International Olympic Committee IPC infection prevention and control LED light-emitting diode MCC Medical Command Centre MG mass gathering(s) MG EWARS Mass Gatherings Early Warning Alert and Response System MIPR major incident preparedness and resilience MMC Medical Command Centre 8 Strengthening health and well-being through sport events Changing the game MOU memorandum of understanding NCC National Command Centre NCD(s) non-communicable disease(s) NGO nongovernmental organization NHICC National Healthcare Incident Command Centre OECD Organization for Economic Co-operation and Development PCR polymerase chain reaction PHEIC public health emergency of international concern PHEOC public health emergency operations centre PHC primary health care PHCC Primary Health Care Corporation PR public relations QFA Qatar Football Association QF Qatar Foundation QEERI Qatar Environment and Energy Research Institute QRCS Qatar Red Crescent Society QU Qatar University RAT rapid antigen test RCCE risk communication and community engagement SARAH Smart AI Resource Assistant for Health S4H Sport for Health SAT situational assessment tool SAVES Surveillance and Vaccine Electronic System SCHC Supreme Committee for Healthcare Communication SC Supreme Committee for Delivery and Legacy TCG tactical command group UN United Nations UNESCO United Nations Educational, Scientific and Cultural Organization WCM-Q Weill Cornell Medicine-Qatar WHO World Health Organization WISH World Innovation Summit for Health 9iii. Abbreviations Executive summary Sport for Health Sport for Health (S4H) is a new model of collaboration between countries, international public health organizations and sports governing bodies. It was designed to use huge international sporting events like the Olympic Games and the FIFA World Cup Qatar 2022, sometimes known as “mega sports events,” as levers to exploit sport’s huge potential to improve long-term public health. The first S4H project was established by Qatar and the World Health Organization (WHO), in collaboration with FIFA, in October 2021. Its full title is Healthy FIFA World Cup Qatar 2022 – Creating a Legacy for Sport and Health, and it was put in place to build a public health legacy for the FIFA World Cup Qatar 2022 more ambitious than any seen before. This meant protecting health during the tournament, so that visitors, players, staff and residents could have a safe and enjoyable time. But it also meant advocating to improve health beyond sport, making the most of the World Cup by associating it with a range of programmes promoting physical activity, healthy nutrition, and healthy lifestyle choices. Both the challenges and the opportunities were immense. While the FIFA World Cup Qatar 2022 was the first sports event of equivalent scale to be held in the Middle East, this was not its only unique feature. It was also the first World Cup held in the northern hemisphere winter – peak season for respiratory disease transmission; the first World Cup held during a global pandemic (SARS-CoV-2 (COVID-19) pandemic); the first World Cup for which the entire tournament would take place in an area the size of a single city; and the first World Cup for which the influx of visitors during the tournament reached a sizeable proportion of the national population. In one month, Qatar welcomed visitors numbering more than half the total national population, with a proportional rise in demand for services of all kinds. The other main purpose of S4H was to serve as a learning experience, incorporating reflection to show that the S4H model can and should be refined and replicated in future. For this to be true, the S4H partnership would have to have real impact and create positive change, not just for the World Cup, but also in the form of lasting improvements for individuals and communities in Qatar and around the world. This report is one outcome of that reflection and learning process, and offers up the first S4H project as a model to be improved and implemented for the long term. It briefly describes the activities undertaken in Qatar through the S4H project, outlining the main achievements, issues and challenges, examining the results and the legacy, and sharing lessons and considerations for the benefit of others. It looks frankly at the project, attempting to identify things that did not work as well as 10 Strengthening health and well-being through sport events Changing the game those that did, assessing the reasons, and sharing the findings in the hope that they will help future efforts meet and overcome their own challenges. It is hoped that the report will be useful for a broad audience that includes organizers of sport events, at any level; government institutions and public health providers in host countries; civil society actors; sports federations; and others. Its lessons come from the experience of organizing a large sporting event – arguably the world’s largest – but many are applicable outside that context, relevant to preparation for any mass gathering, or to other attempts to harness sport’s power to improve health. This report is not a technical review or a guide for planners, but where relevant resources exist, it highlights them to interested readers. © Ministry of Public Health Child playing football as part of a Generation Amazing Foundation activation at the Steering Committee meeting of the Sport for Health partnership 11iv. Executive summary Protecting and providing health Throughout the FIFA World Cup Qatar 2022 period, the overall national health situation was monitored using a daily situation report, or SitRep, that was distributed to public health leaders at a set time each day. Designed to facilitate fast, evidence-based decision making, the SitRep had to cover all health information vital for decision making in a single page, and the processes needed to produce it every day required a degree of innovation. This included the establishment of an Event Review Group (ERG) of public health experts from different disciplines, who were responsible for translating science and data into options for policy- and decision- makers. The report also included global health insights scanned using open-source artificial intelligence. Thankfully, there were no outbreaks during the FIFA World Cup Qatar 2022 period. While COVID-19 cases in Qatar did increase, as expected, there was no significant increase in COVID-19-related admissions to hospital. One of the key goals of S4H was to be able to deliver care to fans, players and other World Cup-related visitors without disrupting day-to-day health services for Qatar residents. To achieve this, a parallel healthcare system was set up, comprising 113 onsite clinics, 116 ambulance vehicles and 212 mobile patrol paramedics. These services saw a total of 44 029 medical encounters during the FIFA World Cup Qatar 2022 period. Of these, 8 709 were cases picked up by mobile teams, which included paramedics patrolling on foot and on buggies, bikes, or scooters to attend to medical needs in stadiums and fan zones. There were 24 504 encounters at onsite medical clinics and 8 483 encounters at hospital emergency departments, the majority of which were visitors to the country. The most common complaint was due to respiratory illness, which accounted for 30.9% of medical encounters. The next most common complaints were minor illnesses (27.3%) and minor trauma (8.99%). During the tournament, there were 359 ambulance transfers from tournament sites to health care facilities. Alcohol intoxication made up only 0.4% of all medical encounters – a figure that was very low compared to previous sporting mass-gathering events, for which cases of alcohol intoxication have ranged between 1% and 10% of all medical encounters. 12 Strengthening health and well-being through sport events Changing the game Promoting and advocating health This last figure may have been in part due to the alcohol-free stadiums policy, implemented during the tournament as part of a wider drive to use the FIFA World Cup Qatar 2022 as a lever to promote overall health and wellbeing across four focus areas: nutrition, physical activity, mental health and tobacco. The Health Promotion pillar of the S4H partnership fought to counter the fact that sports mega-events traditionally create public health challenges as well as opportunities to improve it. These include marketing of unhealthy foods, substances and practices which are deeply ingrained into the sponsorship and revenue generation streams of these events as well as prominent sponsorships promoting sugary drinks, fast food, processed snacks and alcohol. This sends mixed messages that undermine public health, and which need to be countered. Nutrition Shifting the focus towards healthier nutrition is not just an option for event hosts, but a necessity. Offering accessible, appealing healthy options alongside traditional fare at mega sport events empowers people to make informed choices. Countering the marketing power of unhealthy sponsors has to be a strategic objective for those working to protect and promote health. Prioritizing health-positive messaging also aligns with the core values of sport – well- being and high performance. To promote healthy nutrition during the FIFA World Cup Qatar 2022, healthier food options were available in stadiums and fan zones, with healthier food options comprising 30% of the food menu at stadiums and 20% at FIFA Fan Festival sites. Behavioural insights were applied to provide options in a manner that promoted healthier food choices. Initial analysis also points to an increase in sales of the healthier food options. Physical activity Promoting healthy habits and lifestyles is often stated as a goal of mega sports events, but the real-life outcomes can be complex, and depend on a range of different factors including socioeconomic context, cultural norms, and access to resources. In Qatar, a range of different opportunities was available for individuals of all ages and abilities to engage in fun, positive physical activities throughout the tournament. These activities were accessible to the general public and happened across different settings and media, including through digital tools, visual content and in face-to-face “come and try” sessions. The Fan Zone activations and initiatives were designed and scheduled to make the most of periods between matches, when captive audiences were gathered in enclosed areas but their attention was not taken up by the football games. Stadium designs and services had the desired effect of increasing stair use and making people move around the venues to get their food. In addition, the public realm was enhanced with 32 specially designed benches, as many as the teams participating in the tournament, including messages to promote physical activity and mental health. 13iv. Executive summary The new metro network offered 37 metro stations connected to seven out of the eight FIFA World Cup Qatar 2022 stadiums, and 50%-70 % of transport to stadiums during the tournament was by metro – impressive figures in a country previously dominated by private transport. A total of 17 453 457 metro rides were taken during the FIFA World Cup Qatar 2022. The Walk the Talk Doha event, just before the start of the World Cup, attracted thousands of participants and created 226 million potential impressions that emphasized the importance of physical activity. Overall, the Be Active physical activity campaign reached a worldwide audience of 1.5 billion people (according to FIFA estimates). Mental health Around half of all mental health conditions start by age 14, and depression affects more than 260 million people. The S4H partnership wanted to use the platform of the FIFA World Cup Qatar 2022 to raise awareness about mental health , dispel the stigma often associated with mental health conditions and encourage people with mental health problems to seek help. Some of the goals and activities of the mental health part of S4H’s health promotion pillar overlapped with those of the physical activity pillar (as was the case with the Benches project mentioned above), and the benefits of sport and physical activity on mental health are well documented. But S4H also understood the need for targeted efforts to increase understanding of mental health conditions, reduce stigma, scale up services to treat mental health conditions, and increase equitable access to high quality, affordable care. Starting in 2021, WHO worked with FIFA on the #REACHOUT initiative to increase awareness of mental health issues, reduce stigma, encourage seeking help, and encourage actions every day for better mental health. Past and current football players supported the campaign, helping people understand the importance of looking after their – and others’ – mental health. In Qatar, public attitudes to mental health were targeted with large-scale public awareness initiatives like the national “Are You OK?” campaign, launched in 2020, which encouraged people to talk openly about their emotional wellbeing, and which has resulted in greater numbers of people seeking help from mental health services. Knowing that stigma is a key factor in preventing many people in Qatar from seeking mental health services, Qatar has established a National Mental Health Helpline. This has been described as one of the most impactful developments in recent years within the Mental Health Service. 14 Strengthening health and well-being through sport events Changing the game Tobacco The FIFA World Cup Qatar 2022 was an important opportunity to implement some of the tobacco control policies, in line with the WHO Framework Convention on Tobacco Control, on sponsorship, promotion and advertising of tobacco and related products (34). The FIFA Event Policy on Tobacco aimed to ensure 100 % smoke-free event , throughout the World Cup, and to prevent any tobacco or e-cigarette advertising, endorsement and/or sponsorship at any event site. The policy was supported by a dedicated team of 80 inspectors who monitored and enforced the smoke-free policy in stadiums and other event sites that are 100% smoke free. Violation rates ranged between 3.8 to 12.1 per 1 000 fans, with the highest violation rates recorded at Education City Stadium. Accessibility To support and enhance accessibility for all and inclusivity for persons with disabilities during and beyond the World Cup, the Supreme Committee established an Accessibility Forum in 2016. Made up of a diverse group of members with disabilities including those with underlying limitations in mobility, vision, hearing cognitive functions, as well as people with psychosocial disability. Along with representatives of over 30 organizations that they are part of, the Forum set out to ensure a seamless FIFA World Cup Qatar 2022 fan experience for persons with disabilities. In the lead up to the Tournament, the Forum hosted a range of workshops exploring how persons with disabilities could participate in the organization of the tournament, and what needed to be done to ensure an optimal experience for fans with disabilities. Representatives of the Forum visited stadiums to test and feedback on accessibility features. Based on their input, a series of accessibility modifications – mostly focussed on infrastructure and transportation – were made for the tournament and for the longer-term public realm in Qatar. The Qatar Foundation also created a national accessibility guide, trained volunteers to support fans, and helped set up sensory rooms in stadiums and other locations such as the FIFA Fan Festival, the Corniche Activation and Education City Last Mile. Since the tournament, the Qatar Foundation has continued supporting sports and leisure opportunities for persons with disabilities across Qatar, while improving national awareness of accessibility issues. 15iv. Executive summary Conclusion The S4H project broke ground in many areas. It challenged expectations around what is possible for health promotion at major sports events; it challenged sensitive areas like alcohol consumption; it introduced new services to Qatar and expanded and improved existing systems; it capitalized on major World Cup-inspired infrastructural improvements like the country’s first ever subway system; and it moved the needle for national and regional public health in many other areas. It also highlighted the challenges inherent in such an ambitious project, and cast a spotlight on areas where data gathering, monitoring, analysis and evaluation could have been better – and what needs to be done in the future. In the hope this test case is helpful for other countries planning large sporting events and wanting achieve the greatest possible health and social benefit, and on the basis of the experiences outlined in this report, in May 2024 Qatar, together with Belarus, China, Egypt, the European Union and its 27 Member States, Iraq, Japan, Saudi Arabia, Malaysia, Mexico, Morocco, Oman, Serbia, Sri Lanka, Thailand, Türkiye, United Arab Emirates, and Yemen, submitted a resolution to the Seventy-seventh World Health Assembly on strengthening health and well-being through sport events. The resolution, which was approved by consensus by all WHO Member States, strengthens the foundations of the Sport for Health model. It urges WHO Member States to use sport as a lever for a range of actions addressing public health and social challenges including non-communicable disease, preparedness for health emergencies, violence and injury, mental health, and social inclusion. The full text of the resolution is available at this link: https://apps.who. int/gb/ebwha/pdf_files/ WHA77/A77_R12-en.pdf We truly hope that the experience of the FIFA World Cup Qatar 2022 can be seen as an extended learning experience showing that the S4H model should be replicated elsewhere. Sport already offers so many opportunities to promote respect for human rights and bridge cultures in service of dialogue, mutual understanding, fairness, non-discrimination, respect, inclusion and equal opportunity. Now, we hope, it can also offer platforms for public health interventions and improvements around the world. More information on the WHO S4H programme can be found at https://www. who.int/initiatives/sports- and-health 16 Strengthening health and well-being through sport events Changing the game 17iv. Executive summary © Supreme Committee for Delivery and Legacy Lusail stadium lit up for the FIFA World Cup Qatar 2022 closing ceremony. 18 Strengthening health and well-being through sport events Changing the game Introduction: the Healthy FIFA World Cup Qatar 2022 – Creating a legacy for Sport for Health 1 OECD definition of Global Events and definition of Legacy of Global Events (2018) modified Huge international sporting events like the Olympic Games and the FIFA World Cup Qatar 2022, sometimes known as “mega sports events,” are uniquely high-profile gatherings that offer opportunities to make positive long-term changes to the people, communities and economies of host countries. Those opportunities have to be seized with intent. To make the most of them, host countries must clarify their ambitions for the legacy of their event and plan for it well in advance. The activities that will bring that legacy to life must also be carefully planned and implemented, with ongoing monitoring and evaluation from the very first stages of project design. This report discusses legacy as defined as “the planned and unplanned outcomes of hosting a sport event,” in accordance with referencing terminology used by the Organization for Economic Cooperation and Development (OECD)1. This report outlines the work of the Sport for Health Project, or S4H. Sport for Health is a new type of partnership model, established by Qatar – through the Ministry of Public Health and Supreme Committee for Delivery and Legacy (SC) – and WHO, in collaboration with FIFA, in October 2021. Through S4H countries, international organizations and sports governing bodies work together to make the most of sport’s potential to improve public health. Specifically, the model advocates for establishing a partnership between the hosting country government(s); public health organizations like WHO, sport organizations and federations; and local organizing committees. Multisectoral collaboration across the sport and health sectors around sport events means that knowledge, expertise, reach, resources and partners benefit from combining their strengths and can work toward a shared goal of health for all. Its full title is the Healthy FIFA World Cup Qatar 2022 – Creating a Legacy for Sport and Health, and it was designed to create a public health legacy from the FIFA World Cup Qatar 2022 more ambitious than any seen before. This meant protecting health during the 191. Introduction: the Healthy FIFA World Cup Qatar 2022 – Creating a legacy for Sport for Health tournament, so that visitors, players, staff and citizens could have a safe and enjoyable time. But it also meant advocating to improve health beyond sport, making the most of the FIFA World Cup Qatar 2022 by associating it with a range of programmes promoting physical activity, healthy nutrition, and healthier lifestyle choices. The partnership was developed throughout the COVID-19 pandemic and has continued its work since the World Cup came to an end in December 2022. It has been an incredible journey, and a unique opportunity to adopt a health in all policies approach to the World Cup. This report offers up the first S4H project as an example of a model to improve and replicate in future. It shows how the Qatar project set out to create positive change not just for the World Cup, but also in the form of lasting improvements for individuals and communities in Qatar and around the world. It looks frankly at the project, also identifying the things that did not work, and sharing them in the hope that future efforts can meet and overcome these challenges. This report summarizes the activities, the challenges, the results and the legacy of this project and shares lessons and considerations for the benefit of others, including organizers of sport events, at any level; government institutions and public health providers in host countries; civil society actors; sports federations; the private sector; and others. On the basis of these experiences, in May 2024 Qatar and other Member States2 submitted resolution WHA77.12 to the Seventy-seventh World Health Assembly on strengthening health and well-being through sport events. The resolution strengthens the foundations of the Sport for Health model, urging WHO Member States to use sport to take a range of actions that address public health and social challenges including non- communicable disease, preparedness for health emergencies, violence and injury, mental health, and social inclusion (1). We hope that the experience of the FIFA World Cup Qatar 2022 can be seen as a learning experience that argues for the replication of the S4H model elsewhere. Sport already offers so many opportunities to promote respect for human rights and bridge cultures in service of dialogue, mutual understanding, fairness, non-discrimination, respect, inclusion and equal opportunity. Now, we hope, it can also offer platforms for public health interventions and improvements around the world. 2 The resolution was proposed by Qatar, Belarus, China, Egypt, European Union and its 27 Member States, Iraq, Japan, Saudi Arabia, Malaysia, Mexico, Morocco, Oman, Serbia, Sri Lanka, Thailand, Türkiye, United Arab Emirates, and Yemen. 20 Strengthening health and well-being through sport events Changing the game “ The FIFA World Cup Qatar 2022 was a unique event in the history of FIFA World Cups for many reasons [...]. I am proud of the achievements of the Sport for Health partnership and its positive impact [...]. This unique partnership was a major factor in helping Qatar deliver the healthiest and safest FIFA World Cup in history. I extend my thanks to all staff and to the leaders of WHO, FIFA and the SC for their commitment today to working together to ensure we pass on the lessons learned from this experience to organizers of future mega sporting events.” “ …the Sport for Health partnership has not only been a key pillar in delivering the healthiest World Cup ever, but also in ensuring that best practices were developed and shared for future mega- events. We look forward to sharing that knowledge, contributing to the success of future events around the world, and adding to the profound legacy that our World Cup leaves behind.” Minister of Public Health Dr. Hanan Mohamed Al Kuwari, speaking in Geneva, Switzerland, February 2023 © Supreme Committee for Delivery and Legacy The World Cup golden trophy featured at the start of every game of the FIFA World Cup Qatar 2022.  211. Introduction: the Healthy FIFA World Cup Qatar 2022 – Creating a legacy for Sport for Health Methodology: how this report was developed The preparation of this Sport for Health (S4H) report was a collaborative work based on data and insights from Qatar, WHO and other stakeholders. The project was overseen by a Joint Editorial Board of senior representatives from WHO and the Qatar Ministry of Public Health. This board was responsible for reviewing the outline and structure of the report, determining and ensuring its purpose and objectives, providing high level feedback throughout the writing and review stages and reviewing the draft before publication. Content was provided by a diverse Technical Group of experts, whose task was to address the pillars of the Sport for Health WHO-Qatar project (health security, health promotion and health communication) and ensure project coordination and governance. Members of this group were responsible for providing data and information, conducting detailed analysis and research in their respective domains to ensure the evidence base for the report, providing the source content, supporting the editorial process, and supporting the implementation of the Editorial Board’s comments. The report writer was supported day to day by a Coordination Group comprising the WHO S4H Project Coordination team and the S4H Team of the Health in all Policies (HiAP) Unit of the Qatar Ministry of Public Health. This group’s task was to support and coordinate the writing process, collaborate with other groups to ensure communication and task management, and manage the project. The content of the report was based on data and reflections collected from the following sources: • published and unpublished reports from Qatar ministries, technical teams and other public sector bodies; • published and unpublished reports from WHO; • published and unpublished reports from FIFA; • published and unpublished reports from the SC; • published and unpublished reports from other partners and multilateral bodies such as the World Innovation Summit for Health and the Organization for Economic Co- operation and Development; • a series of interviews and meetings that took place between the report writer, the HiAP team and over 40 health professionals responsible for the activities described in this report; • a series of workshops held in the Ministry of Public Health in early 2024 to look back at the S4H experience and – with the benefit of some hindsight - examine the main challenges, discuss what could have been done better, examine the public health impact of S4H interventions to date, and suggest recommendations for consideration by the organizers of future events. Participants in interviews and workshops were aware of, and verbally consented to, the fact that their input was being collected to feed into this report. While every effort was made to ensure that this report is underpinned by publicly available data, some of the content is based on insight into health professionals’ personal experiences and the lessons they identified 22 Strengthening health and well-being through sport events Changing the game through preparing for and running the Sport for Health project alongside a major sports event. To account for this, a portion of the background research was done through interviews and workshops, generating further evidence that is anecdotal in nature and which reflects the experience, perspectives and feelings of those who worked to deliver a safe, Healthy FIFA World Cup Qatar 2022. The Coordination Group has also produced an extended executive summary document and supporting animated video. These were published, in May 2024, to support Qatar’s submission of a resolution on strengthening health and well-being through sport events. This resolution was subsequently adopted by the Seventy-seventh World Health Assembly. The draft full report was reviewed again by the Technical Group and the Joint Editorial Board. Comments were incorporated by the report writer before final review by the Joint Editorial Board and submission to WHO and Ministry of Public Health clearance processes for publication. This report has been published in Arabic and English. Report outline Outline review Data collection Write up of 1st draft 1st review 2nd review Pre-final draft submitted for approval Final version of report Writer & coordination group Joint editorial board Meetings conducted with relevant stakeholders Writer & coordination group Technical group Joint editorial board Joint editorial board Joint WHO - Qatar publication Development process A description of the development process of this report. 232. Methodology: how this report was developed The Sport for Health vision: using sports events to improve public health Mega sport events require huge investments of money and time. They demand the effort and time of thousands of people across dozens of sectors in host countries and the international community, who work hard to plan, build infrastructure, host athletes and spectators, and ensure people’s safety. These events, and particularly high-profile mega sport events like the FIFA World Cup, also reach the eyes and minds of huge populations of supporters and viewers of all ages, at all levels of societies all around the world. According to FIFA, 5 billion people were engaged with the FIFA World Cup Qatar 2022 and the final alone was seen by 1.5 billion people (2). The social and health legacies from such an event include diverse impacts on the social determinants of health, both positive and negative. These events can create job opportunities, provide reasons to develop infrastructure, enhance access to health care and improve living standards; but unequal distribution of opportunities and poorly planned development projects may also exacerbate social disparities. The environmental consequences of major events – air pollution, for example – can indirectly affect health outcomes by aggravating environmental health risks. Health promotion initiatives during mega sport events can encourage healthy behaviours, improving health literacy and community engagement; but the extent of inclusion depends on factors like accessibility, representation and social cohesion. Sponsorship and advertising around mega sports events can also encourage the intake of unhealthy food and beverages and promote alcohol consumption. Mass gatherings of all kinds can also increase the risks posed by communicable diseases and, by virtue of temporary increases in population, raise the overall levels of need for health assistance for a range of different complaints. The FIFA World Cup Qatar 2022 brought thousands and thousands of people to Qatar, including huge crowds of spectators, fans, athletes, teams, journalists, marketers and others. During the tournament period, which comprised 64 matches from 20 November to 18 December 2022, Qatar hosted 1.4 million visitors (3) from 177 nations. Concern about communicable disease was particularly relevant for the FIFA World Cup Qatar 2022 because the COVID-19 pandemic was still not under control at the time of the tournament. The long-term legacy of mega sports events hinges on balancing these impacts, ensuring that development is sustainable, and addressing inequalities in a way that promotes lasting improvements in the social determinants of health. Achieving these benefits requires adopting a “health in all policies” approach that integrates health considerations into decision-making processes across sectors, and requires collaboration and accountability for promoting population health long beyond the event itself. 24 Strengthening health and well-being through sport events Changing the game Through the preparations for the event, the tournament itself and the period that followed, the S4H project worked through partnerships and advocacy focussed on three main areas: The fourth element of this project is the contribution to a wider legacy, helping build the ability and willingness to use future mega sports events to improve health and well-being in the years to come. While the S4H partners created a unique model at the FIFA World Cup Qatar 2022, it should not remain an isolated example. The Sports for Health model aimed to establish the FIFA World Cup Qatar 2022 as a reference, with clear, measurable actions and solutions that can be replicated by others in the future, and to set an example of how to use mega events as levers to promote, protect, and advocate for health. Every such future event is a potential opportunity to advance the public health agenda, allocating resources and time that might not otherwise be available to public health initiatives, and institutionalizing such initiatives to strengthen health systems in the long term. As part of this effort, this report: • provides an overview of the work undertaken by Qatar Ministry of Public Health and WHO, in collaboration with FIFA and the SC, to ensure a healthy and safe FIFA World Cup Qatar 2022; • outlines the impacts and achievements on people’s health; • outlines longer-lasting legacies; • explores some of the challenges and obstacles, and suggests issues that others might expect to meet when planning similar events; • suggests important considerations for planners of future events; • references other resources and dedicated technical reports, where these exist, for those who want in-depth analysis of the work done in specific areas or technical guidance for planning future events. 1. health security: Putting safety and security at the centre of the FIFA World Cup Qatar 2022, while making sure day-to-day health services for the people of Qatar were unaffected; 2. health promotion: Using the FIFA World Cup Qatar 2022 to promote ways for people to lead healthy lives, including through physical activity, healthy diets and tobacco control; 3. health communication: Public information campaigns and messages before and during the event to help people stay healthy and safe, and to make longer term improvements to their habits and health. 253. The Sport for Health vision: using sports events to improve public health Background Noncommunicable diseases (NCDs) account for 63% of all global deaths and 1.77 billion Disability-Adjusted Life Years (DALYs), and their prevalence is rising (4, 5). A substantial proportion of these NCDs can be prevented with very simple actions: increasing physical activity, promoting healthy nutrition, reducing alcohol intake and smoking, and limiting exposure to environmental risks. Several international decisions and resolutions have tried to address these determinants of health. Some of these are listed in Box 1. But it is obvious that more needs to be done to exploit the great potential of simple actions that prevent NCDs. For example: around the world one in three women and one in four men do not do enough physical activity to stay healthy, and there has been no improvement in global levels of physical activity since 2001. In fact, between 2001 and 2016 high income countries saw a 5% increase in the proportion of people who are not active enough, from 31.6% to 36.8% (6). Box 1: Examples of international efforts to address the determinants of health • Sustainable Development Goal 3.4 (reduce premature mortality from NCDs through prevention and treatment and promote mental health and well-being by one-third by 2030) • WHO Global alcohol action plan 2022- 2030 • WHO Global action plan for the prevention and control of non- communicable diseases • WHO Global action plan on physical activity 2018–2030 • WHO Framework Convention on Tobacco Control (FCTC) (2003) • Resolution of the Seventy-seventh World Health Assembly on climate and health (2024) The cost to society of these NCDs is high and set to increase. A 2023 World Bank Report calculates the direct medical costs of just the seven major NCDs to have been around international $16.7 billion in 2019 alone in the six countries in the Gulf Cooperation Council (GCC). The indirect costs, stemming from losses in worker productivity, were a further international $80 billion in the same period (7). Meaningful implementation of the existing international commitments to combat these NCDs will require broader, more intentional work than is presently being done. It calls for whole-of-society approaches that take every possible opportunity, and use every possible regulatory tool or promotional and advocacy mechanism, to make healthy choices easier, more acceptable and more desirable for people. It requires countries to create healthier environments for their citizens to live in. In the FIFA World Cup Qatar 2022, WHO and Qatar identified an opportunity to address these needs through the Sport for Health model. 26 Strengthening health and well-being through sport events Changing the game Context Hosting large sporting events was not a new experience in Qatar. The FIFA World Cup Qatar 2022 was the first sports event of equivalent scale to be held in the Middle East, but as far back as 2006 Doha had hosted the 15th Asian Games, and since then over 20 major sports events have been held successfully in Qatar. Recent larger events included the FIFA Club World Cup Qatar 2019, the World Athletics Championships Qatar 2019 and the FIFA Arab Cup 2021, the last of which was in many ways a pilot exercise for the FIFA World Cup Qatar 2022 (see below). BOX 2: Special considerations for the FIFA World Cup Qatar 2022 • First World Cup held in the northern hemisphere winter - peak season for respiratory disease transmission • First World Cup held during a global pandemic (COVID-19) • First World Cup held in an area the size of a single city • All tournament-related venues were in close proximity, concentrating visitors in a far smaller area than in previous World Cups • The number of visitors in one month was half the total national population © Supreme Committee for Delivery and Legacy FIFA World Cup Qatar 2022 kicks off with hosts Qatar against Ecuador. 274. Background; 4.1 Context Delivering the FIFA World Cup Qatar 2022 during a global pandemic The tournament took place during the COVID-19 pandemic, which disrupted economies and societies around the world, saw severe travel restrictions put in place worldwide, and tested many countries’ health systems and capabilities to their very limits (the Tokyo Olympic Games, held the previous year in 2021, had to take place without spectators). It was also held during the northern hemisphere winter, peak time for transmission of respiratory infections. At first sight, hosting a large and high- profile event at such a vulnerable time was a severe and unexpected challenge: it required extensive preparation and substantial pooling of resources across Qatar’s health system, and meant that all the planning took place in an atmosphere of uncertainty: would people be able to travel? Would an outbreak before or during the tournament require drastic changes to plans? In the worst-case scenario, would the tournament happen at all? Seeking answers to these questions, a predictive modelling exercise was done to visualize possible COVID-19 pressures and responses, particularly around different scenarios for increases in COVID-19 incident cases and what these might mean for hospital admissions. To run this exercise the Ministry of Public Health collaborated with a team of epidemiologists and biostatisticians at the Biomedical Research Programme at Weill Cornell Medicine in Qatar. The models were based on a few main assumptions: that 85% of people in Qatar had been vaccinated against COVID-19; that 75% of the population had had a previous infection; and that there would be 2 million visitors during the World Cup, 50% of whom would have been previously infected. The models suggested that with this many visitors, and if certain control measures were maintained, there would be a moderate increase in incidence of cases, with a substantially larger increase if control measures were lifted. An increase in social contact can amplify the effects of infections, greatly increasing incidence – with possible severe effects on demand for health services. To allow a swift response if needed, contingency plans were made to meet any sudden increases in demand for hospital beds. This finding increased the importance of ensuring that strong monitoring activities and assessment protocols were in place before the tournament (these are described in the surveillance section of this report), underpinned by strong governance and accountability structures. 28 Strengthening health and well-being through sport events Changing the game Creating a more positive legacy from the pandemic From another perspective, however, the coming together of the FIFA World Cup Qatar 2022 and the COVID-19 pandemic was an objective lesson in how the legacies of preparedness and response measures for one public health threat can be leveraged to meet other threats. For example: the COVID-19 pandemic triggered enhancements to Qatar’s public health capacity, as it did in many countries. These enhancements meant Qatar was in a better place to prepare for rapid increases in population density and heightened risks of infectious disease - and respiratory disease in particular - during the FIFA Arab Cup and World Cup. These were used to full effect and with great success. But many of these enhancements were expensive and difficult, and probably would not have happened without the pandemic. In another example, Qatar had to develop a clear, effective health response command and control structure to cope with the pressures of the pandemic. Not only that, but because the pandemic was a real event, it had also been thoroughly tested and refined under genuine pressure, leaving all key players accustomed to their roles. When the FIFA World Cup Qatar 2022 brought another period of intense pressure on the health system, Qatar could impose a World Cup command and control structure almost identical to that used for the COVID-19 response. In the interviews that informed this report, it was frequently stated that different aspects of the health system preparedness, structures, activities and responses functioned well during the FIFA World Cup Qatar 2022 because they had been tested and trained for under the pressure of the pandemic. 1 A U G 2 2 3.5 1.5 2.5 0.5 3 1 2 0 N um be r o f ne w in fe ct io ns p er d ay x 10 4 1 O C T 22 1 D EC 2 2 1 SE P 22 1 N O V 22 1 JA N 2 3 No World Cup visitors With World Cup visitors but no change in contact rate With World Cup visitors and with change in contact rate Figure 1: A predictive model showing number of new incident cases of COVID-19 per day for three different scenarios. 1 August 2022- 31 January 2023 Source: Weil Cornell Medicine-Qatar, 2022 294.1.1 Delivering the FIFA World Cup Qatar 2022 during a global pandemic FIFA Arab Cup: an event to prepare for the big one The 2021 FIFA Arab Cup took place in Qatar between 30 November and 18 December 2021, the year before the FIFA World Cup Qatar 2022 and just over a month after Qatar, FIFA, and WHO signed the S4H collaboration agreement. That agreement saw the Arab Cup and the FIFA World Cup Qatar 2022 as integral parts of the same opportunity, with the Arab Cup – a smaller-scale tournament – as an invaluable opportunity to pilot, strengthen and refine the health plans for the FIFA World Cup Qatar 2022. To make the most of the learning experience, after the conclusion of the Arab Cup the S4H partners carried out an after-action review, sometimes referred to as an “AAR.” This AAR had four main objectives: 1. map existing contingency plans, systems, standards, and procedures that help manage the health risks of large-scale events; 2. identify the gaps and challenges encountered during the Arab Cup; 3. identify the lessons and best practices emerging from the Arab Cup; 4. offer recommendations to strengthen systems, standards, and procedures for managing health risks associated with large-scale events, with particular focus on the World Cup. The review took place on 24 March 2022, focussing on three main areas: (1) preparedness and response for major incidents; (2) health sector operations; and (3) surveillance, risk communication and community engagement (RCCE) and food safety. In each area, the review assessed the systems and capacities in place before the Arab Cup; what happened during the event; and what went well or less well, and why. This process produced a range of recommendations that included the following: • improve coordination, communication and information sharing within and across different sectors by: • strengthening existing coordination mechanisms; • holding regular meetings across sectors; • clarifying roles; and • developing and sharing a multisectoral communication plan. • develop memoranda of understanding (MOUs) with the private health sector – including hospitals and health care providers – before the World Cup; • involve all relevant authorities and bodies in decision making, planning, and implementation as early as possible; • develop and review comprehensive plans and procedures, then test them with an equally comprehensive training and exercise programme. Specific areas were identified for strengthening through training; • increase resources based on detailed needs assessments; • establish feedback mechanisms to gather information from the field and address any issues that arise from that information; • establish mechanisms to strengthen compliance with public health and social measures and other established public health protocols.What happened next 30 Strengthening health and well-being through sport events Changing the game What happened next To follow up the recommendations, the review participants created, and began to implement, a high level plan to act on the review’s findings, embed them in the relevant plans and procedures, and validate and monitor them. The AAR report was presented to high level decision makers and disseminated to a wide range of stakeholders in the planning and execution of the World Cup. A wide range of stakeholders took action to address the AAR findings according to a shared follow-up plan, and worked together on the simulation exercises that were going to be held to ensure readiness for the World Cup. The review was also used to strengthen policies, guidelines and standard operating procedures (SOPs), and to guide the use of funds from the government, donors, and partners. Regular meetings were held to review the implementation of the AAR’s recommendations and maintain accountability for doing it. 314.1.2 FIFA Arab Cup: an event to prepare for the big one How Qatar’s health system works Qatar’s health care system is structured to provide comprehensive and high-quality care through a well-integrated network of public and private institutions. The Ministry of Public Health regulates and oversees the entire system, ensuring standards are met and public health is prioritized. Hamad Medical Corporation (HMC), with its 14 hospitals, makes up the backbone of specialized and acute (secondary and tertiary) care, while the Primary Health Care Corporation (PHCC) now operates 31 health centres and focuses on primary and preventive care. Semi-governmental facilities like Sidra Medicine and various private sector hospitals provide additional specialized services, enhancing patient care options. The Qatar Red Crescent Society also plays a crucial role in extending health care services to vulnerable and low-income populations, ensuring broad access to medical care across the country. Figure 2 Qatar health care system facilities in 2024 Qatar Healthcare System 14 HMC Hospitals (2952 Beds) 1. Hamad General Hospital 2. Aisha Bint Hamad al Attiyah Hospital 3. Women’s Wellness & Research center 4. Al Wakra Hospital 5. Rumaila Hospital 6. National Center for Cancer Care & Research 7. Heart Hospital-Doha 8. The Cuban Hospital 9. Al Khor Hospital 10. Communicable Disease Centre 11. Mental health Service 12. Qatar Rehabilitation Institute 13. Ambulatory Care Center 14. Hazm Mbeireek General Hospital Overall Surge Capacity 4000 available within 24 hrs 31 PHCC 1. Northern region (10) 2. Central region (10) 3. Western region (11) 8 Private Hospitals (468 Beds) Private ClinicsSidra Medicine Aspetar Sports Medicine Governmental Sector Semi-Governmental Sector Private Sector Qatar Red Cresent society 32 Strengthening health and well-being through sport events Changing the game 1. Ministry of Public Health • role: the Ministry is responsible for the overall governance, regulation, and strategic direction of Qatar’s health care system; • functions: • regulation: enforces health care standards and regulations; • public health: manages national health programmes, disease prevention, and health promotion; • licensing: oversees licensing and accreditation of health care professionals and facilities; • policy development: develops and implements national health policies and strategies. 2. Hamad Medical Corporation/HMC • role: HMC is Qatar’s main public health care provider, offering specialized and acute care services across the country; • facilities and services: • hospitals: HMC manages a total of 14 hospitals; • specialized care: this includes services in cardiology, neurology, oncology, and more; • emergency services: provides emergency and trauma care and ambulance services; • research and education: engages in clinical research and medical education. 3. Primary Health Care Corporation/PHCC • role: PHCC is responsible for providing primary health care services and promoting preventive care in communities across Qatar. 4. Semi-private facilities: Sidra Medicine • role: women’s and children’s health. 5. Private sector facilities and hospitals • role: the private health care sector in Qatar complements public services with a range of medical care options through hospitals and clinics. 6. Qatar Red Crescent Society (QRCS) • role: QRCS offers humanitarian and health care services, primarily to underserved populations such as migrant workers. 334.1.3 How Qatar’s health system works © Ministry of Public Health Qatar Minister of Public Health, World Health Organization Director-General, FIFA President, Secretary General of the Supreme Committee for Delivery and Legacy and WHO Goodwill Ambassador Didier Drogba at the project Steering Committee meeting in April 2022. Qatar Minister of Public Health signs a Sport for Health banner at the Steering Committee in April 2022.  Qatar Minister of Public Health and WHO Director General at the Steering Committee in April 2022 Partnering for Sport for Health “Qatar and FIFA entered into an innovative partnership with WHO allowing to make sport events and in particular the FIFA World Cup Qatar 2022 a health event. Through the Healthy FIFA World Cup Qatar 2022, billions of people around the world were reached with health messages, and many benefited from the health promotion activities and enhanced health security strategies implemented during the tournament. I truly hope that this partnership model will continue guiding positive changes across future sport events, and the continuous integration of health within sport.” Dr Gaudenz Silberschmidt, Director, Health and Multilateral Partnerships, WHO headquarters Governance of the partnership The governance structure of the Sports for Health Partnership was designed for effective coordination and decision-making across three levels: strategic, tactical, and operational [ref. figure number/s]. At strategic level, a Steering Committee was the central hub for high level oversight and decision-making. Chaired jointly by the WHO Director-General and the Minister of Public Health of Qatar, this committee also included the WHO Regional Director for the Eastern Mediterranean Region, the Secretary General of the Supreme Committee for Delivery and Legacy and the President of FIFA. Its role was to set the course of the project, making sure its work was aligned with its objectives. Committee members reviewed plans, endorsed changes, and advocated for the partnership’s goals. Tactical Coordination was led by the Senior Advisory Group, which was made up of members from organizations like the Supreme Committee, FIFA, and Aspire Zone Foundation, and co-chaired by the Qatar Ministry of Public Health and WHO. The Senior Advisory Group was an enabling group, guiding Sports for Health partners on performance, challenges, lessons, and policy dialogue. Operational coordination was spearheaded by the Partnership Coordination Team, which focused on the delivery of agreed objectives, coordinating dedicated working groups and developing action plans. The Team was made up of technical focal points from the Ministry of Public Health and WHO, and was responsible for ensuring adherence to objectives, identifying challenges, and facilitating communication among stakeholders. This team took decisions on how to turn strategy into action. © Ministry of Public Health Qatar Minister of Public Health, WHO Director General, and FIFA President engaged in conversation. 36 Strengthening health and well-being through sport events Changing the game Operational governance for the FIFA World Cup Qatar 2022 Office of Minister of Health Health Sector Strategic Command Group Ambulance Service Tactical Command (NOC, NCC) FIFA Medical Director MOC Main Operation Centre Tournament Strategic Command (Gold Suite, NCC) Tournament Tactical Command (TCC, NCC) Host Country Chief Medical Officer THQ Tournament Headquarters Health Services Tactical Command (NHICC, MCC) Diwan Office of FIFA President Emergency Operations Scheduled Operations Corniche Activations 8 Stadiums * Other Fan Activations Team Base camp / Practice fields / FIFA Hotels Other Non- Competition venues Hospitals MopH PHCC HIA Transfers Fan Festival Asian Town* DEC HGH Health Screening DIA International Retrievals Al Khor* DECC Sidra Pharmacy & Drug Control WIP Security/ Convoys Congested Areas Qetaifan Island NCC Aspetar Private Facilities Sealine Katara Media Centers WWRC Health Surveillance Ali Bin Hamad Al Attiya Heart Hospital Doha Grand Port Al Khor Abu Samra Al Wakra Fan Villages Aisha Bint Hamad Al- Attiya HMGH Po lit ic al (p la tin um ) Ta ct ic al (S ilv er ) St ra te gi c (G ol d) O pe ra ti on al (B ro nz e) Figure 3 Operational command framework for large scale events Source: HMC ambulance service, 2022 375.1 Governance of the partnership; 5.2 Operational governance for the FIFA World Cup Qatar 2022 Event governance Any FIFA World Cup is arguably not a single mass gathering, but rather four separate mass gatherings, in the form of the group stage matches, every day – not to mention the fan zones, media centres and other points that bring together large numbers of people. With the addition of dozens of competition and non-competition sites, a World Cup becomes a multi-mass gathering that requires very effective governance structures in order to be managed safely, and surge capacity in place when needed. The FIFA World Cup Qatar 2022 took place across eight stadiums in the same city – unique for a World Cup and more like a hybrid between a conventional World Cup and the Olympic Games — although the Olympic Games would seldom, if ever, see as many simultaneous, closely located events with attendance as high as a World Cup football match in a full stadium. This type of event had never happened before. Running a World Cup safely during a pandemic required a highly coherent governance, leadership and management approach to health, both preparing for the event and while hosting the tournament. This meant new structures and ways of working, new supporting infrastructure, and clear channels and methods for different stakeholders to work together. Furthermore, this would have to be done with no additional financing, using only normal operational budgets. In June 2021, following advice and discussions within the S4H partnership, the Minister of Public Health decided that the best way to manage health preparations would be to form command arrangements similar to those used for the COVID-19 response. This was a military-style command and control approach to final delivery and implementation of the health plan in three layers – strategic, tactical and operational. Each has clear definitions of responsibility, authority and accountability, and clear tactical and operational command and control arrangements at each high priority location (during the early stages of the tournament, this meant four stadiums each day and five additional non-competition sites). Under this structure, staff could work with well-defined roles, backed up by clear written instructions. This structure – tweaked and improved following learning from the Arab Cup – was required not just in case something went wrong (though it would certainly be needed then), but also to make sure that operations ran well under the expected day-to-day stresses of the tournament, and to manage the complex coordination of logistics. It split health professionals into two broad groups – one in the field and one inside secondary and tertiary care services – with set practices and arrangements for patient referrals from one to the other. It also required cross-sectoral arrangements, agreed by all participating providers, on how to report daily – providing not only numbers, but also the supporting information from the field that decision-makers needed to understand nuance and context. Each command centre had lines of reporting up to the Medical Command Centre (MCC). This structure (see next section), along with the overall control provided by the World Cup Strategic Command group, gave the health system flexibility. It allowed for rapid shifts in focus at short notice to deal with situations that developed very late in the day, or to address issues beyond the direct influence of the health sector. 38 Strengthening health and well-being through sport events Changing the game To make the most of existing learning and capacity, the World Cup Strategic Command Group worked closely with the pre-existing COVID-19 Command Group (many senior staff were core members of both groups). The COVID-19 group discussed FIFA World Cup Qatar 2022 issues as a standing agenda item at every meeting, and its Chair briefed the FIFA World Cup Qatar 2022 group regularly. As the tournament grew closer, representatives of the SC and FIFA were invited onto the COVID-19 group. The Senior Medical Officer at FIFA was also closely involved with both groups, facilitating health discussions with FIFA whenever they were required. The task was to ensure that all health and supporting services were ready for the worst-case infectious disease scenario by the time the FIFA World Cup Qatar 2022 started. That scenario: an outbreak in Qatar, during the tournament, of an immune-evasive COVID-19 variant or similar pathogen capable of causing serious illness leading to hospitalization. © Hamad Medical Corporation A command team monitoring the games in real-time. 395.2.1 Event governance Medical command centre The MCC was located within the National Health care Incident Command Centre (NHICC) and was the centre for all coordination between medical service providers involved in the World Cup. Its job was to work with everyone to coordinate health care provision. This meant supporting a wide range of services from different providers, including the clinics, ambulances and mobile patrol teams across all competition and non-competition sites team training sites, national points of entry and other coordination centres. The MCC also had to coordinate, manage and support all health care facilities, and to ensure provision of care for FIFA visitors, authorities, high profile persons, delegates, teams, and the FIFA World Cup Qatar 2022 workforce. To help with this, the MCC designed and set up an integrated, multiagency referral system that worked across all required clinical specialties. This system allowed centralized tracking of patients in real-time as they were transferred from event sites to hospitals and monitored until discharge, collecting data on care, transport and outcomes. The system also provided real time notifications and produced daily, weekly and consolidated reports. Information was also communicated in real time through secure chat groups. The MCC was linked to media and communications, and to the outputs of the social listening programmes, so that it was better able to predict and react to demand for services, and so it could send public messages though the government communications office as events unfolded. Major incident preparedness and resilience The Major Incident Preparedness & Resilience (MIPR) Committee had the job of ensuring that the public health sector was ready to respond to and recover from any major incident impacting the health system – particularly with respect to the World Cup. The MIPR Committee was made up of representatives from HMC, PHCC, Ministry of Public Health and Sidra and had five tactical objectives: 1. identify, assess and plan to mitigate risks with the potential to cause a major incident (8); 2. ensure that all parts of the public health sector have up-to-date plans to address these risks; 3. ensure these plans are tested against likely scenarios; 4. establish the NHICC to coordinate the health sector response to any major incident; 5. ensure plans are in place to manage a resurgence of COVID-19. The MIPR Committee introduced a new command and control structure to oversee the response to any major incident. This structure was based on international best practice and split into three levels of command: Gold (strategic), Silver (tactical) and Bronze (operational). Overall management of any response was through Gold Command, based in the NHICC. 40 Strengthening health and well-being through sport events Changing the game PHCC silver command Hospital Cluster Silver Commands Cluster 1: Hamad General Cluster 2: Al Wakra/ Mesaiced/ Hazm Mebaireck Cluster 3: Al Khor/Ras Laffan/ Sheikha Aisha bin Hamad Cluster 4: The Cuban Cluster 5: WWRC/QRI/ACC Cluster 6: Heart/Rumailah/ CDC/ NCCCR/Dental/ Mental Health/HHCS HMCAS gold command MOPH silver command Food safety Communicable diseases and liaison Private sector laison Third sector liaison Environmental safety National/ government response committee Corporate departments siver commands Activation is incident dependent - to be co-Ibcated with NHICC Cluster A: supply chain management/ hospitality/ engineering/ human resoures Cluster B: HICT Hospitals/departments bronze commands (includes EDs) Health centers ‘Hospital clusters’ only exist for major incident response purposes Ta ct ic al (s ilv er ) St ra te gi c (g ol d) O pe ra ti on al (b ro nz e) HMC gold command hosted in the NHICC Preset gold command team mobilized for any major incident activation Figure 4 Emergency response command structure for healthcare services Source: HMC ambulance service, 2022 415.2.1 Event governance Improvements to the command structure From November 2022 until midnight on 18 December 2022, the NHICC was staffed and operational as Gold Command. On all match days, a Gold Commander was resident in the NHICC, supported by a Tactical Advisor and other key support roles. These arrangements were in place from two hours before the first match of the day kicked off until two hours after the day’s last match finished. To prepare for the World Cup, the MIPR Committee made the following enhancements to the Gold Command infrastructure: • introduction of a system to improve information on casualty numbers and disposition of those casualties to health care facilities, with real time insight into capacity to receive casualties in HMC emergency departments and in-patient beds; • development of robust, resilient communication technologies to ensure that Gold Command is always linked to the National Command Centre (NCC) and to HMC Silver Commands; • introduction of two new senior operational roles into Gold Command to support the Gold Commander. During the tournament period, it was expected that Silver Commands whose hospitals would receive casualties from any incident at a stadium would be at heightened readiness. A detailed daily schedule was issued to all Silver Commands. Gold Command contacted the Silver Commands on all match days for routine readiness briefings and to test communications links. 42 Strengthening health and well-being through sport events Changing the game National health care incident command centre Established in 2020 and based at HMC’s Ambulance Service headquarters, the Centre coordinates the major incident responses of all Qatar’s key agencies and acts as a health care system focal point, coordinating with the Ministry of Public Health, health care providers in Qatar (including HMC, PHCC and Sidra Medicine), and other government agencies. The NHICC is staffed and running 24/7 at all times, not just during major events like the World Cup. During the tournament the NHICC was put at state of heightened readiness to ensure Qatar was in the best possible position to respond to any incident that might occur. © Hamad Medical Corporation The National Health Incident Command Center closely monitoring the live status of the tournament. 435.2.1 Event governance Box 3: The tactical command group: managing an event to ensure a legacy The Tactical Command Group (TCG) was set up inside the Ministry of Public Health. It included every team with a role in preparing for major incidents and minimizing their impact on the tournament, and for liaising with FIFA to ensure their needs were met. The key members of the TCG came from the following Ministry of Public Health departments: • Health Protection; • Communicable Diseases Control; • Food Safety and Environmental Health; • Noncommunicable Diseases; • Pharmacy and Drug Control; • The Health Emergency Department; and • the National Medical Commission. Public health emergency operations centre A public health emergency operations centre, or PHEOC, is an important part of the national disaster management infrastructure. The PHEOC is a physical location for coordinating information and resources to support incident management and can be run permanently as part of the national health system or set up temporarily when needed. For the World Cup, Qatar opened a PHEOC to play this coordinating role, but also to provide mass gatherings training to other institutions and departments and run risk assessments before, during and after the tournament. The PHEOC approach isn’t new, but the 2021 FIFA Arab Cup and the FIFA World Cup Qatar 2022 were the first times it was used in Qatar, and it was a new way for the Ministry of Public Health to coordinate services under one roof. During the World Cup, the PHEOC linked relevant actors within and outside the health sector and provided a central platform through which everybody could contribute data. This facilitated the flow of information in ways that gave the Ministry oversight of operations at all times. As mentioned earlier, the work of the PHEOC was made easier because the COVID-19 response meant that much of the necessary capacity was already in place – for example, management resources and structures, screening capacity, infection prevention and control (IPC) protocols, contact tracing capacity, testing services that could be used for fans and visitors, etc. As an excellent example of the legacy of the FIFA World Cup Qatar 2022, early in 2024 the decision was made to establish a fully functioning PHEOC as a permanent part of the Health Emergency Department. 44 Strengthening health and well-being through sport events Changing the game As well as preparing for anything that might happen during the World Cup, the TCG had an important role in creating longer term legacy. It had six tactical objectives designed to strengthen the public health system in ways that lasted beyond the World Cup: • developing and enforcing health regulations, standards, guidelines, and policies, improving the policy and regulatory environment to improve public health in the long term; • enhancing health promotion and research, improving knowledge, attitudes, skills, and behaviours for a long-term positive influence on quality of life in Qatar and for visitors; • enhancing surveillance and prevention to prevent diseases and epidemics, protect the World Cup, and improve long term use of public health resources; • emergency management and stakeholder coordination, including risk assessment, implementing strategies to contain threats, and coordinating and assigning public health tasks; • ensuring availability of medicines and vaccines: managing procurement for populations at risk, while maintaining Qatar’s Essential Emergency Stockpile of medications and medical consumables; • ensuring indoor water and air quality: because waterborne infections and respiratory illnesses are notorious for disrupting mass gatherings, continuous monitoring of indoor air and water quality is a crucial part of prevent illness and protecting the event. 455.2.1 Event governance Ambulances are stationed nearby during the games to respond to any immediate emergencies or medical needs. Event staff, including WHO Qatar and paramedics from Qatar health sector gather at the Fan Zone, representing health and safety teams for the tournament. © Hamad Medical Corporation Protecting health Objectives The Health Security component of the S4H project had two tasks: 1. ensure the health and safety of everybody attending the FIFA World Cup Qatar 2022; 2. protect business-as-usual health services for the local population, so that their regular access to health care was unaffected by the tournament. In addition, the capacity building, improvement to national systems, data gathering, analysis and research under this pillar was all meant to strengthen public health and health security for mass gatherings in Qatar for the long term. Main activities The FIFA World Cup Qatar 2022 health security strategy fulfilled its objectives: there were no major health incidents during the tournament or linked to it, and the national health care system did continue to provide day-to-day services to residents with no negative impact on performance throughout the tournament. While it was fortunate that no major outbreaks or other incidents affected Qatar during this time, the FIFA World Cup Qatar 2022 still exerted serious pressure on the health system. Its resilience under that pressure was because of thorough preparation and effective execution in a few key areas. 48 Strengthening health and well-being through sport events Changing the game Providing easy access to care, close to where it was needed Establishing multiple clinics in and around the FIFA World Cup Qatar 2022 competition and non-competition sites (sometimes known as “in-event health services”) was an important part of the strategy. Setting up temporary clinics rather than relying on moving people to established facilities, achieved two things. Firstly, it gave fans easy access to medical care close to where they needed it; and secondly, it reduced the number of fans visiting hospitals and health centres, so routine medical services for local residents weren’t disrupted. This strategy was supported by active promotion of virtual services and urgent care centres for residents, and the further provision of care for visitors at Primary Health Care Centres throughout the tournament. Strong governance A strong governance structure was set up early to deliver the public health strategy. Technical sub-committees, with representation from across the health and other sectors, reported to the Minister of Public Health’s FIFA World Cup Qatar 2022 Health Strategic Command Group. This setup provided many benefits, including but not limited to clear direction and strategy, early identification of risks, clear lines of accountability, and centralized budget control. Strong health surveillance and response A robust surveillance system was needed for early detection and prevention of disease outbreaks. Improvements to Qatar’s surveillance structure were planned and carried out before the tournament, with special focus on mass gatherings but also including many longer-term improvements to national systems. Working together as a health care system Any success in keeping people healthy and safe during the tournament depended on the hard work and collaboration of hundreds of staff across several local health care organizations, supported by international partners like FIFA and WHO and thousands of FIFA World Cup Qatar 2022 volunteers. 496. Protecting health Public health system Surveillance Hosting a World Cup while the COVID-19 pandemic was still happening was a real challenge. As mentioned earlier, it was also a valuable opportunity to strengthen Qatar’s surveillance system beyond what had been done in the pandemic. Over 1.4 million visitors (3) coming into a country of just under 3 million people in a few weeks was expected to strain the health system, and surveillance functions in particular. These pressures would be exacerbated by the northern hemisphere winter – peak season for respiratory disease – and concentration of all visitors in an area the size of a single city. Strengthening surveillance was felt to be essential. Enhancements of the surveillance structure were planned with special focus on mass gatherings, but with the longer-term goal of leaving lasting improvements to public health, and adding to the evidence base for mass gatherings surveillance. This was reflected in the diseases prioritized for monitoring and the type of surveillance systems and tools that were adopted. Capacity building and training initiatives, and improvements to coordination and information sharing were also prioritized. In alignment with the WHO Global strategy on digital health 2020-2025, any modifications to digital surveillance were made with full consideration for the importance of legal and ethical frameworks for assuring patient safety, data security, appropriate use and ownership of health data, recoverability of privacy data and the protection of intellectual property rights. Improvements included enhanced reporting of the number of diseases through indicator- based surveillance (IBS); monitoring global public health threats from official and unofficial sources through event- based surveillance (EBS); and monitoring the number of people with high priority symptoms but as yet without a diagnosis (syndromic surveillance).  Surveillance procedures and guidelines were updated for the World Cup, and contingency plans were developed for communicable and vaccine-preventable diseases. To support rapid notification of emerging or imported cases, improved communication channels were put in place at points of entry and in temporary “floating hotels,” (these were cruise ships docked in Doha to accommodate tournament visitors). As part of this improved communication, the Ministry of Public Health had focal points from technical teams assessing, monitoring and responding to any relevant signs of risk, and a PHEOC (see later in the text) was set up to coordinate information from different sectors and teams. Contacts were also strengthened with the Ministry of Municipality’s Animal Health Department before the tournament, to support rapid reporting of any potential emerging zoonotic infections. In addition, WHO staff were embedded into the Ministry of Public Health throughout the tournament, helping ensure effective communication and responses to potential health hazards. A Mass Gatherings Early Warning Alert & Response System (MG EWARS) was set up to complement routine surveillance and allow faster disease identification, notification and response. Its design was shaped by three things: a risk assessment of the upcoming mass gatherings; a gap analysis of existing surveillance functions and resources; and 50 Strengthening health and well-being through sport events Changing the game Surveillance unit Investigate, Verify, Confirm Event review group Multidisciplinary team of subject matter experts for recommendations and risk rating FIFA World Cup 2022 health strategic command group Minister of Public Health Health in all policies unit Data compilation and reporting PHEOC Responsible units for action FIFAWC 2022 Daily sit report Infectious disease surveillance Environmental surveillance Emergency service uptake Hospitalized cases Public healthcare facility In-event health facilities Research institutes Private healthcare facilities Online health signals General public complaints via email/hotline Figure 5 Flow of information for daily monitoring of the health situation during the FIFA World Cup Qatar 2022 516.1 Public health system; 6.1.1 Surveillance Syndromic surveillance What it did: Following recommendations from WHO, Qatar set up a new syndromic surveillance programme. The Ministry of Public Health surveillance team generated a list of priority syndromes for early detection that included the symptoms of measles, poliovirus, respiratory disease, diseases caused by fecal/oral transmission, and vector-borne diseases. When monkeypox (also known as “mpox”) was declared a public health emergency of international concern, or PHEIC, in July 2022, this was added to the list. To cover these, the programme identified four high priority presentations – gastroenteritis, acute respiratory illnesses, fever and rash – and updated thresholds and criteria for priority diseases to account for the changes in population expected with the influx of FIFA World Cup Qatar 2022 visitors. An enhanced drug surveillance plan was rolled out in collaboration with the Pharmacy and Drug Control Department, monitoring drug sales to support syndromic surveillance. How it differed from previous routine surveillance: Establishing syndromic surveillance allowed quicker responses to emerging threats while waiting for confirmed diagnoses. “The design of the S4H project, which started before COVID-19, stimulated what would become essential investments in health in a multitude of domains, across mass gathering preparedness, response capacities and protocols and sports and wellbeing – including nutrition, physical activity and mental health. Another interesting aspect is its scope: it has a global perspective at its core, but WHO and Ministry of Public Health committed to showcase a successful first local implementation in Qatar that would shine enough to push global action later!” – Dr Rayana Bou Haka, WHO Representative in Qatar an analysis of the Surveillance Section’s strengths, weaknesses, opportunities and threats (also known as a SWOT analysis). These activities generated recommendations to improve the flexibility, speed, sensitivity, and responsiveness of the system. The section below outlines some of the key upgrades that were made to the surveillance system in advance of the World Cup, with a brief explanation of how each one improved national capacity. 52 Strengthening health and well-being through sport events Changing the game 10000 6000 8000 4000 3000 9000 5000 7000 2000 1000 0 Gastroentiritis 323 Fever 63 Fever & Rash 1 Headache 1081 Back Pain 137 Acute respiratory illness 9501 Rash 106 Sexually Transmitted Disease 1 Blisters 263 Vomiting 64 Figure 6 Syndromic surveillance: total number of cases presenting to onsite medical services by syndrome from 25 November to 24 December 2022 Source: Surveillance Unit, Ministry of Public Health-Qatar, 2022 600 400 300 500 200 100 0 566 538547 515 441 424 322 224 200 390 428 218213 200 182 173 309 284 24 11 2 2 0 227 350 288 304 277 192 151 113 9692 66 46 478 441 470 15 /1 1 16 /1 1 17 /1 1 18 /1 1 19 /1 1 20 /1 1 21 /1 1 22 /1 1 23 /1 1 24 /1 1 25 /1 1 26 /1 1 27 /1 1 28 /1 1 29 /1 1 30 /1 1 1/ 12 2/ 12 3/ 12 4/ 12 5/ 12 6/ 12 7/ 12 8/ 12 9/ 12 10 /1 2 11 /1 2 12 /1 2 13 /1 2 14 /1 2 15 /1 2 16 /1 2 17 /1 2 18 /1 2 19 /1 2 20 /1 2 21 /1 2 22 /1 2 23 /1 2 24 /1 2 Kick off Round of 16 Quarter Finals Semi Finals 3rd place & Final Reset Days Figure 7 Number of daily cases presenting to onsite medical clinics with acute respiratory illness from 15 November to 24 December 2022 Source: Surveillance unit, Ministry of Public Health, Qatar, 2022 536.1.1 Surveillance Screening Sentinel Sites (FIFA Sports Clinics) Open-Source Literature Hospitals Laboratories Primary Healthcare Sources The notification enhancement project What it did: improve infectious disease reporting by upgrading electronic systems for reporting communicable diseases; strengthening communication with and between health facilities and health workers; training more than 2 000 health workers in government and private health facilities and at FIFA health facility sites; running a campaign to raise health care workers’ awareness of the importance of early reporting; and coordinating with other Ministry of Public Health departments (like the Department of Infection Prevention and Control and the Department of Public Relations and Communication), to prepare training materials and programmes (9, 10). How it differed from previous routine surveillance: these enhancements improved the effectiveness and efficiency of infectious disease reporting. This ensured faster responses, better-prepared health workers, and more accurate data collection. Previously, reporting of notifiable diseases had been done by email/fax and paper reports, and was reliant on facilities sending information, which could cause delays. 54 Strengthening health and well-being through sport events Changing the game Pre-existing surveillanceactivities which were enhanced Additionally implemented fot the FIFA World Cup Qatar 2022 Sentinel- Syndromic Sentinel Syndromic Lab Event Based Indicator Based Risk Assessment Data Analyses and Reports Monitoring Trends Real-time Reports Case Investigation Control Measures Risk Communication Surveillance Approaches in Qatar Response Figure 8 Surveillance enhancements for FIFA World Cup Qatar 2022 (10) 556.1.1 Surveillance Interventions during FIFA World Cup Qatar 2022 • Establishing zoonotic surveillance • Establishing drug surveillance • Establishing sentinal surveillance Training More than 2000 healthcare workers Enhance Electronic Tools Re-design the notification form Enhance Communication Internal & External Communication MoPH Experts Surveillance Leaders Literature ReviewSurvey 541 HCW completed the survey Pre-assessment Phase1 Implementation Phase2 Post Assessment Phase3 Figure 9. Notification enhancement project flowchart (9) 56 Strengthening health and well-being through sport events Changing the game JUN OCTAUG DECFEB JUL NOVSEPJAN MAR Pre-Intervention Phase Post-Intervention Phase 1 Post-Intervention Phase 2 (FIFA WC2022) 1034 1515 1151 1462 701 3044 3349 3315 4168 4540 4435 4335 Figure 10. Infection diseases notifications by health care workers from 1 January to 31 December 2022 (9) The surveillance and vaccine electronic system The Surveillance & Vaccine Electronic System (SAVES) is a national electronic tool that was set up in early 2020 in response to COVID-19, then enhanced for the World Cup. What it did: produce an updated, user- friendly SAVES manual; provide training and refresher sessions for staff and for new private health care facilities; create new SOPs to triage cases from all health care facilities, so it was easier to identify urgent cases; accelerate importation of cases into the SAVES software; develop daily SAVES surveillance analysis and reports; and share those reports through a new real time dashboard. How it differed from previous routine surveillance: SAVES was supported by more user-friendly documentation, and a comprehensively updated, easy-to- navigate manual; and it had more effective, streamlined SOPs for triaging cases, making it easier to identify urgent cases quickly. SAVES allows real time reporting. These enhancements significantly improve the efficiency, accuracy, and responsiveness of the system, ensuring better preparedness and quicker action in response to communicable disease events. Previously, reporting of vaccination data had been done by email, fax or paper reports. 576.1.1 Surveillance Event-based surveillance What it did: Event-based surveillance collects and analyses information from a range of sources including news reports, social media, and other informal channels, to detect and assess public health threats in real time, enabling rapid responses to any emerging risk. When EBS was set up in Qatar in 2017, it established closer collaboration with the Ministry of Public Health Public Relations and Communication Department, which was important in gathering and disseminating information about health threats. Further enhancements for the FIFA World Cup Qatar 2022 included improving communication and coordination with important stakeholders, including the Ministry of Environment, the Animal Health Department and the Drug and Pharmacy Department. This greater collaboration created a more comprehensive approach to surveillance that better considered environmental hazards, zoonotic diseases, pharmaceutical issues, and other public health concerns. In 2022, Qatar further upgraded its EBS capabilities by integrating the Epidemic Intelligence from Open Sources (EIOS) platform, in collaboration with WHO. EIOS uses advanced algorithms and tools to enhance the detection, verification, and assessment of threats, and allows the Ministry to sift more efficiently through large volumes of online information. This capability has significantly boosted Qatar’s ability to identify and respond to potential health emergencies quickly. This enhancement was particularly important for ensuring the safety and well-being of both residents and visitors during major events like the FIFA World Cup. Establishing EIOS began with WHO training sessions for key staff, followed by a range of improvements that included a dedicated team to monitor EIOS and improve its use; increased staff numbers and shifts to provide 24/7 coverage of signals during the tournament period; technical improvements to the EIOS database, data collection and reporting tools, and the signal filtering and reviewing processes; creation of a FIFA World Cup Qatar 2022 dashboard to display information; ongoing training for the EIOS team so they could keep up with risk updates; and increased collaboration with WHO and the European Centre for Disease Prevention and Control (ECDC) on daily signal screenings. How it differed from previous routine surveillance: the enhancements made to Qatar’s EBS system for the FIFA World Cup Qatar 2022 are a significant advancement over previous routine surveillance methods. By integrating real time monitoring, expanding stakeholder collaboration, utilizing advanced technologies like EIOS, and ensuring 24/7 coverage, Qatar has developed a more responsive and comprehensive public health monitoring system. These improvements enable quicker detection, verification, and response to potential health threats, ensuring better protection for residents and visitors during major events. 58 Strengthening health and well-being through sport events Changing the game Exclusion Exclusion Exclusion Monitor Status Report Action and Feedback Screening (n=300,077) (Title/Full Text Screening) Step 1 Triage (n=2542) (Initial/Complete) Step 2 Verification and Risk (n=1032) Step 3 Figure 11 Steps followed in processing the articles filtered by the EIOS FIFA World Cup Qatar 2022 dashboard (11) 596.1.1 Surveillance “Boosting the surveillance system for the FIFA World Cup Qatar 2022 was like managing a game, where our strategy and teamwork led to a winning goal. By outmaneuvering health threats faster than a striker on a breakaway, we not only protect public health but also set a new standard for future events— proving that with the right game plan, you can win.” Dr Mohamed Sallam, Surveillance and Response to Epidemic Section, HP/CDC Qatar CDC email system – a channel for public communication Improvements were made to the email system of the HMC Communicable Diseases Centre (CDC). Available to everyone, this system is the official communication channel between health providers and the public, giving the public a platform to share information on any incidents of communicable disease, public health concerns, or rumours with the Ministry of Public Health. Enhancements were made to the system in expectation of increased use during the World Cup. What it did: increase staff shifts to ensure 24/7 service during the tournament; provide extra training so staff could handle all notifications and queries; and provide rolling updates and modifications to the CDC email guidelines to make sure staff were fully prepared. How it differed from previous routine surveillance: these enhancements ensured that Qatar’s public health reporting system remained robust, flexible, and responsive during the high-demand period of the FIFA World Cup Qatar 2022, significantly improving upon the limitations of previous routine surveillance methods 60 Strengthening health and well-being through sport events Changing the game MG EWARS The MG EWARS was first set up for the FIFA Arab Cup Qatar 2021, enhancing surveillance in areas including: • identifying high-priority infectious diseases • rapid capture of communicable disease notifications from different sources • data management and production of daily epidemiological reports • implementing a range of different surveillance tools • developing emergency response and contingency plans • documenting event challenges and achievements and conducting post-event evaluations In mid-2022, the MG EWARS was re- established for the World Cup. Following WHO guidance, international standards, the WHO Framework for Assessment of Surveillance Systems and the literature on preparedness for sports events, the Surveillance Section’s resources were expanded hugely ahead of the tournament (12, 13). The MG EWARS teams took on an improved structure, made up of: • a case registration and notification team and an outbreak investigation and response team; • four new support teams (covering quality improvement; project management; administration and communication; and capacity building); and • a research unit. Establishing the MG EWARS cell In early November 2022, MG EWARS moved into its operational phase. This meant activating a new structure: the MG EWARS Cell. The Cell was a hub to capture, monitor, and communicate signals of high interest from different surveillance sources, and support rapid responses. It used a robust and sensitive system to detect, verify, and assess signals, and reported daily to the Head of the Surveillance section and other focal points like the PHEOC. The Cell had its own staff, including dedicated liaisons with other functions like the CDC email, SAVES and event-based surveillance. The Cell team members recorded surveillance signals, provided briefs on communicable disease trends during the tournament, and prepared, produced, and presented daily reports during daily meetings. They also prepared spot reports and conducted risk assessments whenever an event of concern was identified. The Cell worked without interfering with the operations or functions of other workflows and teams: it was there to complement and support them. 616.1.1 Surveillance Other monitoring activities COVID-19 and infectious disease protocols Throughout the COVID-19 pandemic, Qatar maintained one of the lowest COVID-19 mortality rates in the world (14). This was thanks to a combination of factors that included the efforts of health care staff across the system and the demographic structure of the country. Although cases declined steadily in the lead-up to the FIFA World Cup Qatar 2022, the pandemic’s challenge to public health wasn’t over when the tournament began. It was still important for people to protect themselves, their families and contacts from the virus. To help with this, a comprehensive FIFA World Cup COVID-19 Protocol was developed for the benefit of participants and spectators: FIFA officials took part in regular meetings of the health care sector COVID-19 Strategic Command Group before and throughout the tournament (15). Other initiatives to prevent and control infectious diseases included COVID-19 testing using polymerase chain reaction (PCR) testing or Rapid Antigen Tests (RAT): screening was provided on request to staff including hotel staff and catering companies before the tournament, with a total of 28 919 swabs performed. COVID-19 testing was not mandatory for entry to Qatar, hence people opting for COVID-19 rapid antigen test were people that were experiencing respiratory symptoms or required a negative test result to return home. The positivity rate to COVID-19 tests detected between 1 November and 31 December is presented in Figure 12 for residents in Qatar and visitors. The data show an initial increase of cases of COVID-19 during the first phase of the tournament followed by a decrease and return to pre-tournament levels shortly after the end of the World Cup. During the same time period, hospitalizations levels for COVID-19 remained stable. Kick off Round of 16 Semi Finals 3rd place & Final 01 /1 1 03 /1 1 05 /1 1 07 /1 1 09 /1 1 11 /1 1 13 /1 1 15 /1 1 17 /1 1 19 /1 1 21 /1 1 23 /1 1 25 /1 1 27 /1 1 29 /1 1 01 /1 2 03 /1 2 05 /1 2 07 /1 2 09 /1 2 11 /1 2 13 /1 2 15 /1 2 17 /1 2 19 /1 2 21 /1 2 23 /1 2 25 /1 2 27 /1 2 29 /1 2 31 /1 2 18% 14% 6% 16% 8% 12% 4% 10% 2% 0% Figure 12 Daily COVID-19 positivity rate among residents (Qatari & non-Qatari) and among tournament visitors from 1 November to 31 December 2022 Source: HMC Business Intelligence Unit, 2022 Positivity rate (Visitors) Positivity rate (Residents) Quarter Finals 62 Strengthening health and well-being through sport events Changing the game Wastewater surveillance Wastewater surveillance – also known as wastewater epidemiology – involves monitoring the sewage system for pathogens and chemicals. This type of surveillance is an innovative approach to monitoring public health trends, and can detect early signals of infectious disease outbreaks. Qatar first used this approach during the COVID-19 pandemic. A research team led by the Ministry of Public Health, the Qatar Environment & Energy Research Institute (QEERI) and Hamad Bin Khalifa University, in close collaboration the Public Works Authority at Ashghal and Weill-Cornell Medicine - Qatar, used the SARS-CoV2 viral load in sewage as an indicator to identify infection trends and monitor the effectiveness of national public health interventions (16, 17). During the World Cup, the scope and frequency of wastewater surveillance were increased and included other pathogens such as poliovirus and other enteroviruses. This allowed closer monitoring of the frequency of these diseases (18). Figure 13 Qatar wastewater treatment plants catchment areas Source: Qatar Environment and Energy Research Institute, 2022 636.1.2 Other monitoring activities Clinical Cases4 Points Moving Average Total Viral Load Total Viral Load 6.0X1015 5.0X1015 4.0X1015 5.5X1015 4.5X1015 3.5X1015 3.0X1015 2.5X1015 1.0X1013 0 200 600 1000 400 800 1200 1.0X1014 5.0X1014 2.0X1014 1.5X1014T ot al V ira l L oa d (c op y/ da y) D ai ly C lin ic al C as es Figure 14 Total viral load of SARS-Cov2 in wastewater against daily clinical cases in Qatar from 9 September 2022 to 1 January 2023 Source: Qatar Environment and Energy Research Institute, 2022 4 Se p 20 22 11 S ep 2 02 2 18 S ep 2 02 2 25 S ep 2 02 2 2 O ct 2 02 2 9 O ct 2 02 2 16 O ct 2 02 2 23 O ct 2 02 2 30 O ct 2 02 2 6 N ov 2 02 2 13 N ov 2 02 2 20 N ov 2 02 2 27 N ov 2 02 2 4 D ec 2 02 2 11 D ec 2 02 2 18 D ec 2 02 2 18 D ec 2 02 2 25 D ec 2 02 2 1 Ja n 20 22 64 Strengthening health and well-being through sport events Changing the game Environmental health and the air quality health index Air quality is one of the major health determinants for NCDs. This is of particular concern in desert regions, especially in the Middle East, because of interactions between pollutants resulting from human activities and those from natural sources, like dust. Climate and environmental changes and risks are a concern across the Middle East. Thanks to S4H’s collaboration with QEERI and the Ministry of Public Health Environmental Team, special attention was paid to air quality monitoring for the World Cup, and two additional air quality monitoring stations were added to the pre-existing national network for the duration of the tournament. Enhancing collaboration in this way improved Qatar’s capacity to monitor air quality, assess health impacts and monitor the implementation of interventions to reduce harmful exposure. As part of this effort, the Ministry added a range of new surveillance targets and tools to the national system to focus on environmental and airborne issues. These included the following: • surveillance of air quality to produce an ambient Air Quality Health Index (19) and modelling and forecasting of daily Air Quality Health Indexes. This allowed daily reporting to pick up potential dust events or storms that might impact the respiratory health of residents and visitors in Qatar. The air quality data was collected at six monitoring stations operated by QEERI and one run by the Ministry of Public Health Environmental Health Unit; Figure 15 Air quality monitoring stations by Qatar Energy and Environment Research Institute (5) and air quality monitoring station (1) by the Ministry of Public Health: Geographic location. Qatar 2022. 656.1.2 Other monitoring activities • regular collection of bioaerosol samples from indoor venues such as hotels, fan villages, stadiums, floating hotels, etc.; • increased frequency and enhanced monitoring of medical waste and water quality, including in recreational facilities like hotel swimming pools; • developing a seawater surveillance system that included chemical and microbiological analysis of seawater around three floating hotels docked in the Doha Port. The air quality health index (AQHI) measures the air quality in relation to human health on a scale from 1 to 10. The higher the number, the greater the health risk associated with the air quality. When the amount of air pollution is very high, the number will be reported as 10+. It is calculated based on the relative risks of a combination of common air pollutants that are known to harm human health. It factors in Ozone (O3) at ground level, Particulate Matter (PM2.5/PM10) and Nitrogen Dioxide (NO2). Preassigned thresholds affect the AQHI (1-3 = low, 4-6 =moderate, 7-10 = high, and 11+ = severe), according to which people are advised. For instance, for moderate conditions, the most sensitive part (at risk groups) of the population is invited to wear masks and avoid being outdoors. Food safety The Ministry of Public Health Food Safety Department was responsible for providing enhanced laboratory food testing services throughout the World Cup. Meeting this need meant that the Qatar Central Food Laboratory, two branch laboratories at points of entry (Ruwais Port and Hamad Port) and four mobile laboratories all had to remain open 24 hours a day during the tournament, working non-stop to provide the combined ability to test 2040 samples per day.  This required the services of 15 managers and administrative staff, ten supervisors and 107 food safety inspectors. From 1 November 2022 until the end of the tournament, this team carried out 3 567 inspections and tested a total of 54 306 food samples. This work was supported by increased recruitment. Substantial training was also provided on data collection and reporting in mass gathering and emergency situations. Other changes Further surveillance improvements were made in areas including multisectoral coordination, emergency plans and procedures, health care capacities and workforce strengthening. These included: • upgrading over 30 guidelines, plans and technical directives; • implementing a programme of research activity; • obliging all animal health centres and veterinarians in Qatar to report cases of zoonotic diseases to the CDC during the tournament, and all animal health facilities to do daily “zero reporting” (i.e. reporting the absence of cases) to the CDC. 66 Strengthening health and well-being through sport events Changing the game Figure 16. Daily air quality health index in stadiums and the Doha city urban area: 22 November - 18 December 2022 Source: Qatar Environment and Energy Research Institute, 2022 Al Janoub Stadium Ahmad Bin Ali StadiumAl Thumama Stadium Education City Stadium Khalifa International Stadium 974 Stadium Al Bayt Stadium Lusail Stadium 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 7 6 5 4 3 2 1 0 7 6 5 4 3 2 1 0 7 6 5 4 3 2 1 0 7 6 5 4 3 2 1 0 7 6 5 4 3 2 1 0 7 6 5 4 3 2 1 0 7 6 5 4 3 2 1 0 7 6 5 4 3 2 1 0 Doha Area 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 7 6 5 4 3 2 1 0 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 16/11/22 23/11/22 30/11/22 07/12/22 14/11/22 676.1.2 Other monitoring activities Surveillance: reflections Issues, challenges and responses • As the sensitivity and flexibility of the surveillance system improved, the volume of signals received through notification channels also increased. Staff had to adjust and respond to make sure that all signals were captured and verified in time, and in standardized ways. New systems were needed to meet the need for faster communication, and to analyse on greater volumes of information. Focal points were identified to deal with this, and specially adapted communication processes were adopted. • Accurate numbers of fans in different areas of the country versus residents and detailed game attendance statistics were unavailable during the World Cup. This made modelling infection rates among the population very challenging. • Producing the surveillance and PHEOC daily situational reports was challenging: the surveillance team had to collect, analyse, interpret, deliver, and present reports in less than a couple of hours every day. This was hardest during the first week of the tournament, when a continuous improvement approach required several changes to the report template. Constant pressure to verify and report on FIFA World Cup Qatar 2022 issues on top of already demanding workloads was source of added stress for many staff. • The sudden emergence and global spread of Mpox meant staff had to react quickly to make sure systems were sensitive enough to detect new cases in the context of a mass gathering. Case definitions had to be updated and Mpox-specific action plans, investigation forms, guidelines and SOPs had to be developed and tested. • While preventive food safety measures were put in place across all venues by all partners in charge of managing food safety, including the Ministry of Public Health, Katara Hospitality and Ministry of Municipality, once the FIFA World Cup Qatar 2022 began, monitoring food safety in stadiums was the sole responsibility of the Ministry of Municipality, working in collaboration with a team from FIFA. This meant that The Ministry of Public Health did not have direct control over food safety in stadiums and was forced to react to incidents without being able to implement preventative interventions at the source. In hindsight, running parallel teams with overlapping responsibilities was inefficient and future events should anticipate and plan for this situation. In the end, thankfully, only a very limited number of food safety problems occurred in stadia and no outbreaks were reported. • New fan zones and commercial events were repeatedly set up with very little warning throughout the tournament. This put strain on several parts of the system that would be responsible for ensuring health during these events, and had to meet that responsibility, but which had little time to prepare and no resources set aside to do it. For example: in these situations, the Food Safety Department had to take control of event zones at the last minute and ensure food safety, absorbing unplanned but essential additional work and adjusting inspection frequencies based on daily compliance data. 68 Strengthening health and well-being through sport events Changing the game Considerations for future events • Making the most of an opportunity as big as a World Cup requires careful planning, prioritization and step-by- step implementation. Indeed, the range of possible surveillance improvements was so far-reaching as to be potentially overwhelming for the Ministry of Public Health. The S4H model allowed close technical collaboration with partners, and particularly WHO, to design and implement a manageable framework for surveillance improvements. • Because Qatar has an integrated health care system, and because visitor care was integrated into that system, Qatar now also hosts the largest mass event health care database in the world. This dataset, run by HMC and subject to international standards for data protection and confidentiality, contains information from over 50 000 patients. As such, it is potentially a valuable resource for research that advances the science of mass gatherings health care – a huge part of the legacy of the FIFA World Cup Qatar 2022 and an important asset for future host countries (and for the continued development of the S4H model). External requests to access the database for research purposes are subject to review of appropriate research proposals and ethical approvals, carried out by a dedicated committee that makes decisions on when and how to share the database or part of it. • Surveillance is a prerequisite for action. It must not only provide quick and accurate information, but also provide it in a way that can be understood easily and informs action to improve disease control and prevention. This was the core principle of the daily FIFA World Cup Qatar 2022 SitRep. Daily reports were assessed by an expert group (the Event Review Group), © Ministry of Public Health Surveillance team participating in discussions and debriefing during a workshop session. 696.1.3 Surveillance: reflections ; 6.1.4 Issues, challenges and responses; 6.1.5 Considerations for future events which discussed and interpreted the findings and presented action-oriented recommendations to the Minister and other policy-makers for decisions. In high pressure situations, this type of workflow is best carried out through simple, clearly written reports and comprehensive electronic dashboards. • A large event like the World Cup could be more used as a launching point for expansion and enhancement of event- based surveillance, including by engaging other ministries in reporting systems. Host countries should plan from the start with a clear idea of the system they would like to achieve in the years following the event. • Any attempt to build longer-term capacity must include consideration of knock-on resourcing and training needs. For example, case and field investigation teams need to be sustained, and will require resourcing and ongoing programmes that maintain and build their capabilities through continuous training. • It is essential to integrate stadium food safety systems into stadium management systems and protocols. • The use of the EIOS for event-based surveillance was a significant added value for the FIFA World Cup Qatar 2022 and its systematic use should be considered for future mass gatherings. • Wastewater surveillance played a pivotal role during the FIFA World Cup Qatar 2022, helping detect infections and track transmission within the population, without the clinical or socioeconomic biases associated with the use case reporting alone. Integration of wastewater surveillance for infectious diseases surveillance during mass gatherings has demonstrated its effectiveness, making it possible to provide timely warnings of infection to host countries and global public health authorities. 70 Strengthening health and well-being through sport events Changing the game Example: social listening and RCCE To inform communities about risk in a way that helps them avoid or reduce that risk, you need trust and connection between those communities and the people making health policy. There’s no single right way to create or manage that trust – and very little material on RCCE training in the context of mass gatherings – but professional consensus suggests that investing in community engagement is important, particularly during health crises such as epidemics. But – as COVID-19 showed – good two- way risk RCCE is complicated and hard, especially when based on highly nuanced social epidemiology and/or ever-changing science. Social listening is a powerful tool to help manage this problem. It means monitoring public conversation so that decision-makers are informed about specific populations’ concerns. For Qatar’s World Cup Supreme Committee for Health Care Communication (SCHC), social listening was an important part of health security for the World Cup. Social listening and S4H Through the S4H partnership, social listening for the FIFA World Cup Qatar 2022 was provided by WHO. WHO contracted an expert consultancy called Marble Global to run social listening programmes using a list of search terms identified through a risk assessment. These programmes generated comprehensive reports of key findings related to different high priority risks, as well as a wealth of technical data on the volume and ranking of online discussions. Ranking was done both by volume and by speed of growth, with the latter defined as percentage change in volume of conversation on a given topic versus the previous week. WHO RCCE teams then combined this information with data from other sources to produce social listening reports for Qatar, which were shared through the WHO Country Office for Qatar, the head of which was a member of the ERG. Six of these reports, designed to support public health decision-making and communication, were produced: one before the tournament kicked off; four during the FIFA World Cup Qatar 2022 itself, and one after it ended. Figure 17 summarizes a snapshot of social media screening by RCCE teams, showing the results observed in one week immediately before the tournament by user demographics and selected topics discussed on three social media platforms. Figure 18 shows the global indexed google searches (a relative measure of search interest or popularity of topics over time) for “COVID-19”, “Qatar World Cup 2022”, and “MERS-CoV” over time. 716.1.6 Example: social listening and RCCE FACEBOOK 1. India 2. United States of America 3. Indonesia 4. Brazil 5. Mexico 56% Male 44% Female 25-34 18-24 35-44 45-54 55-64 13-17 >65 TWITTER 1. United States of America 2. Japan 3. India 4. Brazil 5. United Kingdom of Great Britain and Northern Ireland 55% Male 45% Female REDDIT 1. United States of America 2. United Kingdom of Great Britain and Northern Ireland 3. Canada 4. Australia 5. Germany 18-24 25-34 13-17 35-44 45-54 55-64 >65 33% 24% 17% 10% 6% 6% 5% 42% 22% 14% 11% 8% 2% 1% *According to the GlobalWebIndex, 19.9% of all internet users that access the web to seek for health-related information use Reddit. Age groups Age groups Figure 17 User demographics per social media platform developed by Marble Global from 14 November to 20 November 2022 100 80 40 90 50 70 30 60 10 0 29 /1 0 01 /1 1 04 /1 1 07 /1 1 13 /1 1 10 /1 1 13 /1 1 16 /1 1 19 /1 1 22 /1 1 25 /1 1 28 /1 1 29 /1 1 01 /1 2 01 /1 2 20 Nov: Qatar World Cup kicks off 29 Nov: Anglophone nations United States of America, England, Wales play COVID-19 Qatar World Cup 2022 MERS-COV Figure 18 Global indexed google searches (in English language) for “COVID-19”, “Qatar World Cup 2022”, “MERS-CoV” from 29 October to 2 December 2022. Source: Marble Global, 2022 Po pu la rit y in de x 72 Strengthening health and well-being through sport events Changing the game Issues and challenges This process ended up needing significant resources, because the Marble Global reports, while useful, required extensive analysis by WHO RCCE and mass gatherings teams before they could be used to guide public health action. This was partly because of software shortcomings. Commercially available social listening technology is mostly built and used for marketing, to analyse online activity and influence consumer behaviour. But public health discussions are different to those that inform commercial campaigns: they don’t capture a lot of public attention, and they tend to be relatively low volume and of limited reach. Using available technology for public health purposes meant generating and processing huge volumes of data that wasn’t always obviously health-related, consuming time and resources. It was also challenging to triangulate social listening findings with data from other sources to generate findings that accurately reflected situations on the ground and their impacts on people’s behaviours and beliefs. There were further problems whenever there was a need to manage and respond to mis- and disinformation. For example: at one point, an article in The Lancet sparked major concern about the possibility of an outbreak of Middle East Respiratory Syndrome (MERS) in Qatar (20). Considering the prestige and credibility of The Lancet, publication of this paper generated comments and concerns in social media. The response required a concerted effort to gather data and evidence that could not be carried out immediately, although it resulted in the 2023 publication of a paper entitled Middle East respiratory syndrome coronavirus (MERS-CoV) and the 2022 World Cup football tournament in Qatar (21). While this careful, evidence-based approach was necessary, it meant that the response to the concerns in The Lancet article was not public until early 2023 – which shows the difficulties faced by public health authorities when they have to respond quickly to fake news or excessive alarm. Dealing with public health concerns requires active engagement - integrating online social listening with community engagement in the real world. Unfortunately, this type of engagement wasn’t a big enough part of the FIFA World Cup Qatar 2022 plans. In the absence of solid community feedback mechanisms, there was limited interaction with audiences and insufficient insight into their concerns, questions, and the effectiveness of communication strategies in meeting their needs and building their trust. There was also some lack of clarity and coordination on how to incorporate social listening reports into policymaking decisions. These were brand new tools addressing new needs (such as like dealing with infodemics and monitoring social media), and both the tools and the approaches to using them were evolving fast. 736.1.6 Example: social listening and RCCE Considerations for future events Because social listening data is so varied in nature, and because there’s so much of it, interpreting it for public health requires a lot of collaboration between different sectors – and must include data science and social and behavioural experts. Countries hosting future mega events should consider developing or leveraging online and offline social listening and community feedback mechanisms, managed by a team of experts in relevant fields to support data analysis and help make public health recommendations. Planning should include creating (or strengthening existing) community-based feedback mechanisms like hotlines and community forums that can be used to gather real time insight into public concerns, and engaging closely with key community influencers, nongovernmental organizations (NGOs), civil society and community organizations of all kinds. Planning should allow sufficient time for this engagement, and to decide the core objectives of the social listening exercise and the relevance and specificity of different types of findings, then properly brief everybody who needs it before the event. Protocols are needed for how social listening should feed into, and shape, decision making. When social listening suggests that concerns are arising, it is important to assess their scope and significance and respond immediately. S4H experiences in Qatar suggest that host countries should consider national investment in digital software designed specifically for (a) the local context and (b) public health listening purposes, and in establishing a national system that integrates social listening with other data sources to produce targeted communication strategies that address misinformation quickly. Developing in-house technical capability within government agencies would reduce reliance on external vendors. WHO can provide technical support for this work. Because the private sector dominates the social listening market, which is currently driven by commercial objectives, government intervention may also be needed to make sure this technology is used ethically and aligned with public health. Data privacy, transparency, and accountability are paramount. To protect people’s rights countries could consider implementing national regulations to govern the use social listening data for public health. The S4H model and network can also be used by host countries to strengthen partnerships with other regional and international public health agencies and experts, creating working relationships that result in more relevant, effective and usable social listening recommendations and activities. This strengthening could include training for social listening teams, helping improve their understanding of public health concepts and emergency response protocols. Social listening and conversation monitoring are useful tools for gathering information and understanding public sentiment, but they are not sufficient on their own to manage rumours and control misinformation, The volume and speed of Information they 74 Strengthening health and well-being through sport events Changing the game generate – especially during a high profile event – can be overwhelming and impossible to keep up with, making it difficult to identify and address misinformation quickly. Managing misinformation requires real time response capabilities in the form of coordinated response teams that can quickly verify information, communicate corrections, and engage with the public. Simple monitoring tools often lack the ability to provide instant alerts or facilitate immediate action Effectively managing rumours and controlling misinformation during a major sport mass gathering event like FIFA needs a comprehensive approach that combines advanced technological tools, triangulation of findings with other critical data sources, community feedback mechanisms, and strategic planning with human expertise. “ During the FIFA World Cup Qatar 2022, social listening was a game-changer in our efforts to monitor public health conversations and sentiments and respond promptly and effectively to alarming signs. It allowed our RCCE taskforce to stay attuned to community concerns and guide our two ways communication effectively. For future mass gathering events of this scale, investing in specialized public health listening tools and fostering closer collaboration with data science experts is crucial. By enhancing our capacity to filter relevant information and generate actionable insights, we can ensure more effective and timely public health interventions, ultimately strengthening community trust and engagement.” Statement from the RCCE team, WHO Regional Office for the Eastern Mediterranean 756.1.6 Example: social listening and RCCE Education City Stadium Al Thumama Stadium Ahmad bin Ali Stadium Stadium 974 Khalifa International Stadium Al Janoub Stadium Al Bayt Stadium Lusail Stadium renovatedbuilt stadiums dedicated to the World Cup8 7 1 More than 3 million tickets sold On average 40% of tickets were sold to residents in Qatar Average stadium occupancy 96% 1.4 million visitors 76 Strengthening health and well-being through sport events Changing the game 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 Total fan zone attendance 2 687 567 Total attendees to corniche activations 3 646 456 On average around 242 144 were attending activations daily 300 000 articles screened by Epidemic Intelligence from Open source (EIOS) 0 zero outbreaks 54 306 food samples 3 567 food safety inspections 776.1.7 Summary Mobile teams on foot patrol and bicycles equipped with medical supplies. © Hamad Medical Corporation Providing health Health care system Managing health systems during the FIFA World Cup Qatar 2022 meant working to core principles: • making sure that day-to-day national health care services for Qatar residents were unaffected by the World Cup; • providing primary care services to spectators in all the tournament venues in a way that protected emergency departments from being overwhelmed; • providing comprehensive health care coverage to everyone that needed it throughout the tournament; • providing free emergency and urgent care services to all Hayya Card holders (see Box 4); • providing athlete care in line with FIFA requirements for host countries; • being fully prepared for any major incident. These goals were ambitious. Achieving them meant making the most of the efficiencies offered by the S4H model, and working closely with many local health care partners to deliver medical and support services. Qatar set up a parallel health care system to provide in-event health services and support set-up and take-down of tournament sites. Ultimately, it worked: this health system registered 53 083 visits across over 100 FIFA World Cup Qatar 2022 competition and non-competition sites, around 83% of which were during the 30-day World Cup period, without a measurable effect on day-to-day performance data. The parallel health care system was running for a total of 278 days (216 days supporting set-up, 30 days for the FIFA World Cup Qatar 2022 tournament, and 32 days to support the disassembly period). The majority of the medical visits were registered during the tournament. 80 Strengthening health and well-being through sport events Changing the game It is likely that the long period of preparedness helped ensure the smooth running of the tournament. It is also notable that the FIFA World Cup Qatar 2022 was structured very early on as a family- oriented event, the fact that the stadia were alcohol free significantly reduced the risks associated with the harmful use of alcohol among spectators. Throughout the tournament, Qatar saw only 177 cases of alcohol intoxication, corresponding to 0.4% of all patient presentations. This proportion is lower than the range reported for other sports events around the world (from 1% to 10%) (22). Other things that may contributed to the safe outcome include a public health working culture that set very high standards; a large number of drills and exercises and the use of the FIFA Arab Cup in 2021 as a testing event that used the same, fully occupied, stadiums as the World Cup; an all-hazards approach to risk assessment and preparation; and the high levels of surveillance and intensive activity in response to the COVID-19 pandemic. Figure 19 Number of patient encounters in tournament related healthcare services from 18 April 2022 to 19 January 2023 Source: HMC Business Intelligence Unit, 2022 Before 18 April 2022 - 19 Nov 2022 5 546 visits During 20 Nov 2022 - 18 Dec 2022 44 029 visits After 19 Dec 2022 - 19 Jan 2023 3 508 visits 50,000 30,000 40,000 20,000 10,000 0 216 Days 30 Days 32 Days Dismantling of service 817.1 Health care system Figure 20 Hayya application profile user interface (23) 82 Strengthening health and well-being through sport events Changing the game The Hayya card Anyone visiting Qatar between 1 November and 23 December 2022 had to have an approved Hayya Card prior to entry. The Hayya Digital Card allowed visitors entry to Qatar, free public transportation, and easy entry into stadiums for matches. The Hayya Card was available digitally, through an app, and in physical form. It was a compulsory entry requirement for all international visitors – including GCC nationals and residents – regardless of the purpose of their visit, from 1 November to 23 December 2022. The Hayya Digital Card was used as secure identification: citizens and residents needed their ticket number, Qatar ID number and date of birth details to apply for the card, while visitors needed their ticket number, accommodation details and personal information. Once approved, the digital version of the ID was also available in the Hayya mobile app. A Hayya Match Day Pass was also introduced. This was an entry permit valid for up to 48 hours from the designated arrival date, and applied to all international ticket holders in Qatar during the tournament. Spectators needed a valid FIFA Match ticket and a valid passport in order to obtain a Match Day Pass. Features of the Hayya digital card: • served as the only entry permit to Qatar • fully digital service (physical Hayya also available) • secure identification and stadium access with FIFA match ticket • access to free public transportation services – metro, bus and taxis Features of the Hayya mobile app: • access to holder’s personalized digital Hayya Card and ID • access to match tickets • journey planning • access to tourist attractions and information 837.1 Health care system Predictive modelling Throughout 2021 and 2022, health care teams worked to assess risk and carry out predictive modelling for different aspects of health services at the FIFA World Cup Qatar 2022, namely: 1. demand for clinical services (minor injuries, ambulance calls, hospital admissions, etc.); 2. COVID-19 pressures and responses (i.e., modelling to predict increases in COVID-19 transmission and subsequent hospital admissions); 3. major incident bed capacity (predictions were made for a range of major incident scenarios, and bed capacity escalation plans were put in place to meet potential increases in demand). The data used to build the model on demand for clinical services came from a study done during the Brazil FIFA World Cup in Fortaleza in 2014, and from the FIFA Tournament Time Demand Model (24, 25). The data for COVID-19 prediction were developed by a collaborative effort of several institutions in Qatar3 on the basis of the epidemic evolution in the country. This modelling programme was an important part of the development of the overall FIFA World Cup Qatar 2022 public health strategy and staff resourcing plans. Throughout the tournament, the modelling proved quite accurate, and services operated broadly as planned. 15 20 10 25 5 0 H os pi ta l o cc up an cy o f C O VI D -1 9 pa tie nt s in IC U -c ar e be ds 01/08/22 01/10/22 01/12/2201/09/22 01/11/22 01/01/23 Figure 21 Number of expected ICU bed occupancy for COVID-19 cases on the basis of three scenarios with changing contact rate during the FIFA World Cup Qatar 2022 Source: Weill Cornell Medicine-Qatar, 2022 Duration of stay of World Cup visitors = 4 days Duration of stay of World Cup visitors = 7 days Duration of stay of World Cup visitors = 14 days 3 Infectious Disease Epidemiology Group and WHO Collaborating Center for Disease Epidemiology Analytics on HIV/AIDS - Weill Cornell Medicine-Qatar; Ministry of Public Health; Hamad Medical Corporation 84 Strengthening health and well-being through sport events Changing the game 1400 500000 600 250000 800 300000 1200 450000 400 200000 1000 400000 350000 200 150000 100000 50000 0 0 16 /1 1 17 /1 1 18 /1 1 19 /1 1 20 /1 1 21 /1 1 22 /1 1 23 /1 1 24 /1 1 25 /1 1 26 /1 1 27 /1 1 28 /1 1 29 /1 1 30 /1 1 1/ 12 2/ 12 3/ 12 4/ 12 5/ 12 6/ 12 7/ 12 8/ 12 9/ 12 10 /1 2 11 /1 2 12 /1 2 13 /1 2 14 /1 2 15 /1 2 16 /1 2 17 /1 2 18 /1 2 19 /1 2 20 /1 2 21 /1 2 22 /1 2 23 /1 2 24 /1 2 25 /1 2 Medical Encounters Visitors M ed ic al E nc ou nt er s To ta l V is ito rs Figure 22 Number of expected visitors and expected daily medical encounters in Qatar during the FIFA World Cup 2022 Source: HMC Business Intelligence Unit, 2022 Experience of past events Qatar hosted many high-profile sporting events in the years running up to the FIFA World Cup Qatar 2022 and has continued to do so since. The health care system played important roles in supporting the successful hosting of all of these events – including but not limited to the 2019 FIFA Club World Cup, the International Association of Athletics Federations (IAAF) World Athletics Championships 2019 and the FIFA Arab Cup 2021 (the last of which was followed by the full after-action review mentioned earlier in this document). This gave the health care sector valuable experience of coping with large events, and provided opportunities to test major incident response plans ahead of the World Cup. 857.1.1 Predictive modelling Access to health care The heart of the health care strategy for visitors was simple: enable easy access to high-quality medical care for all fans. The second priority, just as important, was to make sure that day-to-day health care for Qatar residents was completely unaffected. Visitors coming to Qatar for the tournament could get medical care at any private or public hospital, medical centre, clinic or pharmacy. If they needed emergency or urgent medical care, they could get it at HMC facilities throughout the tournament, free of charge if they presented their Hayya Card. If they received non-emergency or non-urgent health care services at public facilities instead of the dedicated FIFA World Cup Qatar 2022 facilities set up for the tournament (where they could get them free), then charges did apply. The easy access principle meant providing services in the locations most visited by fans and tournament participants. This meant setting up temporary urgent care medical clinics across stadiums, fan zones, training grounds and accommodation sites, decentralizing to the greatest possible extent the emergency and urgent care services provided by existing facilities. These facilities included: • 113 medical clinics • 114 ambulances • 212 mobile medical units • 2 275 health care staff Figure 23 summarizes the medical encounters during the FIFA World Cup Qatar 2022 by type of service. Overall, there were 44 029 medical encounters, of which 19.8% were handled by mobile teams; 55% were seen in urgent care clinics at stadiums, fan zones and fan villages; 19.9% at hospital emergency departments; and 5.3% in other health facilities. In 52.5% of all medical encounters using FIFA World Cup Qatar 2022 health services, the patients were staff members, including FIFA staff. © Hamad Medical Corporation Emergency mobile team providing care during an incident with support from bicycle and ambulance units. 86 Strengthening health and well-being through sport events Changing the game Figure 23 Tournament related medical encounters at World Cup health services (mobile medical teams and onsite clinics), and hospital emergency departments from 20 November to 18 December 20224 Source: HMC Business Intelligence Unit, 2022 To p lo ca ti on s Pa ti en t ty pe Buggy: 67 Scooter: 230 Golf cart: 637 Bike team 749 Foot patrol: 7 017 8 70 9 Mobile Team Encounters Activations 35.1% Stadiums 32.9% Fan zone 32% Staff 45.4% Spectators 51.2% Other 3.4% 8 48 3 Hospital ED Encounters HG Hamad ED 59.1% Spectators 83% Staff 14.5% Other 13.9% AW Al Wakra ED 20.9% Ak Al Khor ED 6.1% Other 13.9% 24 5 04 Onsite Clinic Encounters Stadiums 42.8% Staff 83% Spectators 25.7% Fan zones 15.5% Fan villages 11.6% Other 4.5% Other 30.1% 4 World Cup health services are defined as those services created specifically to address the needs of people working at or attending the World Cup, as described in this report; or requests to access day-to-day health services from people who were in Qatar for the World Cup (i.e. those people using the Hayya Card) 877.1.2 Access to health care The emergency departments of Qatar’s hospitals saw a total of 8305 medical encounters with spectators and visitors during the tournament. Considering that the estimated number of individual total visitors in Qatar for the FIFA World Cup Qatar 2022 was 1.4 million people (3) , the estimated presentation rate of spectators and visitors at the emergency department was 5.93 per 1 000. During the course of the FIFA World Cup Qatar 2022 there was a total of 359 ambulance transfers from tournament locations (i.e. stadium, fan zones or fan activation zones) to medical facilities. There were five cases of cardiac arrest among spectators, of whom three were successfully resuscitated and survived by the emergency team. Two patients died and this corresponds to a crude death rate of 1 in 700 000 spectators (Ministry of Public Health of Qatar, Sport for Health Database, unpublished data, 2024). The largest proportion of requests for medical assistance were due to respiratory symptoms (30.9%); other minor illnesses (27.3%); and minor trauma (9%). There were 177 cases of acute intoxication, mostly alcohol related, corresponding to 0.4% of total medical encounters (Ministry of Public Health of Qatar, Sport for Health Database, unpublished data, 2024). Spectator 43% Other categories and unspecified 2% Players 1% Media 2% Staff (security, volunteers, workforce, FIFA Staff etc) 52% Figure 24 Patient type using tournament related health facilities during the FIFA World Cup Qatar from 20 November to 18 December 2022 Source: HMC Business Intelligence Unit, 2022 Throughout the FIFA World Cup Qatar 2022 a total of 3 234 039 spectators attended matches in the stadiums. Among these spectators, there was a total of 3 771 medical encounters, corresponding to a rate of 1.16 medical encounters for every 1 000 spectators. This compares with rates observed in previous World Cups, which show a spectator presentation rate ranging from 1.21 to 2.7 per 1 000 spectators (24, 26, 27). 88 Strengthening health and well-being through sport events Changing the game The MCC unified language bank The Language Bank was a legacy programme initially built to support translation needs for patients and staff during the World Cup. It provided a 24/7 translation service through over 400 volunteer staff supported by over 30+ embassies in Qatar, with additional access to handheld translation technology. While HMC has around 31 000 staff and expected to be able to cover most of the languages that would be needed, the network was widened to allow remote communication for any exceptions. The Language Bank was managed by the NHICC, staffed by the MCC, and available through a dedicated phone number accessible by Emergency Departments, Urgent Care Centres, and medical staff. The service ran from 1 November to 19 December 2022. Figure 25 Language bank flyer 897.1.2 Access to health care Boosting the workforce Because of the firm commitment to avoid disrupting routine services, and because a steep increase in demand was expected, the health care workforce had to be expanded. Three things were done to cover this demand: internal redeployment of 1793 HMC staff and 139 PHCC staff; local recruitment of 170 new staff; and locum recruitment of 386 additional temporary staff members. Locum recruitment was particularly expensive – during a pandemic, qualified staff were at a premium, and they all had to be accommodated when accommodation was in extremely high demand – but it was essential in order to meet the commitment not to affect residents’ health services. It did, however, have the additional benefit of adding different languages to the workforce during the tournament period, which proved very useful. Other measures included cancelling all leave for essential staff for the FIFA World Cup Qatar 2022 period. Predictably, this wasn’t popular, especially because it had been done several times during the COVID-19 pandemic; but it did free up thousands of staff who could then be redeployed into clinical or nursing roles. In addition, a number of nursing staff were reoriented to work as foot patrol teams. Competition sites The “competition sites” were the FIFA World Cup Qatar 2022 football stadiums. On match days, health care teams provided a broad set of services within each stadium that went well beyond those contractually required by FIFA to support the tournament. More than 80 medical clinics were set up across the eight tournament venues, along with other important health care and supporting infrastructure. These facilities and services included: • up to 13 medical clinics within and around each stadium • two specialized field-of-play medical teams for each match • dedicated medical teams and ambulances for players • a range of emergency services, including up to 31 mobile medical teams and a minimum of eight ambulances per stadium. 90 Strengthening health and well-being through sport events Changing the game Non-competition sites There were over 25 designated “non- competition sites,” including accommodation villages for fans at Barwa Madinatna and Barahat Al Janoub; hotels for FIFA officials and high-profile visitors and authorities; national points of entry at Hamad International Airport, Doha International Airport, Doha Port and the Bu Samra border; media and broadcast centres; and operations and command centres. Across all of these sites, the health care sector provided a total of 108 mobile medical teams, 26 clinics (some of which were operating 24 hours a day, every day), 26 dedicated ambulances and approximately 1100 staff. One of the most high-profile aspects of this work, and one of the most demanding in terms of resources, was the provision of medical services at all official FIFA Fan Zones. The size and scale of the media and broadcast centre was also notable and should be borne in mind when preparing for any future event for which – like the World Cup – revenue is generated mainly through media rights. The scale of the centre, and the strategic importance of the supporting infrastructure, were almost on a par with the equivalent measures for spectators. © Supreme Committee for Delivery and Legacy The entrance to the FIFA World Cup Qatar 2022 Fan Zone. 917.1.2 Access to health care Hospitals The hospital system had to do a lot of emergency preparation, increasing bed capacity and making other arrangements necessary to receive potentially large numbers of people. Surge capacity was planned for around 4 000 additional beds, available within 24 hours. A large blood donation drive took place before the tournament to make sure national blood reserves were ready to meet the needs of large numbers of people. Hospitals prepared to operate under intense media scrutiny, and made ready for the implications of potential high-profile cases (for example, receiving well-known players with traumatic football injuries, or other high profile individuals attending the tournament and falling ill). FIFA rules required high priority patient care routes and various other special processes for high profile people, all of which were integrated into preparations. The Aspetar Orthopaedic and Sports Medicine Hospital in Doha was responsible for managing sports-related cases (28). Primary health care centres Primary health care centres were an important part of the health care strategy. The PHCC used its network of 30 health centres in 2022, 24-hour urgent care facilities and a community call centre to provide health care for self-presenting visitors and address public health concerns, including in onsite clinics in stadiums, hotels, and media centres. To enhance accessibility, the PHCC increased the use of virtual health care, expanded call centre capacities, and promoted services that delivered medication to people at home. The workforce hub To support the expanded clinical workforce, a dedicated hub was established at the HMC Medical Education Centre. The Workforce Hub was a centralized service that had the job of managing daily assignment of clinical staff to stadiums and non-competition venues. Among other crucial tasks, the Hub documented all staff time and attendance records, provided daily staff briefings, and collected and distributed FIFA accreditation passes. The Hub had over 30 staff of its own and worked 24/7 to support the FIFA World Cup Qatar 2022 workforce. This also meant managing transport arrangements. Approximately 3 000 clinical staff per day had to move between the central Hub and their shifts at assigned competition and non-competition sites. Qatar has a high level of private car use but couldn’t have accommodated this many people moving to and from a small number of destinations at the same time in private vehicles, so the Hub was given the task of arranging team transport. 92 Strengthening health and well-being through sport events Changing the game Communication across the health system Communications teams at the Ministry of Public Health, HMC and the PHCC worked with other colleagues across the health care sector to ensure everyone at the FIFA World Cup Qatar 2022 was aware of the full range of health care available to them. A dedicated website provided local and visiting fans with information on health care services and health advice. Communications teams delivered regular messages to local and international fans through media including press releases, interviews and social media messaging. As part of the work of the S4H partnership, health communication teams also worked closely with communications teams at WHO, FIFA, and the SC to promote healthy lifestyles and ensure a safe FIFA World Cup Qatar 2022 experience for all. More information on these initiatives can be found elsewhere in this report. 937.1.2 Access to health care Key services Ambulance services The HMC Ambulance Service, Qatar’s national ambulance provider, planned for a higher volume of calls than normal during the tournament. 116 ambulances were available for the tournament period, and each stadium had eight ambulances present and a further four on standby when matches were taking place. The Ambulance Service was able to respond to over 4 000 World Cup-related calls without impacting normal services, despite being the most World-Cup affected component of the health system. FIFA imposes a large number of specific ambulance requirements in a World Cup tournament (for example, how many ambulances have to be stationed at stadiums, training sites, etc.), and the supply of vehicles, equipment and consumables was limited. In previous tournaments held in larger countries, host cities have historically borrowed ambulances and other mobile infrastructure from non-host cities. But in 2022, Qatar’s small size – it has only one major city – means that moving additional internal resources around the country was impossible. Because of the COVID-19 pandemic, it was also impossible to borrow resources from neighbours like Saudi Arabia and Dubai. The solution was to modify the national ambulance refreshment scheme, extending the lifetime of some vehicles to cover the tournament period and bringing forward the next round of procurement. World Cup preparation started early for the ambulance teams. Like other uniformed services, they had the benefit of being used to the more military-style command and control structures that were adopted for the World Cup, in a way that other health care professionals tend not to be. Testing was done in small teams using the FIFA World Cup Qatar 2022 strategic, tactical and operational command structures to oversee operations and produce daily sitreps. One legacy component of the work of the Ambulance Service is the Health Care Locum programme, which was set up to bring in foreign health care providers on temporary contracts to support health care service provision in mass gatherings. Recruited staff go through an onboarding schedule, then support health care provision for three to four months, then leave to apply the skills they learn in Qatar in their home countries. Since the World Cup, this system has been used for multiple events – some sports related, like the Asian Football Confederation Asian Cup Qatar 2023 (held in February 2024), and some cultural in nature. 94 Strengthening health and well-being through sport events Changing the game Sobering stations High alcohol consumption among spectators at large sporting events, and particularly football events, has caused or exacerbated problems managing safe and healthy mass gatherings in the past (29). The cultural context of Qatar meant that prior to the World Cup, national health services had only limited experience dealing with these issues. Specific preparation and response mechanisms were needed. As a result, and after consultation with staff who had worked in previous World Cups (for example, in South Africa in 2010 and in Russia in 2018), the ambulance service staff developed an experience-based guideline for how to handle such cases. Considerable time was spent to ensure that Qatar was well prepared and resourced with specialized sobering stations at each of the major non- competition sites, linked to emergency departments at medical facilities and HMC hospitals. This was done as part of efforts to ensure a family-friendly tournament, and to mitigate any potential risks. This unique approach, which was only done in Qatar and the United States of America, serves as a pilot, which can benefit other countries. The network consisted of two event-based sobering stations (20 beds at the FIFA Fan Festival, operational until 3am daily and 20 more at the Qetai FanZone, operational until 4am daily); three hospital- based sobering stations, at Hamad General Hospital, Al Wakra Hospital and Al Khor Hospital respectively, all operational 24/7. A single Clinical Guideline for Sobering Stations (Figure 25) was in use at all sites, supplemented by alcohol management pathways and training materials that were widely shared with security agencies and event management teams. These facilities were completely new to Qatar, where a severe case of alcohol intoxication might previously have expected medical treatment according to their presentation – that is to say, with immediate transfer to an emergency department, and perhaps even a CT scan and an onward referral to mental health services. Clearly this approach would not be advisable or cost effective in the type of situation that might – looking at previous World Cups - be expected to develop during the tournament, with multiple cases of alcohol intoxication. Use of dedicated stations was the answer. 957.1.3 Key services Figure 26 Clinical guideline for sobering stations developed by HMC ambulance service Medical assessment of any injuries and of the level of consciousness/alertness Ambulance Service (or other medical team member) assessment at the scene No Injuries and A or V on the AVPU scale Unable to walk with the aid of one other person Assessment of Vital Signs RBS > 4.5mmol Pulse :> 55/<120 Resp. R: >10/<25 Temp: >34/<38 No Injuries and A on the AVPU scale Can walk unassisted or with the aid of one other person Instruct to leave the area and return to their accommodation Refer to the nearest Emergency Department Instruct to leave the area and retum to their accommodation Refer to the nearest sobering station (or ED if needed) Injured and/or P on the AVPU scale Are vital signs normal? NO NO YES YES YES YES YES Does the patient request medical assistance? Accompanied and now able to walk BUT unaccompanied and unable to walk BUT unable to walk with the aid of one other person 96 Strengthening health and well-being through sport events Changing the game GCS 15/15 Vital signs within normal limits Coordinated movements Able to walk unaided, or with the aide of a friend/relative And not in danger of falls / danger to self Patient declining advice and electing to self-discharge - must be asked to sign a discharge against medical advice form Advise Discharge Advise staying in sobering station or transfer to ED Are all the above criteria met? 977.1.3 Key services However: despite providing 93 beds across five sites, these facilities were only accessed 66 times across the entire tournament, and several of these admissions were unrelated to alcohol (coming instead from pragmatic decisions to use the facilities to provide other care). Evidence suggests that patient presentation rate for alcohol intoxication r (i.e. the total number of patients presenting with intoxication/total number of patients) has ranged between 1% and 10% for previous sporting mass gatherings. In contrast, Qatar had only 177 total cases of intoxication during the FIFA World Cup Qatar 2022. for a patient presentation rate of 0.4%, significantly lower than the value reported for sports events around the world (22). Reasons for this may include the fact that stadia were alcohol free, which reduced opportunities for fans going to matches to consume alcohol, thus decreasing the potential for intoxication; the fact that intoxicated people were often part of a group of friends familiar with the symptoms, who took care of their intoxicated companions at their hotel or elsewhere; and the decision to promote a family-friendly tournament. Urgent care walk-in units Dedicated walk-in units were set up in hospitals across the country to treat fans with urgent but non-emergency care needs. Over 6 000 patients benefited from these units. In the meantime, the PHCC’s eight existing urgent care health centres were not advertised to visitors in Qatar for the World Cup, but were heavily promoted to residents, in an effort to reduce unnecessary pressure on the Ambulance and Emergency Services. Sexual assault referral mechanism It was a FIFA requirement that preparations be made for any potential rise in incidence of sexual assaults during the World Cup (30). Initially, planners in Doha considered establishing a dedicated centre, but eventually decided that it would be more efficient to establish a referral mechanism instead. Placed within Al Wakra Emergency department, this mechanism was an innovative approach for Qatar. It offered services including screening for sexually transmitted infections, prevention and treatment including psychological support. In the event, this expected rise in assaults did not materialise. It is very likely that the lower-than-expected incidence was another consequence of the partial ban on alcohol sales and the deliberate effort to create a family friendly environment around the tournament. This area of work provided further long- term benefit to the health system by strengthening working relationships between the Ministry of Public Health, health providers and other departments and sectors. For example, preparations for dealing with sexual assaults meant establishing relationships with forensics services, which in Qatar are the responsibility of the Ministry of Interior. 98 Strengthening health and well-being through sport events Changing the game The FIFA World Cup Qatar 2022 helpline A Government Health care hotline was available around the clock. Fans and visitors could call this free phone number for advice about the health care services they could get during the tournament at any of the country’s private or public hospitals, medical centres, clinics, or pharmacies. Operators could also answer any other health care enquiries. Fans could access the line by calling the toll-free helpdesk on 16000 at any time of the day or night. To help fans and visitors communicate, operators spoke a range of languages. If a caller had a question about medical and urgent care, operators could guide them to the nearest fan clinic. To make sure the public received proper and accurate information when they needed it, collaboration was established between the 16000 helpline and the World Cup Hayya Helpline (established to handle queries about use of the Hayya Card, including ticket and visa enquiries), so that Hayya operators knew how to channel health care queries to the right places. Between 9 November and 31 December 2022, the 16000 call centre received over 6 700 calls from fans about health care services, medical and urgent care, travel policy, travel health insurance, and treatment for chronic diseases. 997.1.3 Key services The FIFA World Cup Qatar 2022 daily situational report Strategic and tactical decision-makers are not always technical experts in public health, and data can be of limited use to them unless it is validated, analysed, interpreted and presented in a digestible format. If leaders do regularly receive information prepared in this way, then they can make accurate, effective decisions under pressure. Inspired by a system developed by the Japanese government and WHO for health reporting during the 2020 Tokyo Olympic Games, planners decided to compile a daily health situation report (or SitRep) and distribute it to public health leaders at a set time each day before, during and after the World Cup. The SitRep was the result of collaboration between different teams and departments. Designed to facilitate fast, evidence-based decision making, it had to cover all health information vital for decision making in a single page. The processes needed to produce the SitRep every day required the establishment of an Event Review Group of public health experts from different disciplines, who were responsible for translating science and data into options for policy- and decision-makers. It required a system for constant involvement of important stakeholders in the health system and research community and ongoing collaboration with WHO. Development The Health in All Policies team developed a concept for the report, informed by discussions with other stakeholders around the availability of data and the prioritization of indicators. The report evolved through several iterations through the engagement of experts from the Strategic Planning and Performance and Innovation Department, the Ambulance Service, HMC’s Business Intelligence Unit, the Ministry of Public Health surveillance team, and other national research and policy teams. It was also discussed extensively with WHO, to capitalize on the experiences of other mass gathering events. Developing this tool meant overcoming a number of challenges. The report had to be extremely concise and on time every day. Space on a one-page document was scarce, and a number of stakeholders requested more space for more indicators. This made effective prioritization crucial. The speed of reporting was also carefully considered in the selection of the indicators for the report. A period of intense negotiations around content and timing – supported by close collaboration with WHO – saw development of 11 versions of the report and accompanying production processes. These led up to a penultimate version that was finalized by the Event Review Group before review and approval by the Strategic Health Command Group and the Minister of Public Health. This outcome of this process was a seamless, smooth meshing of information from different sectors of public health and health care, generating a comprehensive set of up-to- date information for policy makers. Every contributor had a full understanding of the process and was literally “on the same page.” 100 Strengthening health and well-being through sport events Changing the game “ The FIFA 2022 Daily Situational Report showcased excellent public health surveillance at large events. Its success came from the dedication of everyone involved, with teams working 24/7 to ensure a smooth and timely exchange of information. The ERG was crucial, actively contributing to surveillance and providing quick, actionable insights. The report was well- designed, offering detailed risk assessments while including an important air quality health index, often missed in similar reports but vital for vulnerable groups. Working on this report was an incredible experience. Early mornings and tight deadlines were challenging, but collaborating with diverse health providers and turning data into actionable steps was truly rewarding, the enthusiastic and efficient teamwork made it all worth it. Overall, the Sit report demonstrated how quickly health data can be turned into actionable information, much like watching a video on fast forward.”                                                        -Sara Khalife, Research Specialist and Sitrep HiAP Unit Focal Point- Ministry of Public Health 1017.1.4 The FIFA World Cup Qatar 2022 daily situational report Total COVID-19 & ty rate 5.9 8.9 0.0 2.0 4.0 6.0 8.0 10.0 12.0 0 200 400 600 800 1000 1200 1400 1600 01.10.22 01.11.22 Total Po ves Moving average cases (7 days) Moving average posi vity rate (7 days) SURVEILLANCE FIFA WORLD CUP 02 December 2022 DAILY SIT REPORT Global, Regional & Na ghts: •Measles: South Africa (71 cases), United States of America (99 cases), India (7 cases , 17 suspected), •COVID-19: United States of America(130 cases of XBB reported), France increasing ns, China, Hong Kong SAR (10,137 cases of pneumonia due to COVID) •Meningi : France (4 cases, 1 death) •Dengue fever: Sudan (500 cases, 29 deaths), Bangladesh (380 cases), Pakistan (48 cases) Daily Risk Assessment Poten al impact on na al health Comments: •Levels of risk unchanged ng n of stabil of indicators1 2 3 4 5 X Poten al impact on games X ERG Insight/Recommenda •There are early signals of stabiliza on of frequency of s. •Slight further increase of NO2 due to traffic n. Emergency Encounters HMC/PHCCHospital Occupancy (Excluding surge capacity) UPTAKE OF TOURNAMENT HEALTH SERVICES Data Feed Remarks: •1 suspected s case reported on 1 December was confirmed •10 suspected (1) was posi ve for HHV6; (1) was posi ve for HSV1. (8) other cases all •7 new hospital admissions due to COVID-19 •Suspected MERS case update: the confirmatory tests were Sobering Area Beds pts Bidda Park 20 0 Al Khor 11 0 HGH 22 2 Wakra 20 0 Qetaifan 20 0 *Occupancy data extracted at 08:43(HMC), 13:00 (private hospitals) PCR An gen Tests Daily total 0 20 40 60 80100120140160180200 Coordina on Centers (5) Event Hubs (2) Fan Villages (4) Corniche ac va on Lusail Boulevard Media Centers (4) Hotels (53) Ports of Entry (6) Non-match Stadiums (4) Training Facility (33) Other Mobile teams Urgent Care Clinics Ambulance transfers RSV Flu A/B 3 20Daily confirmed cases Unit Capacity Non-COVID COVID Occupancy Occup% Acute care 2290 1,821 45 1866 81% ICU 159 116 1 117 74% PICU 36 22 0 22 61% NICU 142 114 0 114 80% Total 2627 2073 46 2119 81% Acute care 454 NA NA 290 64% Cri cal care 88 NA NA 64 73% Total 542 NA NA 354 65% HM C Pr iva te Date Walk in Amb. Transfer PHCC Walk in Amb. transfer PHCC Total 25-Nov 218 76 15 3,059 360 363 4091 26-Nov 257 87 20 3,173 383 403 4323 27-Nov 251 87 17 3,038 425 363 4181 28-Nov 246 72 18 2,854 424 348 3962 29-Nov 293 84 15 2,899 405 347 4043 30-Nov 275 78 24 2,816 404 338 3935 1-Dec 317 72 20 2,548 395 358 3710 Tournament related Non-tournament Related Time: 00:00 to 23:59 Ambulance calls: ↑17% (same day in 2019) Top Prese complaints: 1. Respiratory (majority minor) 2. Minor illness 3. Pain (body extre es & back) (01 Dec 2022) ↓ ↓ ↓ ↓ ↓ ↓ ↓ (241) (1,211) (35) ↓ ↓ ↓ Event sites HMC Gastroenteri s 18↑ 0↓ ARI 535↓ 117↓ Fever 1↓ 6↑ Rash 2↓ 0 Syndromic repor ng 0 5 10 15 20 25-Nov 26-Nov 27-Nov 28-Nov 29-Nov 30-Nov 1-Dec Gastroenteri s Rash 0 200 400 600 25-Nov 26-Nov 27-Nov 28-Nov 29-Nov 30-Nov 1-Dec ARI cases GI & Rash cases Confirmed infec •COVID19(Ct≤25):25 •Rhinovirus: 1 Capacity Mobile Team Urgent Care clinic Amb. Transfer 1 Al Thumama 44,000 45 146 2 2 Khalifa 44,000 18 13 2 3 Ahmad Bin Ali 44,000 26 159 2 4 Al Bayt 66,000 9 188 1 Total 198,000 98 506 7 1 Al Bidda Park 50,000 24 40 1 2 Al Khor 15,000 1 17 1 3 Asian Town 40,000 13 33 0 4 Qetaifan Island 30,000 3 6 1 Total 135,000 41 96 3 Match Stadiums Fan zones ↓ ↓ ↓ Figure 27 One day FIFA World Cup Qatar 2022 daily situational report Source: Sport for Health database, 2022 102 Strengthening health and well-being through sport events Changing the game Figure 28 One day of the air quality health index summary report submitted as an appendix to the situational report on a daily basis Source: Sport for Health database, 2022 12/10/2022 Air Quality Health Index 0 2 4 6 8 10 Yesterday Today Tomorrow Doha AQHI: 5 ThumamaKhalifa buonaJlACE479liasuLABAtyaB lA Comments: Alerts: Strong NW winds, up to 30-35 km/h, for Saturday 10 Dec Forecast Data Provided by QEERI AQHI Key: 1-3 (low), 4-6 (moderate), 7-10(high), 11+ (severe) Date PM2.5 PM10 NO2 O3 HI 9-Dec 15.9 55.9 29.6 79.1 23.1°C* 10-Dec 30.8 117.3 60.6 78.1 22.3°C 11-Dec 28.7 107.8 60.3 74.7 21.9°C Monitoring station location (owned by): • American School of Doha (QEERI) • Al Thumama Stadium (QEERI) • Education city (QEERI) • Hamad Medical City (QEERI) • Al Wakra Hospital (QEERI) • Madinat Khalifa (MOPH) 09/12/2022 10/12/2022 11/12/2022 Stadium/AQHI 24h 3h-Max 24h 3h-Max 24h 3h-Max Al Bayt 3 5 (14:00-17:00) 4 5 (18:00-21:00) 4 5 (16:00-19:00) Khalifa 5 7 (16:00-19:00) 5 7 (16:00-19:00) 5 7 (20:00-23:00) Al Thumama 5 6 (18:00-21:00) 5 7 (21:00-24:00) 5 6 (19:00-22:00) Ahmad Bin Ali 3 5 (17:00-20:00) 3 4 (17:00-20:00) 3 4 (17:00-20:00) Lusail 4 4 (19:00-22:00) 4 4 (19:00-22:00) 4 5 (20:00-23:00) 974 Stadium 3 3 (06:00-09:00) 3 4 (06:00-09:00) 3 5 (21:00-24:00) Education city 5 7 (18:00-21:00) 5 7 (18:00-21:00) 5 6 (19:00-22:00) Al Janoub 4 6 (18:00-21:00) 5 6 (18:00-21:00) 5 6 (20:00-23:00) *Averaged data The confidence interval for AQHI is 1 AQHI Key: 1-3 (low), 4-6 (moderate), 7-10(high), 11+ (severe) 3-hour maximum forecast provided by QEERI 1037.1.4 The FIFA World Cup Qatar 2022 daily situational report Objectives Designed as a tool to help different stakeholders work towards common goals using up-to-date information, the one-page Sit Report was a brief, clear and comprehensive daily overview of the health situation in Qatar, drawn from pre-interpreted data presented to support evidence-based decisions based on full risk assessments. The Sit Report had three goals: 1. summarize a set of predetermined, high priority health indicators; 2. provide daily updates of validated data; 3. provide daily insight and expert recommendations to support rapid, targeted strategic and tactical decisions by high level authorities. Each SitRep was a snapshot of the health situation and related news on that day and had to meet specific criteria. It had to be comprehensive, with enough data to allow strategic risk assessments, and had to include data not only from lab and core systems, but also from analysis of non- infectious threats like air quality. It therefore had to be the highly coordinated result of information pulled from across different data sources and surveillance tools. Process This need for coordination in close to real time required completely new processes to capture, gather and display information for action, then deliver it to a central coordinating point for analysis. That analysis had to be done by a team with expertise in mass gatherings; an overarching view of public health; knowledge of the pressures of the World Cup; and an understanding of the command, coordination, and communication arrangements in place for the event. Input Compilation Risk assessment & recommendations Revision of report & executive summary Decision making Pr oc es s Ministry of Public Health – Public Health Emergency Operations Centre 09 :0 0 Health in All Policies Unit 11 :0 0 Event Review Group (ERG) FIFA World Cup 2022 Health Strategic Command Group The Minister of Public Health National Health Incident Command Center/ Hamad Medical Corporation Business Intelligence Unit Qatar Environment and Energy Research Institute Primary Health Care Corporation Sidra Medicine Ministry of Public Health – Environmental Health Division D el iv er ab le Templates FIFA World Cup Qatar 2022 SitRep Risk Assessment Recommendations & Executive Summary Decision Focal Point sent the data by 9:00 Data source focal points sent data by 9:00 Sit Rep focal point compiles data and developed the first version of Sit Report At 9:45 all data focal points met for confirmation & briefing Discussed & interpreted data Evaluated & voted on risk assessment Added recommendations & insights Reviewed FIFA World Cup Qatar 2022 Took necessary action & answered queries if needed Received FIFA World Cup Qatar 2022 Executive Summary for decision 09 .0 0 104 Strengthening health and well-being through sport events Changing the game Input Compilation Risk assessment & recommendations Revision of report & executive summary Decision making Pr oc es s Ministry of Public Health – Public Health Emergency Operations Centre 09 :0 0 Health in All Policies Unit 11 :0 0 Event Review Group (ERG) FIFA World Cup 2022 Health Strategic Command Group The Minister of Public Health National Health Incident Command Center/ Hamad Medical Corporation Business Intelligence Unit Qatar Environment and Energy Research Institute Primary Health Care Corporation Sidra Medicine Ministry of Public Health – Environmental Health Division D el iv er ab le Templates FIFA World Cup Qatar 2022 SitRep Risk Assessment Recommendations & Executive Summary Decision Focal Point sent the data by 9:00 Data source focal points sent data by 9:00 Sit Rep focal point compiles data and developed the first version of Sit Report At 9:45 all data focal points met for confirmation & briefing Discussed & interpreted data Evaluated & voted on risk assessment Added recommendations & insights Reviewed FIFA World Cup Qatar 2022 Took necessary action & answered queries if needed Received FIFA World Cup Qatar 2022 Executive Summary for decision Executive Summary Executive Summary Priority Health Indicators Priority Health Indicators Risk Assessment Priority Health Indicators Risk Assessment Risk Assessment Executive Summary 13 .0 0 15 .0 0 11 .0 0 Figure 29 Process and timetable of the daily situational report Source: Sport for Health database, 2022 1057.1.4 The FIFA World Cup Qatar 2022 daily situational report Function Area of expertise Chair Public Health Vice Chair Governance & communication Sitrep focal point Epidemiology & project management Surveillance EIOS Infectious disease surveillence Environmental surveillance Food safety COVID surveillance Emergency response PHEOC Ambulance service Health emergency Global Health WHO mass gathering & Risk Communication and Community Engagement WHO coordination with headquarter and regions Medical laboratory Virology Microbiology Modeling Predictive modeling on healthcare utilization Predictive modelling on COVID and other infectious diseases Healthcare service Access Hospital care and primary Health care service utilization Academia Healthcare policy & research Epidemiology & public health Table 1 Recommended functions and areas of expertise to be part of a mass gathering event review group 106 Strengthening health and well-being through sport events Changing the game Every day, data was gathered from a wide range of sources (including different Ministry of Public Health units, public and private hospitals, and research institutes) then analysed early in the morning by the Health in All Policies Unit and compiled into an initial report (Figure 29). At 1100hrs each day, that report was reviewed by the ERG, a specially assembled mix of experts in epidemiology, environmental health, infectious diseases, virology, surveillance systems and data, ambulance and health services, RCCE, and mass gatherings (Table 1). The ERG also included WHO representatives to make sure that ERG decisions were aligned with the International Health Regulations and relevant global health monitoring and alert systems. Each day, the ERG considered data, trends and insights in members’ respective focus areas, and summarized the information in a risk score, based on set criteria, from 1 (“no action required”) to 5 (“emergency response”). Those scores were accompanied with recommendations for decision-makers. The SitRep also included daily ERG assessments of the potential health implications of air quality health index scores and air quality forecasts. Finally, the ERG added an executive summary to each daily report, highlighting the day’s most important health signals and options for decision-making. This was then assessed by the World Cup Health Strategic Command Group before submission to the Minister of Health for evaluation and decision. Each Sit Report (Figure 27) contained several sections: 1. uptake of tournament health services: summarizing the burden on tournament health services in competition and non- competition sites; 2. surveillance: outlining key information from infectious disease surveillance (with focus on COVID-19 and influenza cases), syndromic surveillance and wastewater surveillance (the latter was included twice weekly); 3. health care system status: covering public and private hospital occupancy rates (sorted into tournament- and non- tournament-related cases), emergency hospital admissions and use of emergency care for each day in the preceding week; 4. global, regional, and national insights: listing the main relevant health signals picked up by EIOS (see the Surveillance section); 5. data feed remarks: highlighting emerging relevant health signals and observations from data providers in the field; 6. daily risk assessment grading the potential impact of risks on national health and on the tournament; and 7. ERG insight/recommendations: the final section, including the daily risk assessment and the insights and recommendations of the ERG committee. 1077.1.4 The FIFA World Cup Qatar 2022 daily situational report Interview with Dr Roberto Bertollini, Public Health Advisor to the Minister of Public Health What were the benefits of having a sitrep during the FIFA World Cup Qatar 2022? The SitRep allowed for coordinated, systematic collection of health data during the FIFA World Cup Qatar 2022 to identify critical issues and facilitate public health response if and when necessary. Can you provide examples of how this informed or supported decision-making? We informed the Minister of growing air pollution levels that might require a public health announcement and provision of information to the public. The situation rapidly improved afterwards and this wasn’t necessary. Another example was the actions undertaken to check data on meningitis and cholera which turned out to be false alarms. What are your recommendations for future organizers of sport events? Make sure that daily health information is collected in real time with a high level of sensitivity, and that data are carefully checked and reviewed. Then present them to a group of scientific experts of different disciplines to provide decision makers with proper interpretations and options for action. Incident readiness and response The Ministry of Public Health and its health care partners were ready to deploy comprehensive major incident response plans at any time throughout the FIFA World Cup Qatar 2022. In the end, no major incident occurred and these services weren’t used. To ensure that Qatar was ready to face any health risk, or several years before the World Cup, the Ministry worked with WHO and national and international partners to develop and review major tournament-related incident response plans. These plans were put through a stringent series of simulation exercises that tested and evaluated health emergency response operations and the effectiveness of different teams. Based on the reviews of these exercises, plans and protocols were modified as needed. When the tournament began, systems were in place and command and control arrangements (See the event governance section) were clear. On match days, Mobile Command Units and dedicated major incident response teams were stationed at each stadium, backed up by routine ambulance service support. The Command Units were also communications hubs, relaying real time information, providing coordination, and standing ready to activate the response plans. In addition to the Command Units, each stadium also had a Major Incident Response Vehicle that contained all the resources needed to set up temporary field treatment areas – including a range of air-conditioned tents in which to treat patients with different levels of needs. 108 Strengthening health and well-being through sport events Changing the game Lab capacity Qatar’s laboratory capacity was increased to cope with increasing demands for testing under anti-doping procedures for the tournament. Additional supplies were procured. Other extraordinary measures were implemented for COVID-19 testing. From the beginning of the preparation period for the Arab Cup, an increased supply of testing consumables was brought in to deal with potential spikes in COVID-19 cases, and availability of testing instruments and manpower was increased to provide a significant boost to testing capacity. At peak, capacity was available to perform 80 000 COVID-19 tests per day. Preparations were also made for other possible outbreaks, including but not limited to outbreaks of emergent viruses, food poisoning, gastroenteritis and influenza. A send-out service was set up, using an organized network to refer any highly specialized tests to external laboratories in case of need. For blood and blood products, inventories of blood types were increased, preparations were made for donor collection drives if required, and five mobile donor truck teams were deployed across Doha. Agreements were in place with the armed forces for rapid mobilization of blood in case of a major event. A dashboard to give overall visibility of all stocks was created, and daily updates of stocks were circulated. All mortuaries were mobilized, with additional surge capacity and a daily dashboard to provide overall visibility of all available capacity. “ The HMC Department of Laboratory Medicine and Pathology was already on a heightened footing for the World Cup, following-on from the preparations put in place for the pandemic, which was still very much regarded as ongoing when the tournament began. A realignment of services as part of the return to normal practice was augmented with specific contingency planning for coping with emergency demands. For example, additional resources for any surge in COVID-19 transmission was expedited and the Blood Transfusion Service recruited additional donors to cope in the event of a major demand for platelets and blood. Thankfully the service faced no insurmountable demands and coped well within its margins of safety and resources.” - Dr Peter Coyle, Senior Consultant and head of Virology, HMC 1097.1.5 Incident readiness and response Specialist incident preparations The high-profile nature of the World Cup meant that Qatar had to be ready for extreme scenarios including mass casualty incidents, acts of terrorism and so-called “deliberate events” – that is to say, malicious acts intended to cause harm. Traditionally, deliberate events involve the use of hazardous substances such as chemical, biological, toxic and/or radio-nuclear (CBRN) materials, but the landscape of threats is become more complex. Emerging new threats also include disinformation and the misuse of digital and other technologies. The range of incidents and situations for which Qatar had to prepare meant it was necessary for health planners and teams to collaborate with colleagues in the security sector to build joint capacity to respond to high-risk situations. This involved a lot of learning, both from the literature and from these new partners’ experiences responding to mass shootings, explosions, and other traumatic events – for example, it was necessary to review expertise and research on limb amputations after blasts, and a drill was run around a poisoning scenario involving deliberate contamination of the food chain. After this process, changes were made to place particular resources at strategic sites – those places where quick, correct interventions were most likely to save lives after trauma. This included deploying tactical tourniquet teams during the tournament, and pre-positioning mass haemorrhage kits at potential target sites. The mortuary system was also prepared, and surge capacity was in place to accommodate a mass fatality event. Special repatriation arrangements were in place to make sure that the remains of any visitors who might die in Qatar would be treated properly and quickly. Simulation exercises and drills In preparation for the tournament, Qatar ran several exercises, including full-scale national health mass casualty exercises (Table 2). Not only were these exercises designed to test and refine national preparedness, but they were also intended to establish and reinforce a long-term environment and culture of learning, testing, exercising and practicing major incident response plans, policies, and procedures. Much of this testing was done using full- scale exercises, complex events that require detailed planning across many different sectors (31). These exercises were valuable opportunities for HMC, PHCC, Sidra Medical and the Ministry of Public Health to work together at all levels, from central national coordinating offices down to local service providers and responders, to identify, test and strengthen health system response capabilities for major incidents. The testing of plans took place at three levels: within individual parts of the health sector bodies; between parts of the health sector; and between the health sector and other national agencies. 110 Strengthening health and well-being through sport events Changing the game Agency Training and exercises HMC WHO Mass Casualty Management Course (for front line ED staff) – March 2022 Cybersecurity Workshops – April-June 2022 Training of all HMC GOLD Commanders – June 2022 GOLD Command Communications Exercise – July 2022 SILVER Command Team training for all HMC facilities – May – June 2022 GOLD/SILVER Command Communications Exercise – October 2022 All HMC facilities locally tested MIPR plans at SILVER/BRONZE level All Health Sector WHO Arab Cup Mass Gathering Tabletop Exercise – November 2021 FIFA Arab Cup Debrief and After-Action Review (led by WHO After Action Review Team) – March 2022 HealthCheck 3 (large-scale functional exercise facilitated by WHO SimEx and Mass Gatherings Team) – August 2022 (25) All Health Sector with other external agencies Al Watan: National World Cup Security Exercise – November 2021 Al Watan: National World Cup Security Exercise – October 2022 HMC Ambulance Service with other external agencies Joint functional and tabletop exercises with Qatar Rail – February – August 2022 Doha International Airport Airport Test Exercise – June 2022 Joint functional and tabletop exercises with Qatar Rail – August – November 2022 Table 2 Health sector major incident preparedness exercises and training 1117.1.5 Incident readiness and response Improving case investigation and outbreak response Many different actions were taken to improve case investigation and outbreak response capacities for the World Cup. These included setting up an entirely new outbreak investigation team; running new risk assessments and gap analyses; creating a series of manuals, guidelines, and SOPs to improve workflow (including the guidelines for outbreak investigation and response in mass gatherings); hiring more multilingual, multidisciplinary investigators; opening communication with other teams through the PHEOC; increasing the level and frequency of training, simulation exercises and workshops for case investigators; incorporating new software into the COVID-19 investigation workflow to enhance and accelerate data entry, data sharing, and monitoring; and creating a range of new reporting tools. Emergency medical teams As preparations advanced, it became clear that there are no established international minimum standards for the medical planning of mass gatherings. The work of S4H partners began to suggest that the emergency medical team (EMT) methodology (i.e. normative guiding principles, core/ technical standards and coordination mechanisms such as the WHO Classification and minimum standards for emergency medical teams (33) could be applied to mass gatherings. In June 2022, the Sport for Health partnership therefore held a two- day joint Ministry of Public Health-WHO workshop (34) that was the first ever formal opportunity to discuss the application of established EMT methodology – including guiding principles, core standards, coordination and quality – to planning medical care for mass gatherings. The workshop convened a wide range and depth of leadership and frontline EMT expertise. Along with the core S4H partners, included representatives of the Qatar Red Crescent Society; the International Centre for Sport Security; WHO’s EMT Secretariat and Border Health and Mass Gathering Unit; and professionals from Qatar’s military, civil defence, Lekhwiya (the internal security force) and police force. The consensus was after two days of intense discussion was that established EMT methodology could indeed be a useful framework for planning the medical care components of MG events. The following year a two-day consultation was held at the WHO office in Lyon, France to explore the development of a set of standards and recommendations. This meeting was organized by the WHO EMT and other Rapid Response Capacities Unit and the Border Health and Mass Gatherings Unit, and built on S4H activities by convening senior professionals and leaders from 14 Member States across all six WHO Regions; representatives from international organizations including the International Olympic Committee (IOC), FIFA and the International Criminal Police Organization (Interpol), and experts from WHO Collaborating Centres on Mass Gatherings and Health Security. Following this meeting, WHO committed to developing a set of standards and recommendations for the medical (care) planning of mass gatherings, and to setting up a technical working group to develop the model on the bedrock of the existing EMT methodology of principles, standards and quality domains (35). This will then be followed by further consultations and testing of the model with key stakeholders. 112 Strengthening health and well-being through sport events Changing the game Example: real time information for real time response An important part of the work of the World Cup command groups was monitoring high risk areas, like World Cup side events and FIFA Fan Zones, and maintaining constant contact with the people running those spaces and events to keep them safe. A FIFA Fan Zone is a large area into which hundreds or thousands of people pile every day. Alcohol is served in these zones, and late concerts and other events run through the night and into the early morning. One way in which the tactical command group monitored risks in these spaces was through live picture feeds from the Fan Zones. On the first day of the tournament, a crowd formed outside the entrance to one Fan Zone that was so big and so tightly packed that the people in it could not move. Frustration and panic started to set in, people began to push and to fall, and the risk of serious injuries, even deaths, rose rapidly. Thanks to continuous monitoring of live feeds from Fan Zones, the situation was noticed immediately and identified as a serious risk. Orders were passed down to the site managers to take rapid action to reduce the crush. The crowd was managed successfully, and no one was seriously hurt. An immediate analysis identified the main cause of what had happened. Once this particular Fan Zone became full, people began to gather in large numbers outside one of the exit gates in an area from which it was possible to see the stage inside. This was a small area, and the crowd rapidly became a relatively large press into relatively small space, sharply increasing the danger. The solution was simple: when events began in the Fan Zone the next day, billboards had been set up so that it was now impossible to look into the zone from outside. This problem did not arise again. © Hamad Medical Corporation An emergency team participating in simulation exercises. 1137.1.6 Example: real time information for real time response Healthcare: reflections Issues, challenges and responses A changing context An event like the World Cup creates very special circumstances that might require health professionals to adjust their expectations, or put them without warning in unfamiliar situations. This happened in Qatar as well. There was some expectation from the start of planning that frontline professionals would have to deal with day-to-day situations involving things not usually seen in the country, and that this would require some adjustment of protocols, expectations and customary responses as a result. Some of these novel circumstances are explored briefly below. Many of the risk assessments and impact analyses needed for planning were complicated because relevant risk factors, like alcohol consumption, were unfamiliar. Many of these concerns cut across different areas. For example, smoking was banned in stadiums, and enforcement protocols seemed simple enough – until the realization that it might be necessary to prepare frontline inspectors not only to enforce the smoking ban, but also to approach football fans who had had a few beers and were correspondingly likely to become annoyed at being told not to smoke. On top of that, these fans were likely to be unfamiliar with the cultural context they were in, and therefore more likely to do or say things that an unprepared smoking inspector might find highly offensive or inappropriate. To meet the needs of this particular situation, a lot of guidance materials were created for smoking inspectors on how to approach football fans. In hospitals, staff had to become comfortable with the idea that a drunk person does not necessarily need that CT scan; they might just need to sleep it off. At the time of writing this report, there seems to have been lasting change in treatment protocols for cases of intoxication - a drunk person presenting in the emergency department is now more likely to be laid down and observed than taken away for expensive diagnostics. 114 Strengthening health and well-being through sport events Changing the game Building and shaping a temporary workforce The involvement of so many partners, the need for locum staff and the recruitment of people who could communicate with visitors from around the world created a temporary, multilingual, multinational workforce new to Qatar. All these people – including a sizeable cadre of foreign doctors and paramedics who were only committed to around two months of work – had to be moulded into a cohesive, integrated workforce with shared knowledge of clinical pathways to care, when and where to refer, and all the other practical considerations needed to do a good job under high pressure. All this had to be done in a context where organizers were uncertain to the very last minute about whether the FIFA World Cup Qatar 2022 would have to take place in a pandemic-oriented form like that used for the Tokyo Olympics in 2021, or whether it would be the more relaxed event it eventually was. Each required a very different approach. The task of workforce integration was further complicated by the need to deploy around 900 nurses used to working in high-end, fully resourced hospitals, equip them with mobile care kits and deploy them into the field with little or no triage experience. In their normal roles, most of these staff were accustomed to receiving and carrying out orders, but now they would have to make independent decisions in field conditions. Finally, it was not possible to retain most of the staff hired for the World Cup, which resulted in the loss of valuable institutional memory and much of the technical expertise gained during the 6-month period of continuous operation. Managing high profile people The health system and the security sector were also obliged to cater to the needs of important, high-profile persons including international superstar footballers and ex-footballers, media personalities and performers; and individuals officially classed as “internationally protected persons” — i.e. heads of state, heads of government, foreign ministers, ambassadors, other official diplomats and members of their families. The needs of the latter in particular require preparation and careful handling. They are generally required by their status, diplomatic protocol and the terms of their insurance – not to mention their own expectations – to receive treatment that imposes particular logistical challenges (for example, the need to travel in protected convoys). Services for high profile visitors were offered at Hamad General Hospital (and Aspetar Hospital in some cases); and a dedicated pathway with concierge service was in place at the Hamad General Hospital Emergency Department, with a 24/7 Operations Centre overseeing the admission pathway for the following three groups of patients: high profile players and VIPs (Group 1); VIP members of the FIFA Workforce and the media (Group 2); and anyone else coming from an event site (Group 3). A comprehensive tracking and notification process was managed by the MCC, with documented pathways for each group and for the tracking process. 1157.1.7 Healthcare: reflections; 7.1.8 Issues, challenges and responses Workers’ welfare The welfare of workers was very important. The weather was hot, and hundreds of workers were operating outside in the sun. It was necessary to make sure that everyone was made to drink water and avoid dehydration. This required an assessment and strengthening of drinking water supplies to different sites. Health care access across all sites was provided for everyone, including workers inside the zones, who were free to access services if they felt unwell. In some areas, data showed that the people the demand for health care services was split around 50/50 between event staff and visitors/fans. Dealing with private sector gatherings A high-profile event like a World Cup brings a huge amount of attention and activity. Businesses and individuals are likely to try to capitalize commercially, and not always with adequate planning. The behaviour of private operators during the FIFA World Cup Qatar 2022 was a major difficulty and had the potential to undermine the health plan severely. A number of last-minute commercial side events were held, sometimes in venues capable of holding thousands of people, without any budget for health. These events disturbed the FIFA World Cup Qatar 2022 health plan because ensuring their safety was not optional, so resources had to be deployed to do it – but at times this left the country without any uncommitted reserve health capability for potential emergencies. The risk inherent in this situation was increased by the fact that the public health system received no additional budget to deliver the FIFA World Cup Qatar 2022 health plan. This was already a major restriction for planners, with knock on effects for workforce and procurement, and last- minute stresses like these removed any remaining margin for error. The SC was aware of this risk, but the eventual scale – and lateness – at which it manifested still significantly stressed the plan. A safe resolution was ultimately possible because the health sector was able, at moments of extreme need, to mobilize the highest levels of political authority to oblige private operators to buy in medical support. Thankfully, the response was not tested by any additional emergencies that might have overloaded capacity. Had that happened, the outcome might have been different. However: the long-term outcome is in fact a significant legacy benefit for Qatar. Since the World Cup, the country has been working to draft and implement legislation imposing regulatory change to events approval processes. These new regulations will make sure that health needs are covered before such events are approved. 116 Strengthening health and well-being through sport events Changing the game Considerations for future events Planning The experiences of implementing S4H in Qatar suggest that a good public health plan for a mega event should start early and be built around enhanced multisectoral collaboration, capacity building, and training. Strengthening international collaboration with organizations like WHO, including through the S4H model, can help improve readiness and response capabilities and provides access to a wide range of expertise and insight. In Qatar’s post-event review processes, it was suggested that future World Cups (and other events) with more than one host country would benefit from establishing a single, integrated entity empowered to oversee and support public health operations across different countries. With each country likely to have its own distinct practices, a centralized entity is likely to be needed to harmonize national workflows. • It is also important to have a legal framework that obliges compliance with public health rules – and the ability to enforce it. One way to build compliance into planning is by designing processes with hard stops. For example, protocols for approving side events could include set dates for assessment and approval by health officers without which those events cannot happen. • Good planning should strive to build systems that are not just robust, but also adaptable. Flexible, scalable planning allows swift adjustment and efficient allocation of resources in response to events. Setting up a robust feedback system for primary care during the event helps guide those adjustments (including by adjusting virtual and e-services for primary care to improve access and efficiency). • Establishing clear protocols for interagency and interdepartmental collaboration proved instrumental in Qatar – valuable evidence for future organizers that fostering transparent and effective communication between national stakeholders is crucial. • Implementing plans requires time, no matter how good they are. It is a cardinal sin of planning – though sadly a common one– for planners to use 90% of available time for preparation and expect staff to implement them in the remaining 10%. For example, post event reviews suggested that the PHEOC should have been stood up earlier in order to facilitate the setup of systems, staff recruitment, and facility management. • Protecting day-to-day health care structures should be a strategic goal from the start. Without this planning, any emergency during the mass gathering risks consuming emergency services with the response. Host countries need enough reserve to cope with threats without damaging general services, and a history of testing and exercising that inspires confidence in the ability to pivot towards any threat. Event health care services (and any changes to the delivery of normal services during the event) should be promoted extensively and widely ahead of time – including on event-specific websites. 1177.1.9 Considerations for future events • Stress tested systems are stronger and better: handling the sustained pressures of COVID-19 required constant re-iteration of Qatar’s control structures for emergency response until they were good enough to cope. This included the creation of a Strategic Command Group with general oversight and tactical command groups for operations, resulting in a set of systems and institutional knowledge that could be used for the World Cup, and into which it was easy to embed control arrangements for data collection, surveillance, reporting and other key functions. In the absence of a pandemic, much of this can be achieved through a regular and thorough programme of testing and exercising. • A military-style command and control approach is a major strength when managing the pressures of major events. This requires: • clear tasks and lines of accountability • systems that feed the right information into the command structures • live information feeds and ongoing review of that information – including ongoing assessment of trends and incidence; and • live monitoring of the safety of high-risk areas. • The S4H model can provide a platform for more complicated or sensitive legacy gains that might not be achievable without the deep impact of a mega event like the World Cup. In Qatar, this meant opening up the culture and the country, building technical capacity to provide services normally seen as culturally counterintuitive – for example, setting up a reference mechanism for victims of sexual assault. Sport can be a powerful tool to challenge customs, societal norms and cultural expectations in a positive way, without breaking them down, but in a manner that allows sensitive questions. When such questions are asked in the right way, ultimately, more people receive the care they need. • Effective evaluation requires advance planning too. To date, the FIFA World Cup Qatar 2022 has resulted in a limited number of publications and reports that document actions and challenges. More extensive capacity-building for research and publication should have been prioritized before and during the event to ensure timely dissemination of findings. With a process as large and complicated as the World Cup, writing up the work done should be a core part of operations rather than a process for later. Once operations start there will be no space for this work if it was not built into the plan. Prioritizing a robust data collection system before the event minimizes the need for extensive data cleaning afterwards, enabling more efficient analysis and publication. 118 Strengthening health and well-being through sport events Changing the game Training • Readiness for mega events requires thorough training programmes run well in advance of the event, including venue- specific training for staff. • On-the-job training is a crucially important part of any such programme, enabling new staff to build capability, and strengthening the resilience and capacity of their organizations. • Hosting a major event often means recruiting temporary staff, as was the case in Qatar. If this is necessary, planning should include measures to capture and capitalize on their experiences before they leave (for example, documentation procedures or shadowing by junior staff). The goal is to retain as much institutional knowledge as possible. • Relevant experience can be found in unexpected places. For example: in Qatar, the National Ambulance Service provides health care at Hamad International Airport, where it maintains a 24/7 airside clinic with a physician and a nursing team on permanent rotation. As Doha is a huge international hub, this team treats a huge variety of patients with different needs, around 90% of whom are in transit, and some of whom are intoxicated. Running this clinic for many years has given the health system opportunities to test responses, and build knowledge and experience, that are not generally required elsewhere. This experience gave greater confidence in the operational reliability of World Cup planning, and was used as a foundation from which to fill gaps by recruiting colleagues with specific experience of large events and venues. 1197.1.9 Considerations for future events 8 709 mobile team encounters 359 ambulance transfers 24 504 onsite encounters 44 029 total medical visits during the 30 day World Cup period 120 Strengthening health and well-being through sport events Changing the game Tournament specific facilities included 113 medical clinics 212 mobile medical units 116 ambulances 2 275 healthcare staff 1217.1.10 Summary Active individuals of all ages and abilities engage in various sports and fitness activities, including running, padel, yoga, and wheelchair exercises. © Ministry of Public Health Promoting health 124 Strengthening health and well-being through sport events Changing the game Mega sporting events like the World Cup are highly valuable opportunities to improve public health beyond the realm of sports. These events foster a sense of community and excitement, and, by their very nature, promote focus on sport and physical activity. But they also bring with them challenges to health, not least of which is the marketing of unhealthy foods, substances and practices which are deeply ingrained into the sponsorship and revenue generation streams of these events (36, 37). On one hand, the global reach of mega sports events and the passionate nature of their audiences are wonderful vehicles for the promotion of health and wellness; on the other, they are a vehicle for the dominance of unhealthy food and beverage marketing, raising public health concerns and undermining the inherent positive values of sport. From sugary drinks and fast food to processed snacks and alcohol, these sponsorships permeate everything from concession stands to athlete endorsements, sending mixed messages that undermine public health (38). The Health Promotion pillar of the S4H partnership tried to tip the scales in a positive way, leveraging the reach and influence of the FIFA World Cup Qatar 2022 to promote overall health and well-being across four focus areas: nutrition, physical activity, mental health and tobacco. 1258. Promoting health Nutrition Studies show that unhealthy options outnumber healthy alternatives at high profile sporting tournaments and events. Research at Euro 2016 found unhealthy products dominating sales points inside stadiums and fan zones, with only limited visibility and availability of healthy choices. Similarly, 74.8% of brand marketing references during broadcasts of the 2018 FIFA World Cup in Russian Federation were for unhealthy food and beverages (37). Children are especially vulnerable to marketing influences and particularly heavily exposed to these unhealthy choices. At the same time, the juxtaposition of athleticism with unhealthy sponsors creates a confusing message, undermining the positive health associations usually linked with sport (38). Shifting the focus towards healthier nutrition is not just an option for event hosts, but a necessity. Offering accessible, appealing healthy options alongside traditional fare at mega sport events empowers people to make informed choices. Countering the marketing power of unhealthy sponsors has to be a strategic objective for those working to protect and promote health. Prioritizing health-positive messaging also aligns with the core values of sport – well-being and high performance. Past examples of successful initiatives include the 2012 London Olympics “Food Charter,” which led to an increase in fruit and vegetable consumption among attendees (39). The implementation of stricter, healthier sponsorship guidelines by the IOC is another step in the right direction. Collaboration between sports organizations, health experts, and local communities can further accelerate the shift towards healthier environments at all sports events. A family enjoying their healthy meal. © Ministry of Public Health 126 Strengthening health and well-being through sport events Changing the game Physical activity Promoting healthy habits and lifestyles is often stated as a goal of mega sports events, but the real-life outcomes can be complex, and depend on a range of different factors including socioeconomic context, cultural norms, and access to resources. The evidence around how major sports events can have a positive impact on community levels of physical activity is less compelling than the evidence around marketing unhealthy food and drink. Few studies have shown sustained increases in physical activity at population level because of mega sport events or their legacies. These events may cause temporary boosts in motivation and participation, but this doesn’t often translate into long-term changes in behaviour. That said, many mega sport events do invest in grassroots initiatives and legacy programmes to promote physical activity in local communities – for example, in countries hosting Olympic Games, including most recently (at time of writing) Paris 2024. These programmes often do things like creating or increasing access to facilities, equipment, and training opportunities to encourage long-term engagement in sports and exercise. Mega sport events can create positive climates for physical activity not only through the extensive media coverage that comes with them, which can increase awareness, but also through investment in developing sport infrastructure, and community engagement through volunteer programmes. Even though there is a need to strengthen the evidence base for what is a relatively new phenomenon, there is considerable interest in efforts that encourage and support people to adopt more active lifestyles in the long term, particularly when combined with other public health initiatives. © Supreme Committee for Delivery and Legacy Children competing against each other in large inflatable football costumes. 1278. Promoting health Mental health Mega sport events can foster community spirit and social cohesion, and these can have positive impacts on mental health. Shared experiences, cheering for a common team, participation in volunteering opportunities and being part of the wider community hosting a high-profile event can all mitigate against feelings of isolation and loneliness (40). Athletes participating in mega sport events can also be positive examples for youth and adults alike, modelling dedication, perseverance and commitment to mental wellbeing that can inspire individuals to prioritize their own mental health. Side by side participation in physical activity associated with major events – whether though volunteering, participation in organized activities linked to the event, changing transport habits or playing sports having been inspired by the event – can reduce stress and improve mood, contributing to overall mental wellbeing. Tobacco Mega sport events are valuable platforms for anti-tobacco mass media campaigns and awareness initiatives. These campaigns can reach large audiences and warn people about the dangers of tobacco use. They also provide important opportunities to implement tobacco control policies in line with the WHO Framework Convention on Tobacco Control, such as ban on sponsorship, promotion and advertising of tobacco and related products (41). Participation in physical activity and engagement in the excitement of mega events can also provide positive alternatives to unhealthy and damaging behaviours like substance abuse. © Ministry of Public Health Qatari football legend engages in conversation at the launch of the 32 friendship benches. 128 Strengthening health and well-being through sport events Changing the game From the very first multisectoral workshops we held, just after the S4H partnership was established, it was clear that there was so much already going on. All stakeholders across different sectors obviously recognized the opportunities hosting a FIFA World Cup offered, and they strived to take advantage of this mega event to promote health and well-being, to raise awareness on a variety of issues, and push their respective agendas – whether it was increasing the use of public transport, fostering inclusivity and accessibility, etc. All of that demonstrated all the more the need for a “health in all policies” approach to planning, implementing and – more importantly – evaluating the delivery of mega events. There was so much appetite for collaboration and there were so many potential synergies, but realizing these requires coordination from the very onset, and baselines to support evaluations of impact post-event and post-interventions. Whilst some fragmentation of efforts was inevitable, and could not be entirely addressed, we were able to capitalize on the Qatar Healthy Cities network to bring some of these efforts together and address some of the data-related limitations we faced when working independently. Hatoun Saeb, Project Manager, HiAP Unit, Ministry of Public Health A “no smoking” sign inside the stadium. © Supreme Committee for Delivery and Legacy 1298. Promoting health Physical activity The S4H partnership aimed to use the FIFA World Cup Qatar 2022 to increase physical activity and participation in community- based sport within Qatar and more widely. The potential benefits of success were clear and wide ranging across mental and physical health. Increasing regular physical activity helps prevent and manage noncommunicable diseases like heart disease, stroke, diabetes and several cancers; it helps prevent hypertension and maintain healthy body weight; and it can improve mental health, quality of life and well-being (6). “Physical activity” in the context of this report includes all movement – for leisure, at work, or while moving from place to place. This definition, aligned with that used by WHO, includes activities like walking or cycling for recreation or transport, sports, active recreation and play – things that can be done at any level of skill for enjoyment by everybody (42). These activities, whether they are done moderately or vigorously, all benefit health. Given the nature of mega sports events, planners often argue that their legacies will include increased participation in sports and physical activity. This assumption is also often included in legacy planning, communications and PR. However: results are rarely documented or achieved – a surprising, collective omission across host cities, countries and sports organizations. Attempts to collect data and analyse achievements and lessons are therefore particularly valuable, and an important legacy contribution in their own right. Focus areas Physical activity work under the S4H programme in Qatar included a wide variety of activities from public engagement in communities up to high level national communication campaigns and involved a range of partners. Together these programmes focussed on four main areas: 1. promoting physical activity and physical activations in community settings, stadiums and Fan Zones 2. promoting active transport: walking, cycling and public transport 3. strengthening national governance, capacity and partnerships for physical activity 4. implementing GenMove, a video game designed to increase physical activity in children and adolescents. 130 Strengthening health and well-being through sport events Changing the game “Strengthening partnerships between health and sport sectors and across the wider ecosystem has potential to help increase participation in physical activity and improve health and wellbeing. However, we have a long way to go. Globally, levels of inactivity are rising, and persistent inequalities remain. Sport events and their legacy initiatives should be integrated into a wider “whole system” approach to be successful and sustainable. Good planning, adequate resourcing and coordination amongst partners can help secure a successful and sustained legacy that leads to lasting impact on sport and physical activity - locally, nationally and internationally.” - Dr. Fiona Bull, Head of Unit, Physical Activity, Dept of Health Promotion, WHO 1318.1 Physical activity Promoting physical activity in community settings, stadiums and fan zones A range of different opportunities was available for individuals of all ages and abilities to engage in fun, positive physical activities throughout the tournament. These activities were accessible to the general public and happened across different settings and media, including through digital tools, visual content and in face-to-face “come and try” sessions. The Fan Zone activations and initiatives were designed and scheduled to make the most of periods between matches, when captive audiences were gathered in enclosed areas but their attention was not taken up by the football games. Stadium designs and services had the desired effect of increasing stair use and making people move around the venues to get their food. © Ministry of Public Health Participants at Walk the Talk Doha, held on the eve of the FIFA World Cup Qatar 2022 132 Strengthening health and well-being through sport events Changing the game Main activities A variety of physical activity communications and activations took place before and during the World Cup. These used a range of strategies and communication channels to achieve different goals in different age groups. Implemented by a range of partners in communities and other targeted settings, they included (but were not limited to): • #BringTheMoves, a collaboration led by FIFA that encouraged young people to be more active by challenging football fans around the world to share their goal celebration moves on social media; • promotion of the “Be Active” message on the armbands worn by teams competing in the FIFA World Cup Qatar 2022 signage around the games throughout the tournament; • a mass participation event called “Walk the Talk Doha” that celebrated the start of the FIFA World Cup Qatar 2022 by encouraging families and communities to join a mass participation walk in central Doha. The event was open to all age groups and abilities and emphasized the physical and mental benefits of simple, achievable activities like walking; • a month-long campaign of in-person and online activities and events led by Qatar University called This is public health – enhancing people’s activity towards a healthier world; • a Sport for Health photography competition, Health Through My Lens, in which participants could express their photographic perspectives on the question “What does health mean to me?” Winning entries were showcased in a WHO-led photography exhibition at Oxygen Park in Education City; • car-free day at Education City: as part of the effort to promote public transport, this was a push away from private cars and towards alternative means of transport including the Metro Green Line, the Education City Tram, and personal scooters and bicycles; • the Sports for Health Friendship Benches project (see the Mental Health section), which placed 32 benches strategically around the stadiums, each of which had a QR code on it through which people could access resources on physical activity and mental health; • physical activity events in FIFA Fan Zones. These included “Obstacle Challenges” – fun events, free and open to people of all ages, in which fans got active and tackled a series of obstacles like climbing walls, tunnels and balance beams, creating enjoyable ways to be exercise with friends and families. Some installations included competitions between participants; • restricting access to lifts in stadiums so that most spectators had to use the stairs. This was planned very early: well- designed staircases and reduced public reliance on lifts were core requirements for tournament stadium designs. This had the additional benefit of improving accessibility for people with mobility difficulties who needed lift access; • self-service food: in-seat food service was unavailable during games, so fans had to get up and retrieve their food, encouraging movement around the stadium. 1338.1.1 Promoting physical activity in community settings, stadiums and fan zones Promoting active transport: walking, cycling and public transport Fans at the FIFA World Cup Qatar 2022 were encouraged to walk, cycle and use public transport to get to games. Plans for the tournament emphasized managing public spaces to increase mobility. Short term measures included pedestrianizing parts of Doha during the tournament, closing them to cars so people could walk, run and cycle safely. One high-profile example was the Corniche beachside area: throughout the World Cup, drivers who normally commute through the Corniche had to switch to public transport, walking or cycling. But the S4H partnership was also determined to make changes that might move people away from car use in the longer term and strengthen the foundations for physical activity. The FIFA World Cup Qatar 2022 was a chance to create supportive urban environments for walking and cycling. Qatar aligned the FIFA World Cup Qatar 2022 planning process with the Qatar National Vision 2030 by developing and a completely new public transport system and making sure it was ready in time for the tournament. The system comprises diverse bus routes covering most of Doha and neighbouring municipalities; metro and tram systems offering access to most capital locations, with accessible stations; a network of cycle lines and bicycles (including electric bicycles) available to rent; a fleet of eco- friendly E-scooters conveniently accessible for rent by scanning a QR code; and – to supplement all of these – flexible and on- demand taxi and ride-hailing services. These networks were fully harmonized in 2021, when the Ministry of Transport established an integrated network called Sila to connect different transport modes across Qatar. The goal of Sila is to provide convenient, rapid transport for citizens, residents, and visitors, while championing public transport use as sustainable, environmentally friendly and beneficial for health outcomes, air pollution and energy consumption. Main activities • Public transport was promoted and incentivised for the FIFA World Cup Qatar 2022 and was free for Hayya Card users throughout the tournament. New metro stations near each stadium made access easy. This determined a marked increase in the use of the Metro (See Figure 29) during the days of the tournament. Interestingly, the use of metro continued to increase over time after the FIFA World Cup Qatar 2022 when the population returned to normal levels compared to the pre-World Cup level. This suggests a potential long term trend for an increased use of public transportation in the country, possibly facilitated by the activities promoting active mobility during the World Cup. • Public signage was improved to help fans move between metro stations and stadiums. • Volunteers were deployed to guide visitors towards public transport. • Car use was discouraged during the tournament. The use of personal cars around the stadiums was prohibited, parking spaces were reduced, and key roads were closed. 134 Strengthening health and well-being through sport events Changing the game “During the planning stage for the World Cup, our ambition was to facilitate seamless journeys to and from stadiums, accommodation and other locations. Qatar’s compact nature meant fans were always close to a stadium, fan zone or entertainment activation. Our aim was to make sure that they had seamless journeys between the various locations. Core to our plans was to offer active alternatives to traditional transport options. Fans were able to rent electric scooters and bicycles in West Bay, Lusail City and the Pearl, which helped us achieve our goal to deliver a sustainable edition of the World Cup in history. They offered a fun and healthy way to explore the country. The transformation that Qatar has seen will benefit its population well after the World Cup, whether it’s providing affordable and sustainable transportation alternatives or by encouraging different options which will help the country stay active.” - Eng. Thani Al Zaraa, SC Mobility Operations Director during Qatar 2022 • The Ministry of Public Health worked with the Ministry of Municipality on a programme of building cycling paths. There are now several such paths around the country, including a 40km cycling path along the southern part of the Doha Expressway. • Local authorities worked hard to make public spaces more attractive. These efforts included a tree planting programme, installation of benches, and providing other amenities to get people outdoors and make them want to stay there. and make them want to stay there. © Supreme Committee for Delivery and Legacy Spectators in a metro station heading to a football game. 1358.1.2 Promoting active transport: walking, cycling and public transport 500 000 COVID-19 Lockdown FIFA World Cup Qatar 2022 Spike 600 000 900 000 400 000 300 000 800 000 700 000 200 000 100 000 0 Ja n 20 Fe b 20 M ar 2 0 A pr 2 0 M ay 2 0 Ju n 20 Ju l 2 0 A ug 2 0 Se p 20 O ct 2 0 N ov 2 0 D ec 2 0 Ja n 21 Fe b 21 M ar 2 1 A pr 2 1 M ay 2 1 Ju n 21 Ju l 2 1 A ug 2 1 Se p 21 O ct 2 1 N ov 2 1 D ec 2 1 Ja n 22 Fe b 22 M ar 2 2 A pr 2 2 M ay 2 2 Ju n 22 Ju l 2 2 A ug 2 2 Se p 22 O ct 2 2 N ov 2 2 D ec 2 2 Ja n 23 Fe b 23 M ar 2 3 A pr 2 3 M ay 2 3 Ju n 23 Ju l 2 3 A ug 2 3 Se p 23 O ct 2 3 N ov 2 3 D ec 2 3 Number of rides per day 30 days moving average Figure 30 Qatar metro daily ridership 2020-2023 and 30 day trendline (kindly shared by Qatar Rail, 2024). 136 Strengthening health and well-being through sport events Changing the game Strengthening national governance, capacity and partnerships The physical activity element of the S4H partnership included work to strengthen multisectoral partnerships, build workforce knowledge and capacity, and strengthen Qatar’s national policy framework to promote and enable sport and physical activity. Main activities • A multisectoral working group was assembled to review national physical activity policy, actions and engagement using the WHO Situational Assessment Tool (SAT). The group assessed Qatar’s progress against the policy recommendations of the WHO Global action plan on physical activity 2018- 2030 to identify strengths, opportunities and gaps that could be considered in the national action plan on physical activity (43). The SAT report informed the National Health Strategy, and its results can be used to enhance the wider implementation of physical activity policies. • The S4H partnership convened a Sport for Health Conference and hosted the 4th annual meeting of the Football is Medicine (FIM) research consortium, providing important forums to exchange knowledge on event legacy work (44). The Conference (described in Box 5) was a platform for international sports and health specialists, researchers, and policymakers to exchange insight and expertise on how mega sport events can promote sport and physical activity. • A summary of evidence and a call for action were published at the World Innovation Summit for Health (WISH) 2022 Conference, in a report entitled Playing the Long Game: A framework for promoting physical activity through sports mega- events (see Box 6). • S4H encouraged further research on physical activity, sport and public health by convening discussions between the Qatar research community, Aspetar, and senior university leaders, and by making connections with international stakeholders like the City of Birmingham in the United Kingdom of Great Britain and Northern Ireland (which hosted the 2022 Commonwealth Games). 1378.1.3 Strengthening national governance, capacity and partnerships The issue Children aged 8-15 aren’t active enough: more than 80% of adolescents don’t get the 60 minutes a day of moderate aerobic activity that they need (6). This is dangerous: low levels of physical activity are linked to poor cardiorespiratory and muscular fitness, weight gain, reduced sleep and behavioural issues. So WHO built GenMove, a video game to get children and adolescents to be active. It launched on 19 November, the day before the FIFA World Cup Qatar 2022 opening ceremony, and was promoted through WHO communications, the FIFA #BringtheMoves campaign, and paid media advertising. The game WHO wanted to make a digital game that would encourage all children – including those with disabilities, of any gender and regardless of fitness, skills or ability – to play regularly. GenMove is built around artificial intelligence (AI) and augmented reality (AR) technology and adapts automatically, increasing in speed and complexity to challenge players at the level they need. The game comes in all six United Nations (UN) core languages and works on simple smartphones without a data connection – because most children around the world don’t have new, expensive devices and fast connections. To make sure it was as inclusive as possible, beta testing included children with different learning abilities and children with disabilities. GenMove offers 50 different movement games designed to develop different motor skills, each one developed with WHO’s Physical Activity Unit, and users can choose the ones they like best. To keep players engaged in regular physical activity, it includes “gamification” features like customizable avatars, idle games (where players send their avatars on adventures, checking in later and responding to quizzes) and in-game “missions” to encourage regular play. Points (which can be exchanged for avatar accessories) are awarded for participation and time spent playing, rather than skills. Implementation of a global active video game – GenMove “Regular physical activity has major, lifelong benefits for physical and mental health, and is essential for the healthy development of children. Digital innovations can be powerful tools to reach young people and get them moving, especially children who might not play sports regularly.” - Dr Tedros Adhanom Ghebreyesus, WHO Director-General 138 Strengthening health and well-being through sport events Changing the game Did it work? Over the FIFA World Cup Qatar 2022 period, GenMove reached 175 countries, with 239 786 visits to the GenMove site and 30 063 downloads. The average length of a GenMove play session was 5 minutes 18 seconds. The gamification features did enhance engagement with the app, and increased the time spent playing the active games. Players who engaged with these features were likely to play more and play for longer, and more likely to continue using the app over several weeks, and therefore spend longer being active. Lessons • Digital games CAN get children and adolescents moving: The game appealed to the target age group, and the gamification features did enhance engagement and increase time being active. • The type of device that kids use to play will probably affect their engagement. GenMove was designed for devices likely to be available to 8–15-year-olds in all countries, but evaluation showed that larger screens and better functionality made the game more enjoyable, so kids played more often and for longer. • Get people to play requires effective promotion. The number of people who downloaded and played GenMove was disappointing. WHO planned promotions across multiple platforms and channels to make the most of the FIFA World Cup Qatar 2022, but competition for coverage and attention was intense. Ultimately GenMove wasn’t sufficiently associated with the tournament. • Effective promotion needs planning and budgets. Modest paid media campaigns generated the most interest and downloads for GenMove, but these started too late to reach a wide audience. Demonstrating the app at events during the FIFA World Cup Qatar 2022 were less successful in attracting downloads. Figure 31 Genmove app user interface GenMove app, a video game designed by WHO to encourage children and adolescents to be active. 1398.1.4 Implementation of a global active video game – GenMove GenMove implementation during the World Cup Ahead of the FIFA World Cup Qatar 2022, I was privileged to attend two very important events that set the pace for Qatar to deliver a Healthy FIFA World Cup Qatar 2022. The events were the World Innovation Summit for Health, in October 2022, and Walk the Talk in November 2022. During the Walk the Talk event one exhibit that captured my attention was the GenMove App, which was launched for the first time at Al Bidda Park in Doha. I had the honourable opportunity to be introduced to the GenMove App by Dr. Fiona Bull of WHO, where I enjoyed vigorous video game experiences, that were great, and fun. The App is an interactive platform that uses advanced movement tracking combined with AI technology. Regular physical activity has been shown to have a positive impact on reducing NCDs and obesity, enhancing well-being, and promoting a healthy population. As a physical activity and healthy living advocate, I was excited when the GenMove digital app was installed at the Qatar Olympic and Sports Museum Activation Zone to enhance health and well-being by promoting physical activity and getting kids moving through different movements that help develop their physical literacy. At the Qatar Olympic and Sports Museum’s Activation Zone, we encouraged the visitors to download the GenMove App and took the time to explain to them the importance of healthy living and regular physical activity. The goal is to carry on the tradition of encouraging physical exercise and good health for all. The games call for a range of different movements that develop different physical skills and are suitable for children with all levels of fitness. In conclusion, I would like to state that the GenMove App has contributed immensely to promoting physical activity and has provided an opportunity to start larger conversations about healthy lifestyles and active living in Qatar and beyond, where participants can find creative ways to stay active in their neighbourhood, workplace, school, family or community. By learning from FIFA World Cup Qatar 2022 as a platform to promote healthy lifestyles, we shall inspire the Qatar Population and millions around the world to engage in physical activity, be more active, and raise awareness of the health benefits of sports. - Moses Oluchiri Amonje, Youth and Family Activation Coordinator, 321 Qatar Olympic and Sports Museum 140 Strengthening health and well-being through sport events Changing the game Box 5: the Sport for Health conference, 2022 The first Sport for Health Conference was hosted by WHO, the Ministry of Public Health and the Generation Amazing Foundation in Doha in October 2022 (44). The Conference brought together global sport and health experts, scientists and policymakers to share knowledge and experience of how mega sports events can improve health and well-being by increasing participation in sport and physical activity. Physical activity is a well-established contributor to preventing NCDs and improving mental well-being. Sport is also recognized as a contributor to lasting friendships, community cohesion, and peace and development. Experts and speakers at the Conference came from – among other places – the Commonwealth Secretariat, the IOC, the OECD and the worlds of professional sports such as golf, cycling, football and rugby. The conference discussed challenges to legacy planning and delivery, and relationships between community sport programmes and local health. There were three scientific sessions, respectively titled “strengthening community and grassroots sport;” “sport mega event legacy in relation to participation in sport and physical activity;” and “scaling delivery and measuring.” These sessions produced five recommendations for action by organizers of and participants in all future such mega events. Recommendations of the conference 1. Strengthen partnerships between sport and health sectors to ensure that mega sports events create sustainable, community-wide impact. 2. Build capacity and strengthen skills for planning, delivering and evaluating the legacy of mega sports events 3. Through follow up meetings and forums, share experiences, and identify key challenges and valuable lessons in relation to the legacies of mega sports events 4. Develop and build consensus on common indicators of mega sports event legacies 5. Invest in building evidence on the impact of mega sports events on physical activity and health © Ministry of Public Health The Sport for Health Conference, incorporating the 4th Annual Meeting of Football is Medicine, held on the sidelines of WISH 2022. © Ministry of Public Health 141 8.1.4 Implementation of a global active video game – GenMove; 8.1.5 Box 5: the first Sport for Health conference, 2022 Box 6: the 2022 World Innovation Summit for Health Playing the long game: A framework for promoting physical activity through sports mega-events is the report of the World Innovation Summit for Health (WISH) 2022 Forum on Sports Mega-Events and Physical Activity (45). Building on a 2020 report on planning for lasting health legacies from major sporting events (46), it looks at how the legacy of mega sports events can improve health by increasing participation in physical activity. The report outlines a case for action, drawing on scientific evidence, research and lessons from past events and the WHO Global action plan on physical activity 2018-2030, and offers a framework for designing and implementing legacy programmes for mega sports events to maximize participation in physical activity. Crucially, it acknowledges that addressing challenges this big requires partnership, cooperation and concerted effort. While event host governments and organizers and sports governing bodies commonly express commitment to positive legacies, systemic barriers to participation in sport and physical activity cannot be resolved by single events, or even by single cities. A lasting legacy of increased physical activity – and the myriad health benefits that come with it – can only be achieved through collective effort by sport event owners and organizers; international sport federations and other sport entities; national, regional and local governments; and other stakeholders. To increase the chances of future success in this area it is crucially important for these stakeholders to share knowledge on the best ways to deliver population-level impacts on physical activity and participation in sport. The report also offers recommendations designed to develop global knowledge, scale up the potential positive health impacts of mega sports events, and support effective planning and delivery of legacy for future events, such as: 1. review and revise bidding processes and criteria to require and incentivize stronger planning and reporting on legacy impact, including a focus on increasing physical activity and participation in sport; 2. support the development of common indicators to assess legacy and strengthen evaluations of population- level impacts on sport and physical activity in the short, medium and long term. Guidance and tools should be provided for collecting and tracking these metrics over a years to gauge accurate evidence for meaningful, long- term change; 3. support the demonstration of model evaluation frameworks in future sport mega events to test and refine evaluation methodology and provide examples of best practice; 4. build capacity and support knowledge transfer within and between sports events and all relevant sectors to strengthen skills and competencies in planning, delivering and evaluating the legacy of mega sports events that increases participation in physical activity and community sport. 142 Strengthening health and well-being through sport events Changing the game Physical activity: reflections Issues, challenges and responses • The high visibility of sports mega events creates very hectic, pressured communications landscape that can make promoting different physical activity events and “activations” with different partners complicated and time-consuming. In Qatar, this was particularly difficult for higher-profile events involving larger organizations: each partner had different clearance procedures and communications focal points were very busy during the tournament. This made effective joint promotion difficult or impossible, and may have had a negative effect on public engagement with the events. • Working with different partners on multiple projects also created complicated management scenarios. For S4H this often meant working with insufficient planning time and poor clarity on the roles, responsibilities and timelines of different partners. Accountability for specific activities and tasks was often duplicated or unclear. • The range and variety of different initiatives and events made it hard to design and implement a coherent monitoring and evaluation programme. Even higher-profile measures and events like those in stadiums and Fan Zones lacked robust evaluation. Opportunities were missed to improve the activities, document successes, and gather data for future use. • This issue was complicated by a lack of baseline data on physical activity, which is essential for measuring progress. Because collection of data was disrupted by COVID-19, S4H had no way to make detailed comparisons of physical activity levels before and after the World Cup. • There was not enough coordination between different WHO teams supporting S4H campaigns. This meant opportunities were missed to align physical activity work with efforts in other areas of health promotion like nutrition, smoking and mental health. • There were not enough opportunities for communication, technical exchange or collaboration with FIFA’s physical activity workplans. 143 8.1.6 Box 6: the 2022 World Innovation Summit for Health; 8.1.7 Physical activity: reflections; 8.1.8 Issues, challenges and responses Considerations for future events • Tangible, lasting, change to levels of physical activity that improves public health requires changes in policies and programmes. As a minimum these need to include improved access to opportunities for physical activity in communities, for everyone. From the very start of the event bidding process, host governments can find opportunities to improve urban environments, and ensure that any plans and budgets for renovating them include provisions for community-based sport and physical activity. An example of a long term initiative built into the FIFA World Cup Qatar 2022 bidding process from the very start in Qatar was the creation of Generation Amazing (see next example). WHO analysis of S4H’s physical activity work in Qatar suggests that all countries hosting mega sports events should consider investing in a national plan to deliver a physical activity legacy, and commit to delivering it over 5-10 years or longer. Planning at this level requires multisectoral systems to monitor progress and build capacity across all sectors and stakeholders that influence people’s physical activity. A recent collaboration between the IOC and the OECD focussed on strengthening evaluation of mega events of all kinds and generated a framework for evaluating the impact of events (47). This framework was not yet available for use in the FIFA World Cup Qatar 2022, but it contains a useful set of indicators and should inform the evaluation of future events. • Communication and targeted outreach are crucial. Experiences in Qatar highlighted the importance of strategies for engaging audiences in physical activity and strong systems to coordinate and communicate between organizers, staff, participants, fans and other attendees. These might involve coordinated use of digital platforms and multilingual support to inform and engage a broad range of attendees across different channels and platforms (like social media, local media, influencers and community engagement), working in collaboration with community partners (like schools, community centres and civil society) to make sure campaigns resonate with their target audiences. • There is great value in sustaining international and local collaborations beyond the event, committing to cultivate partnerships, provide resources, develop educational materials and continue holding physical activity events and challenges over time. Continuing partnerships for the long term also helps host countries and cities learn from each other’s experiences. • A great deal of the experience in Qatar around the FIFA World Cup Qatar 2022 highlighted the need to plan early for data gathering, monitoring and analysis, based on a clear long term analysis and research plan. Solid baseline datasets are needed for evaluation, and all initiatives should be evaluated regularly. Organizing committees and other stakeholders should select their metrics, establish baselines and collect data before, during, and after the event – an effort that can be supported by collaborating with local institutions. • Evaluation should include comprehensive fan feedback to understand what they enjoyed and what they feel could be improved. This feedback is a useful resource for improving the fan experience 144 Strengthening health and well-being through sport events Changing the game at future events, so they are more likely to take part in health initiatives. It is also important to share insights by documenting experiences in peer-reviewed formats. • Physical activity can be encouraged and some of the health gains “locked in” through permanent expansion of pedestrianized areas and cycling infrastructure. Planners should consider leveraging mega sports events to invest in permanent expansion of areas that create safer spaces for walking, running, and cycling, supported by promotional campaigns for active transport that last beyond the event. • Major events are opportunities to bring in “micro-mobility” options like bike-sharing and electric scooter schemes that increase connectivity of public transport. Options like this give commuters convenient and flexible ways to cover short distances and link up other elements of the public transport system, improving the convenience of public transport as lifestyle choice. • Where systems like e-scooters are new to a city or country, Qatar’s experiences suggest that authorities should implement and test regulations and guidelines for their use well in advance, making sure their integration into public transport and the public realm is safe, organized and effective before the event. • Any work on regulations could also address other relevant areas – for example, making car use less convenient to encourage active transport; regulatory change to reduce speed limits, prioritize non-motorized vehicles and pedestrians and create safer public spaces; and policies to create environments and infrastructure that support physical activity. Enhancement of public spaces (for example, by installing shelters from the sun and/or rain, improving lighting to make evening activities safer, providing drinking fountains, and installing fitness equipment and public sports facilities) encourages people to spend time outside and participate in more – and more varied – physical activity. • Roadworks and construction that take place as part of event preparations should prioritize the safety and accessibility of cycling paths and pedestrianized areas, so as not to discourage outdoor activity. 1458.1.9 Considerations for future events Case study: Generation Amazing Foundation The Generation Amazing Foundation (the GA programme) was developed by Qatar as part of the bid to host the FIFA World Cup Qatar 2022 – although it would have been created whether the bid was successful or not. The first ever development initiative to come out of a FIFA World Cup, GA was designed to use the power of sport – especially football – to create social change aligned with the Sustainable Development Goals (SDGs) and Qatar’s National Vision 2030. After over a decade of work with youth and communities around the world, GA was launched for the long term as the Generation Amazing Foundation. As of 2022, GA had: • impacted over a million lives in 75 countries • built 41 football pitches to provide sporting opportunities and spaces for play • trained over 2 300 teachers, coaches, and volunteers worldwide • trained over 200 youth advocates around the world. 146 Strengthening health and well-being through sport events Changing the game How it works GA’s programmes depend on community engagement that allows an understanding of the social, cultural and economic factors affecting people’s lives in target communities and groups. All programmes are designed with a participatory approach that asks for high levels of community involvement in programme design, implementation and decision-making around four areas of work: • providing Sport for Development (S4D) training for coaches • establishing and running GA Community Clubs – safe spaces for young people to develop and express themselves • developing a global network of youth advocates and leaders for social engagement • holding Youth Festivals that connect youth from around the world. Football for development The Football for Development (F4D) programme develops life skills and sports skills, with the sports element teaching not just football but also general physical literacy that supports participants’ lifelong engagement with sport. Each F4D programme is tailored to the target community’s needs and uses an online GA e-learning platform and face-to-face sessions led by GA Master Coaches, occasionally aided by young programme advocates and community leaders. Training sessions focus on sports as a tool for learning life skills like communication, teamwork, and leadership, and try to ensure that every participant leaves empowered to improve their communities and their futures. Community clubs Generation Amazing Community Clubs (GACC) are havens for everyone, irrespective of gender, age, race, ability, or religion. They are platforms for F4D and hubs for wider learning and social enterprise where young people are encouraged to participate at every level from managerial decision- making to day-to-day activities. The first GACC, in Doha, is an expansive space for F4D sessions. The next will be launched in Bugesera District, Rwanda in 2024, for adults and children from underserved communities and rehabilitation centres. Two more Clubs are being built in India and the Philippines, and two further pitches in Jordan (in Aqaba and Baq’qa) will be renovated to GACC standards in 2024. Generation Amazing has discussed using the clubs to support work in other areas, like nutrition and mental health, with partners like WHO and the Ministry of Public Health. In Qatar, the Ministry has already used the Doha hub for physical rehabilitation work. 1478.1.10 Example: Generation Amazing Foundation Youth advocacy Generation Amazing’s Youth Advocates programme is a year-long holistic programme of capacity building opportunities and engagement for young leaders, building the skills and knowledge to be agents of change in their communities.  Youth festivals Generation Amazing Youth Festivals are held annually alongside major sporting events, emphasizing social development through youth participation. The Generation Amazing Youth Festival 2022 included the first-ever international school exchange programme alongside the FIFA World Cup Qatar 2022. Schools from 32 countries engaged in a year-long exchange programme called GOAL 2022, and students took part in virtual Sport for Development workshops to develop life skills and address social issues in their communities. During the World Cup, in collaboration with the United Nations Educational, Scientific and Cultural Organization (UNESCO), the festival welcomed over 400 students for physical training sessions and tournaments designed to implement lessons from the programme. Workshops and panels with 30 partner organizations discussed issues like women in sport; creating positive impact through sport; sustainability; climate change; and inclusive leadership through sport. Attendees also participated in a cultural ceremony and an inclusive football event called the “All-In” tournament. Support for the Afghan refugee crisis During the Afghan refugee crisis in 2021, GA was able to support the Ministry of Foreign Affairs by: • delivering Sport for Development programmes for boys and girls; • creating and providing a programme in response to the refugees’ interests and needs. This included Arabic and English lessons, yoga and sports activities, and art and storytelling workshops for children; • mobilizing local volunteers and international partner NGOs; • delivering the F4D Coach Education Programme to the Afghan national men’s and women’s football teams (coaches and players) and the Afghan national women’s basketball team; • organizing a friendly match between the Afghan and Qatar women’s football teams at Khalifa International Stadium; • hosting support visits to the facility from people like the heads of WHO, the UN High Commission for Refugees and FIFA; David Beckham; ministers from several countries; and notable figures from the entertainment world. © Generation Amazing Foundation Generation Amazing Foundation youth advocates with WHO Goodwill Ambassador Didier Drogba at the Education City stadium 148 Strengthening health and well-being through sport events Changing the game “ As a Generation Amazing youth advocate, I’ve learned it’s very important for communities to understand how football can be transformative and how it can have a positive impact on youth that goes beyond the game.” Bader AlZaharna, GA Advocate “Sports can play a huge role in building relationships because it builds one’s confidence, and it creates bonds between people, especially through team sports. My involvement in sports has enabled me to communicate more with my teachers, make a lot more friendships and even join the Generation Amazing youth advocacy programme” Al Jazi Al Marri, GA Youth Advocate Future plans - a wider legacy Now that the GA Foundation has achieved sustainability, it is exploring how to broaden its health impact. Scoping work has included: • engaging with nutrition, mental health and other physical activity programmes. Focus areas like these can easily be embedded within the GA programme. The Foundation has developed mental health content with the Ministry of Public Health, and intends to deliver professional mental health training. GA continues working with the Ministry to develop and deliver education content and offer new avenues to implement health policy in communities; • while many World Cup organizing committees have been disbanded since the tournament, the GA Foundation remains close to several of Qatar’s key institutions, including the ministries of health, education and foreign affairs. Generation Amazing can be an important diplomatic focal point, offering resources for those who want to embed sports in national or regional programmes, or to use sport in diplomatic contexts; © Generation Amazing Foundation • GA works with organizations across the world to pass on best practices from Qatar 2022. This includes working with all 41 member associations of Concacaf, the FIFA Confederation that will host the 2026 World Cup; • beyond this, GA aims to expand into other sports and create legacies and accelerate social development alongside other mega sporting events around the world. Palestinian child with a leg amputation participates in a Generation Amazing Foundation football game. 1498.1.10 Example: Generation Amazing Foundation Nutrition: healthier food and healthier food environments Challenging the status quo for mega events by ensuring access to healthy food was an important goal for S4H. To achieve this, the partnership reviewed FIFA’s planned menus for stadium areas and Fan Zones, benchmarked them against WHO criteria for healthier foods, and made recommendations to reformulate certain menu options so that at least 30% of the food items were healthier – and tasted good (48). The offer of healthier food was complemented with targeted communications and behavioural insights strategies to encourage consumers to choose the healthier food options. Healthier food at the FIFA World Cup Qatar 2022 “ Engaging in the backstage planning for a mega football event that is the most widely viewed and followed single sports event in the world was at the same time daunting and exiting. Would it be possible to change the paradigm in this type of event to ensure that fans could have access to healthier food?  Would they like it?  The literature was not too optimistic about dietary preferences of football fans. During the collaboration we learnt and appreciated the logistic challenges of securing the food supply - and expediting delivery during match halftimes of tasty meals and snacks to millions of fans from all corners of the world. I was impressed by the food concessionaries who achieved a menu with 30% healthier options, and not least by the Qatar Ministry of Public Health that relentlessly worked for using the mega event to promote health.   For FIFA this is a great beginning and sets an example for other sports event organizers. My dream is that future mega sports events will have an even healthier food offer and be free from marketing of unhealthy food during sports events, for fans at the event as well as for the health of all youth, children and their families watching from home.” - Kaia Engesveen, WHO headquarters, Geneva 150 Strengthening health and well-being through sport events Changing the game Main activities • This project challenged the assumption that major sports events aren’t a place for healthier food. The nutrition team’s work showed that a healthier offering is acceptable to customers, and that it is feasible to offer food at sports events that aligns with the health and wellness values associated with sports. • The team identified clear, ambitious but attainable targets. Thirty percent of the food offering inside stadiums and around 20% of the food offering in the FIFA Fan Zones were considered “healthier” according to WHO criteria for: • balanced energy intake; • increased consumption of encouraged food groups such as fruits and vegetables, whole grains, nuts and legumes, and of water for drinking; and • healthier nutrient profile in terms of energy density and content of total, saturated and trans fats, total sugars, and sodium. This was done based on a detailed analysis of the food and nutrient content of proposed menu options, to identify how the menu could be adapted to meet the established criteria for healthier food through two approaches: (1) reformulation of recipes; and (2) replacing unhealthy options with healthier options. In stadiums, only one of the proposed eleven menu items (meat fatayer) was healthy at the start. The nutrition team engaged a food scientist to suggest recipe reformulations or replacements that were acceptable to the caterer, leading to reformulation of two other menu items: reducing the amount of pastry dough relative to vegetable filling in the spinach fatayer to meet the criteria for energy, total and saturated fats and sodium; and reducing the amount of hummus relative to vegetables in the “veggie sticks with hummus” to meet the criteria for total fats. A fourth menu item, the vegan burger, was replaced by veggie rolls which met the set criteria. As result, four out of eleven (30%) items in the final menu for stadiums were healthier. Recipes for veggie sticks and 11 other healthier meals and snacks that are popular at sports events are included in the action guide for sports event organizers (48), and can be used to achieve healthier food at future sports events. • The team used behavioural insights techniques to make healthier food choices easier for fans. These approaches included: • positioning the four healthier food options at the top of their respective categories on overhead menu displays; • removing unhealthy snacks, condiments, and sauces from counters in all stadiums; • testing an additional package of “nudges” (changes in the presentation of food options designed to make healthy choices easier) in some stadia and half the Fan Zones. These included the addition of contrast to highlight healthier menu items and adding “wobblers” featuring appealing photographs of the healthier food items to the overhead menu boards. Preliminary results demonstrated a significant positive impact, particularly for veggie sticks, with a 257% increase in sales in the treatment stadia 1518.2 Nutrition: healthier food and healthier food environments compared to the control. At the level of the concession stands, the results show a 129% marked increase in sales of veggie sticks. In other words, simple interventions made an item previously only purchased rarely much more popular. Other increases in healthier consumption included a 24% increase for healthy fatayers and a 41% increase for veggie rolls. These benefits were achieved without significant effort or cost: reordering items on a menu or highlighting items is very easily done at no cost and is very easy to implement (except perhaps in negotiation). The additional cost of the wobblers and images was also extremely low. • On the food safety side, Qatar’s work was supported by the Secretariat of the International Food Safety Authorities Network (INFOSAN) (49). In coordination with the WHO mass gathering team, INFOSAN ran several activities that strengthened Qatar’s ability to identify potential food safety events. These included speeding up notification for food safety events and establishing a network with neighbouring countries for rapid coordination if an event did happen. INFOSAN also provided daily reports on global food safety incidents to the FIFA World Cup Qatar 2022 epidemiology team. • The WHO Regional Office for the Eastern Mediterranean supported a review and update of Qatar’s food safety emergency communication and response plans. • Through the SitRep process, a few small clusters of intestinal infections caused by food contamination were picked up during the tournament, mostly among stadium staff. These were identified quickly, corrective actions were taken and the problems were solved. 152 Strengthening health and well-being through sport events Changing the game Healthy eating habits during the FIFA World Cup Qatar 2022 As someone who enjoys snacking during events and games, I never thought I could enjoy having healthier options without compromising the enjoyment of the experience. However, my perspective shifted during my involvement with the Sport for Health Project where one of the aims was to promote healthier eating habits at the FIFA World Cup Qatar 2022. The project implemented an experiment in two stadia where nudges were hung up to encourage healthier eating choices among spectators, while two other stadiums served as control groups with no nudges. Observing the reactions of the attendees, it became evident that their choices were influenced, with a noticeable preference for healthier options. These healthier choices weren’t explicitly marketed as such; there were no signs labeling them as ‘healthy.’ Yet, spectators were nudged towards them, possibly due to pricing, the visual appeal of the nudges, or simply because they appeared healthier than typical offerings like burgers and hot dogs. This realization challenged the misconception that healthy food isn’t enjoyable. By integrating healthier options into the event without overtly promoting them as ‘healthy’, the project demonstrated that people are inclined to make healthier choices when given the opportunity, even if they aren’t consciously seeking to do so. This subtle approach proved successful in encouraging healthier eating habits without imposing them, highlighting the power of choice and accessibility in promoting well-being. Making healthier options a standard part of the food offerings at games can help integrate a culture of better eating habits during sport events. Rayan Sheik – Junior Epidemiologist, HiAP Unit, Ministry of Public Health The coordination and successful execution of the healthy food project for the FIFA World Cup Qatar 2022 was inspiring. Changing the fans’ expectations and mentality in such a context was ambitious. While we probably didn’t achieve the full desired switch in mentality, even though results were positive and significant, hopefully this was a first step in the evolution towards healthy food offering during these international competitions. Against all odds and despite various constraints, I feel that people in general understood the importance of this initiative. And hopefully we will be able to see more of these healthy options in stadia and official venues in future, providing fans with best-in-class experiences, aligning entertainment and health in all aspects of sport. Jérôme Matteucci – former Head of Marketing Rights Delivery, FIFA World Cup Division 1538.2 Nutrition: healthier food and healthier food environments Nutrition: reflections Issues, challenges and responses • The menu and nudges were finalized only a month before the start of the World Cup. Work began early but faced a range of difficulties that delayed implementation, monitoring and evaluation plans. These included: • a general lack of experience in healthy food policies for this type of event; • difficulties changing existing procedures and business priorities for catering and sponsorship because of long term agreements that were already in place; • difficulties, mainly for caterers, in adjusting menus and making supply arrangements to follow WHO’s guidance. This was exacerbated by the fact that Qatar – unusually for a mega event host country – had to import almost all the food for the event; • lack of a common understanding of the S4H nutrition goals across different organizations. This made it hard to identify overlapping interests and build trust between different partners. This delayed caterers’ decisions on healthier food items, which in turn delayed the design of nudges to favour the selection of healthier food; • challenges related to lack of opportunity for engagement with (and training of) staff at point of sale, meaning that those people who were responsible for first line implementation of the strategy were not fully enabled to support it as best they could. • Observations in stadiums showed that there were supply shortages for all food menu items, and uneven distribution of healthier food items between different stalls. Cold healthier food items were particularly affected. Snacks, sauces, and sugar sachets were on the counters of most stalls despite instructions not to place them there, and some stall vendors removed promotional nudges for items that weren’t in stock. Most vendors had insufficient training, and for language reasons did not always understand what was asked of them. This meant they were sometimes unaware of the available healthy food options, or of why certain options were encouraged more than others or requested more than others by customers. • Lack of awareness of the strategy among staff occasionally caused errors, such as removing some nudges (for example, removing wobblers or placing sachets on the counter) rather than seeking support from managers. • Point of sale machines were set up to register sales in a way that did not describe or name items, which were distinguished in the machines’ records only by the cost – which for some differing items were the same (e.g. spinach, cheese and meat fatayer were the same cost across the healthier and unhealthier options). This required the team to make assumptions in data analysis. • Monitoring work was complicated and delayed because, while data collection and analytical methods were defined in advance, the data were not provided or unavailable, or no mechanism was established to collect them – in part 154 Strengthening health and well-being through sport events Changing the game due to resistance to the suggested approaches. There were no mechanisms to integrate feedback and make corrections throughout the tournament. Evaluation plans were never fully defined because of delays finalizing the menu, and because researchers never visited the stadiums in advance to improve their understanding of how selling points were set up and how the sales and purchase mechanisms worked. • While stock data were requested, they were never provided. This was a problem because the strategy was developed based on the assumption that this data would be collected systematically. During implementation the team discovered, to everyone’s surprise, that there was no mechanism to collect or maintain stock data either by stadium or by point of sale. This knowledge would have allowed better definition of desired outcomes and data collection mechanisms. A rigorous assessment of how the nudges impacted sales of healthier items was made more difficult because of the lack of a mechanism to produce and access real time stock data for each point of sale. Considerations for future events • This work outlines a path for the future: major sports events do not have to be hotspots for food high in sugar, salt and/or unhealthy fats. Providing healthier options is possible. Nudges and other techniques can be used to promote and support healthier choices. There is no evidence to suggest that diversifying the food offer and improving the quality and nutritional value of food options poses commercial risks for sponsors or organizers – although it is important that changes are made in an integrated way, with full communication and training of relevant staff, and that nudges and other behavioural interventions are used to underpin the strategy. • The lessons from working on food and food environments in the FIFA World Cup Qatar 2022 are reflected in a joint Ministry of Public Health/WHO action guide called Healthier food and healthier food environments at sports events – a valuable legacy contribution for future events (48). The experiences of the FIFA World Cup Qatar 2022 have shown demand for more targeted guidance and implementation resources in different formats and for different audiences. Figure 32 Healthier food and healthier food environments at sports events: an action guide for sports event organizers Healthier food and healthier food environments at sports events An action guide for sports event organizers 1558.2.1 Nutrition: reflections; 8.2.2 Issues, challenges and responses; 8.2.3 Considerations for future events A new network of institutions (e.g. laboratories) and individuals (food scientists, chefs, behavioural science experts, etc.) is needed to help make healthy food offerings the default approach at major events. This new network could produce creative recommendations for delicious, healthy food and provide testing and quality assurance for healthy food and behaviour change approaches. • Nutrition and behaviour change considerations should be integrated into event organizers’ food and drink policies from the conceptualization phase (hence prior to the definition of contracts or implementation plans) of the experience to be offered, with concrete targets for healthy food offerings and food environments (including marketing regulations). Event organizers will need step-by-step plans to adopt new approaches that take future sponsorship agreements into consideration. This step is crucial: it will help ensure that future food decisions are made to improve health and not to serve corporate interests. • In complex, multilayered mega-events it is critical to identify and engage focal points at different levels and in different organizations as early as possible ideally from concept stage, to align everybody’s priorities. Focal points for procurement, communications, sponsorships, catering, marketing, and so on should be engaged directly by the nutrition planning team to start early on work to making sure healthier options are available. Providing a shared platform for comment and feedback on the strategy helps develop a shared vision and encourages ownership of activities. • The logistics of food supply are complicated. Planners would benefit from making sure that all involved partners consider early on what is needed to achieve a healthier event. This means: • advance consideration of food supply chains and related logistics; • advance planning for nudges, making sure they are suitable for the food on offer and the environment where food choices will be made (and vice versa); • ensuring that menu planning considers any behavioural insight strategy to ensure that the two strategies re- enforce one another; • clarifying early exactly how implementation will be monitored and how to evaluate outcomes; and • defining and agreeing what data to collect, and who will collect it, when and how. • Concessionaires and vending staff are part of the implementation strategy and require additional consultations training and clear SOPs. Regular monitoring and spot checks are needed throughout an event to understand whether healthy food offerings and nudges are working, and whether changes are needed. This requires the establishment of a clear mechanism and plan in advance for who will perform the monitoring, what will be measured, and how. • Target audiences and key consumer messages should be clear at the beginning, so that a communications plan can be developed early. All possible communications platforms should be used. In Qatar, S4H had several approaches to health promotion and communication, but these were not exploited for the healthy food project. In future events, all existing communication opportunities should be used to promote healthier diets. 156 Strengthening health and well-being through sport events Changing the game “ Applying behavioural insights to promote healthy eating in Stadia during the FIFA World Cup Qatar 2022 was a historical moment. Not only was it the first time ever behavioural science had been used in mega sports event, but it did also provide proof of concept that small and cost-effective choice architecture type of interventions can be effective to “nudge” fans into the healthier food options. The evidence-based recommendations compiled through this intervention will be a scalable legacy for future FIFA World Cup events, as they will contribute to healthier lifestyle around the globe, one event at a time!” - Dr. Fadi Makki, Partner and Director, Global Co-Lead of the Behavioural Science Lab at the Boston Consulting Group at Washington DC; and former Director of the Supreme Committee for Delivery and Legacy’s behavioural science initiative, B4Development. 1578.2.3 Considerations for future events Example: alcohol free stadiums FIFA Statement, 18 November 2022 Well, this is awkward... 10:43AM • Nov 18,2022 • Twitter Web App Budweiser @ Budweiser Official Budweiser’s now-deleted tweet. (Budweiser) 158 Strengthening health and well-being through sport events Changing the game A ban on alcohol sales in and around FIFA World Cup Qatar 2022 stadiums was decided two days before the tournament kicked off, making this the first ever FIFA World Cup at which alcohol was not freely available in stadiums throughout the tournament. This change, culturally significant and in many ways unexpected, had a range of positive impacts. It reinforced existing efforts to create family friendly environments in and around stadiums. It was a tangible action in support of health messaging, showing concretely that organizers were serious about acting on everything we know about the damaging effects of alcohol on people’s health. This decision was correlated with lower levels of violence, sexual abuse and demand for health and security services throughout the tournament in comparison to what was expected, or to what had been seen in the past at other events at which alcohol was widely available to all (50). For example, while sobering stations were set up to help inebriated fans, with 93 beds available across five sites, they were only used 66 times across the entire tournament – and several of those cases were unrelated to alcohol. An expected rise in assaults also did not happen. Throughout the tournament, Qatar saw only 177 cases of alcohol intoxication, corresponding to 0.4% of all patient presentations – significantly lower than the range reported for other sports events around the world (from 1% to 10%) (22). Organizers of other events such as the FIFA Women’s World Cup Australia and New Zealand 2023, and Paris 2024 Summer Olympic Games, considered and implemented at times health promoting interventions addressing alcohol consumption and healthy nutrition. “ Everyone has the right to enjoy the tournament and the festive atmosphere while feeling safe and secure. From the security perspective, decisions are made based on a thorough analysis of various factors, particularly the risks associated with specific actions or behaviours. These decisions are continuously reviewed to ensure the highest level of security. We identify, measure, and analyse risks, then find ways to mitigate them. For example, the risk of hostile or aggressive behaviour increases significantly with alcohol intoxication.” “ In mass gatherings, especially at international football events, small incidents can escalate into major ones. Knowing the risk and potential for harm, we took proactive measures to eliminate such risk.” Dr. Sean Mottaleb, Senior Health care Lead at the Emergency, Crisis and Disaster Preparedness Team at the FIFA World Cup Qatar 2022, speaking to CNN in 2022 1598.2.4 Example: alcohol free stadiums Tobacco control The implementation of the tobacco free FIFA 2022 Policy aimed to ensure tobacco and smoke-free stadia throughout the World Cup, and to prevent any tobacco or e-cigarette advertising, promotion and/or sponsorship at any event site. A similar policy was used for the FIFA Football Arab Cup 2021 – the first ever such event to be 100% tobacco-free – and the lessons from that were used to improve planning for the FIFA World Cup Qatar 2022. The decision to make the Arab Cup tobacco-free was also related to the COVID-19 pandemic, and the need to prevent people from gathering in close proximity in designated smoking areas. The FIFA Arab Cup experience showed that a total ban created problems: people smuggled cigarettes into venues and smoked in hiding places, causing health risks and fire risks and exposing non-smokers to smoke. Because of this, planners decided to reduce these risks by providing designated smoking areas (DSAs) in the FIFA World Cup Qatar 2022 that reduced the temptation to smoke in hiding. These DSAs were outside stadiums, and re-entry to stadiums was not permitted. As a result, they were used primarily before and after games, rather than during half-time. Objectives of the Tobacco Free FIFA 2022 Policy 1. Protect athletes, spectators, officials and volunteers from the harms of second-hand smoking 2. Raise awareness of tobacco hazards and promote healthy lifestyles during the World Cup 3. Oversee and monitor implementation of the tobacco free policy 4. Implement concrete, measurable tobacco control strategies that can be replicated by future hosts, positioning the FIFA World Cup Qatar 2022 as a benchmark for other nations organizing major sporting events 5. Use the experience of the FIFA World Cup Qatar 2022 to promote tobacco control legislation and policies at global level 160 Strengthening health and well-being through sport events Changing the game There were four major elements of the planning stages: 1. Develop and implement a tobacco control plan for the World Cup 2. Develop communication strategies to raise spectators’ awareness of the dangers of tobacco and promote smoke-free events 3. Develop an inspection and enforcement plan 4. Ban all forms of promotion, sponsorship and advertisement of any tobacco products during the event. The success of the policy was underlined in May 2023, when the Ministry of Public Health received the WHO World No Tobacco Day Award. This award recognized the Ministry’s collaboration with tournament organizers in ensuring a tobacco and smoke- free environment during the FIFA World Cup Qatar 2022. Main activities • Information on the no-smoking policy were delivered through event tickets, programmes, stadium maps, e-tickets, promotional material, posters, electronic advertising boards on public transport and in public spaces, websites and social media, and communication strategies that included audio and visual tools. These messages promoted smoke-free environments in stadiums and public spaces. Ticket holders were informed in advance about the prohibition of lighters, matches, and restrictions on smoking and e-cigarette use through the Hayya app, fan guides, and emails. Behavioural “nudge” posters were placed in stadium restrooms, where smoking violations are common, to remind attendees of the negative health impacts of smoking. • Audio-visual communications were also developed specifically for use in stadiums, to make sure everyone knew the FIFA World Cup Qatar 2022 was smoke-free, and to raise awareness among attendees. • Ministry of Public Health and private security staff were trained to implement the policy before, during and after matches, to ensure the policy was implemented effectively. This training covered procedures for handling violations and ensuring the policy was consistently upheld. Further training was given to over 71 000 staff and volunteers to help enforce the policy during the event. • Daily reporting templates were developed for a team of over 80 tobacco inspectors, who were responsible for enforcing the policy. The templates helped track smoking violations, items confiscated, and interactions with spectators, assisting in improving strategies for future matches. • Activities during the event included: • set-up of designated smoking areas (DSAs): Specific smoking/vaping areas were set up outside the stadiums to accommodate smokers without violating the tobacco-free policy inside the stadiums; • signage design: behavioural science principles were used to design and place signage informing spectators about the no-smoking policy and the locations of DSAs; • awareness-raising efforts: fans, volunteers, and staff were regularly reminded of the tobacco-free policy 1618.3 Tobacco control; 8.3.1 Main activities through various communication methods before, during and after matches; • ban on lighters and matches in stadiums: Items used to light cigarettes were banned inside the stadiums to prevent smoking; • constant communication: the tobacco- free policy was communicated consistently throughout the FIFA World Cup Qatar 2022 period – including through a short video clip featuring football star Kaká that was promoted across social media to encourage fans not to smoke in prohibited areas; • tobacco inspectors: over 80 tobacco inspectors were deployed to monitor and enforce the policy, report violations, and confiscate prohibited items; • data collection: inspectors’ reports and photos were compiled after each match to gather and analyse data on the number of violations, items confiscated and altercations. Inspectors’ observations were collected to improve approaches and help operations for future matches. Analyses were used to improve the enforcement approach and inform future events. Figure 33 Percent of violators who stopped smoking after being approached by inspectors by stadium Source: Tobacco free policy implementation report, Ministry of Public Health-Qatar, 2022 Education City Stadium (n=4221) 56.17% Ahmad Bin Ali Stadium (n=1429) 76.14% Al Thumama Stadium (n=3203) 58.07% Khalifa International Stadium (n=1729) 77.39% Al Janoub Stadium (n=1266) 69.75% Al Bayt Stadium (n=2345) 69.38% 974 Stadium (n=1186) 79.76% Lusial Stadium (n=3306) 71.99% 100% 80% 60% 40% 20% 90% 70% 50% 30% 10% 0% 162 Strengthening health and well-being through sport events Changing the game Tobacco control: reflections Issues, challenges and responses Delivering the policy was challenging. Spectators and fans from all over the world were accustomed to different policies at home, and sometimes ignored the policy and regulations. • While the smoke-free stadium policy was implemented during the FIFA World Cup Qatar 2022, there was no corresponding national policy in Qatar making all public indoor spaces, such as cafes and restaurants, smoke-free. This inconsistency may have been perceived as a contradiction by visitors, potentially undermining the smoke-free initiative. • Communication was sometimes an issue between tobacco inspectors, security staff and volunteers: security staff weren’t always aware of Inspectors’ roles and responsibilities, and sometimes hindered their work. • There was some conflict between the event policy and national law, which forbids closed smoking areas; but in stadiums the smoking areas had to be closed. Future efforts would be improved by closer alignment between national policy and FIFA regulations (or those of the governing bodies of other mega sports events). • While there was an extensive communication campaign to inform spectators of tobacco regulations, experience suggests that in future events this should be enhanced to ensure that all people are reached by the messages. Gaps in communication and signage for spectators and fans meant they weren’t always aware of the policy, or of the availability and location of DSAs, and communications materials were not used widely enough. FIFA volunteers carried NO SMOKING signboards, but these did not fully cover the stadiums. Video messages were not played frequently enough. • There were not enough DSAs to meet demand and many were too far away from the stadiums, meaning fans sometimes smoked in public places instead. • Stadium “No Re-entry” policies and confusion about smoking areas inside stadiums meant that fans smoked in toilets and staircases (mainly during half-time breaks in matches). In future these policies may need to be better communicated. • While it was felt that implementation of the policy was largely successful, insufficient data – including specific violation statistics – were collected for full analysis of its strengths and weaknesses. Considerations for future events An internal review of the tobacco free policy for the FIFA World Cup Qatar 2022 produced the following recommendations: • start smoke-free event communication spectators and fans well in advance, through messages, email and social media; • provide maps of designated smoking areas with event tickets, and ensure at least one area is available for every two exit gates; • use high volumes of high intensity audiovisual communication to raise awareness of smoke-free event policies. 1638.3.2 Tobacco control: reflections Broadcast NO SMOKING videos before and during sports events (e.g. during half time at football matches); • place obvious NO SMOKING signs on gates, and particularly on toilet doors; • place tobacco alarms and smoke detectors inside toilets; • ensure all relevant staff, including volunteers and security personnel, are properly trained to engage in and/or facilitate tobacco control during the event. Security staff and volunteers were very effective in displaying NO SMOKING signs and directing people to DSAs; • raise awareness among security personnel so they know about the tobacco free policy, follow it themselves, and help enforce it; • there were several reported instances of some people who were invited to stop smoking but refused to do so (see Figure 33). The main results of the inspection activities are presented in Table 3. While inspectors were able to confiscate lighters and matches, they had no mandate to sanction violations – highlighting the need for an enforcement or sanction mechanism, including sizeable fines for those violating the policy, in future events. Table 3 Violations of tobacco restrictions by stadium Stadium total matches violations average violation per stadium total stadium attendance Violation rates per 1000 Education City Stadium 8 4 221 528 349 114 12.1 Al Thumama Stadium 8 3 203 400 337 685 9.5 Khalifa International Stadium 8 1 729 216 355 552 4.9 Ahmad Bin Ali Stadium 7 1 429 204 299 517 4.8 Al Janoub Stadium 7 1 226 .175 288 774 4.2 974 Stadium 7 1 186 169 297 854 4.0 Al Bayt Sradium 9 2 345 261 601 149 3.9 Lusail Stadium 10 3 306 331 874 607 3.8 164 Strengthening health and well-being through sport events Changing the game Around half of all mental health conditions start by age 14, and depression affects more than 260 million people (51). The S4H partnership wanted to use the platform of the FIFA World Cup Qatar 2022 to raise awareness about mental health conditions, dispel the stigma often associated with it, and encourage people who experience stress and anxiety to seek help. Some of the goals of the mental health part of S4H’s health promotion pillar overlapped with those of the physical activity pillar, and the benefits of sport and physical activity on mental health are well documented. But S4H also understood the need for targeted efforts to increase understanding of mental health, reduce stigma, scale up services to treat mental health conditions, and increase equitable access to high quality, affordable care. Main activities • Starting in 2021, WHO began work with FIFA on the #REACHOUT initiative to increase awareness of mental health issues, reduce stigma, encourage seeking help, and encourage actions every day for better mental health. Past and current football players supported the campaign, helping people understand the importance of looking after their – and others’ – mental health. • In Qatar, public attitudes to mental health were targeted with large-scale public awareness initiatives like the national “Are You OK?” campaign launched in 2020. This campaign encouraged people to talk more openly about their emotional wellbeing, and has resulted in greater numbers of people seeking help from mental health services. • Knowing that fear of stigma is a key factor in preventing many people in Qatar from seeking mental health services, Qatar has established a National Mental Health Helpline. This has been described as one of the most impactful developments in recent years within the Mental Health Service. “Mental and physical health are inextricably linked and sports is a clear illustration… Mental health underpins all human endeavours and should be part and parcel of all developmental and humanitarian policies and actions.” - Dr Khalid Saeed, WHO focal point for mental health in the Eastern Mediterranean Region Mental health 1658.4 Mental health Example: friendship benches The S4H Friendship Benches initiative was an awareness-raising programme that focussed attention on mental health during and after the FIFA World Cup Qatar 2022. Thirty-two benches – one for each of the competing nations – were placed strategically around the stadiums, with four benches at each venue. The benches, which were designed by local Qatari artists, based on their experiences in overcoming mental health challenges, were inviting spaces for conversations, moments of rest, and engagement in physical exercise. QR codes were incorporated onto the benches, through which people could access additional resources and useful information on physical activity and mental health. The Friendship Benches model was originally developed in Zimbabwe to provide sustainable, community-based psychological interventions that are accessible and scalable. In Qatar, the initiative was designed to demonstrate the importance of mental health and offer advice on ways to promote mental well-being, including through physical activity and sport. It was aligned with the shared goals and campaigns of each partner organization, including the FIFA/WHO #REACHOUT campaign and the “Are You OK?” project, and also aimed to promote physical activity as a key outcome of the Sport for Health project. To this end, the design of each bench included a series of illustrated advice describing easy, effective exercises that visitors can practice for their physical health. When attending one of the 64 FIFA World Cup Qatar 2022 matches, visitors and fans were encouraged to take some time to visit the benches and reflect on the importance of mental health and well-being. The programme was symbolically launched with a preview of the England team bench at the World Innovation Summit for Health, a global health event hosted by the Qatar Foundation. Sir Mo Farah, the most successful male track and field athlete in British history, inaugurated the bench, before he was joined by Sheikha Hind bint Hamad Al Thani, Vice Chairperson and CEO of Qatar Foundation, for a discussion about sport and mental health. © Ministry of Public Health Launch of the 32 friendship benches at 974 stadium on World Mental Health Day 2022. 166 Strengthening health and well-being through sport events Changing the game “ Benches are useful if you want to speak with anyone anytime. The idea is that whenever you have problems in your life, you shouldn’t keep them to yourself but speak about them, and everyone will be ready to help. Physical activity and sports help with mental health. I had an accident while climbing mountains, and sports helped me recover, think clearly, and regain my confidence. This year, I was able to climb another mountain.” - Fahd Badar, Adventurer and Mountaineer, Qatar (https://rb.gy/nqkxha) “ The initiative behind the Friendship Benches can help frame caring for one’s mental health less as an act of self-care, and more broadly as a practice in community care. There’s a growing body of research dating back decades that highlights how individualistic attitudes and isolation can actively harm a person’s mental health. However, these aren’t always voluntary choices. A physically disabled person struggling to keep above the poverty line, too ashamed to reach out for help due to stigma, and devoid of any support network altogether, is much more likely to be locked into a spiral of declining mental health than a person without those obstacles. That is before taking into account past traumas, neurological conditions or other unknown factors. It is my hope that the Friendship Benches can help foster a shift in mentality from framing poor mental health as a private failing to seeing it as a shared community struggle.” – Feras Al Meer, Head of Partnerships and Outreach, World Innovation Summit for Health – Qatar Foundation 1678.4.1 Example: friendship benches Accessibility To support and enhance accessibility for all and inclusivity for persons with disabilities during and beyond the World Cup, the Supreme Committee established an Accessibility Forum in 2016. Made up of a diverse group of members with disabilities including those with underlying limitations in mobility, vision, hearing cognitive functions, as well as people with psychosocial disability. Along with representatives of over 30 organizations that they are part of, the Forum set out to ensure a seamless FIFA World Cup Qatar 2022 fan experience for persons with disabilities. In the lead up to the Tournament, the Forum hosted a range of workshops exploring how persons with disabilities could participate in the organization of the tournament, and what needed to be done to ensure an optimal experience for fans with disabilities. Representatives of the Forum visited stadiums to test and feedback on accessibility features. Based on their input, a series of accessibility modifications – mostly focussed on infrastructure and transportation – were made for the tournament and for the longer-term public realm in Qatar. The Qatar Foundation also created a national accessibility guide, trained volunteers to support fans, and helped set up sensory rooms in stadiums and other locations such as the FIFA Fan Festival, the Corniche Activation and Education City Last Mile. Since the tournament, the Qatar Foundation has continued supporting sports and leisure opportunities for persons with disabilities across Qatar, while improving national awareness of accessibility issues. © Supreme Committee for Delivery and Legacy A spectator in a wheelchair watches the football game in the designated accessibility area. 168 Strengthening health and well-being through sport events Changing the game “As a child with Autism, my 13-year- old son’s senses can be overloaded at a stadium, but sensory rooms during Qatar 2022 made the experience very manageable. I was delighted to see Ibrahim being given the opportunity to attend football matches. He loves the game, and is always excited when we go to the stadium. Although he loves the sights and sounds of being in the stands, they can sometimes be a bit too much for him. More importantly, these types of facilities give Ibrahim the opportunity to experience large events and gain the confidence to be better integrated in social settings. It was great to see them deployed during the World Cup, a successful experience that will surely create a legacy for future events.” - Adel Al Awad, father of football fan with sensory needs. Both father and son made use of sensory rooms during Qatar 2022 “One of the accessibility features of Qatar 2022 that transformed my ability to enjoy the tournament was Audio Descriptive Commentary. It provided me and other blind fans with a detailed account of what was happening in the stadium, including where the ball was on the pitch, players’ facial expressions and what was happening in the stands. After arriving at the game, I simply downloaded an app on my personal device and used my own headphones to listen to the dedicated commentary, which was available in the Arabic language for the first time. In the past, if I went to a stadium, I would have to rely on the commentary of a friend sitting beside me in the stands, or on the non-descriptive commentary on TV, if I’m watching at home. Thanks to this service, I was able to feel the excitement of being in the stands at a World Cup match while following exactly what’s happening on the pitch. It was an amazing experience that could be replicated in different settings in Qatar and the region,” - Faisal Al Kohaji, a 35-year-old blind lawyer who works in the energy sector in Qatar. © Suprem e C om m ittee for D elivery and Legacy A young boy wearing noise-canceling headphones watches the football match. 1698.5 Accessibility For years I enjoyed being a part of an inspiring journey to make Qatar 2022 as accessible as possible to fans – regardless of their disability, background or social status. The Supreme Committee for Delivery and Legacy made huge strides in the area of accessibility, putting together a series of initiatives and programmes across multiple teams to ensure that the World Cup, when it came to this region for the first time, was be one that everyone could enjoy. One of the projects that I am particularly proud of is the sensory rooms we deployed across stadiums, firstly during a number of test events leading up to the World Cup, then during the tournament itself. First used during the Amir Cup final and the inauguration of Al Janoub Stadium in 2019, the sensory rooms provide a safe space for fans with autism, and other neurobehavioral needs, to retreat to when the stands get too loud. The sensory rooms are outfitted with a range of toys and interactive activities that are specifically designed to provide a controlled environment for young people, mostly children, to feel safe and relaxed, while still having the opportunity to watch the game from inside the room, or even venture out into the seats whenever they think they are ready to. The rooms are filled with things such as interactive projectors, bean bags and bubble tubes, along with controlled lighting to create both an enjoyable experience during the match and one that would enable these fans to build the necessary skills to go out and socialise with other supporters, and society at large, in large sporting events and beyond. In many ways, it was the perfect embodiment of the type of legacy we worked to leave behind after the final whistle was blown on 18 December 2022 at Lusail Stadium. It was also a great example of the successful community partnerships we built in the lead-up to the big tournament. None of the sensory rooms we put together would have been possible without the expertise of organizations that specialize in the provision of services for the autism community. These include the Qatar Rehabilitation Institute and the Renad and Awsaj academies at Qatar Foundation – two inclusive schools that provide world- class education to students with autism. But for me, a key stakeholder throughout the process was the group of parents that both trusted us with this initiative and gave us the necessary feedback to continue improving on the sensory rooms as 170 Strengthening health and well-being through sport events Changing the game we got ready to deploy them during the World Cup. When we first made a sensory room available to them and the community at the FIFA Club World Cup, seeing the faces of those young fans light up from the experience of being in the stadium reminded me that this tournament will leave an impact that goes much further than the football itself. Working in fan engagement meant continuously fine-tuning the fan experience ahead of Qatar 2022 so that it was enjoyable and memorable during the World Cup. For me and my team, a huge component of that was one that was also central to the tournament’s sustainability plan – and that is accessibility – for fans with autism and other accessibility needs. The sensory rooms were a great example of how Qatar 2022 was a tournament for all, and a milestone in the entire region’s journey towards creating more accessible spaces in stadiums and beyond. Samantha Sifah, former Head of Community Outreach, Marketing and Communications, Supreme Committee for Delivery and Legacy Sensory friendly rooms at the FIFA World Cup Qatar 2022 stadiums. © FIFA 1718.5 Accessibility Advocating for health Sport for Health’s central communications goal was using the most watched sporting event in the world – with an audience of over 1.5 billion people (2) – to promote healthy lifestyles and #HealthForAll. The Sport for Health Healthy World Cup Campaign set out to reach millions of people with advocacy and communication activities linked to the tournament’s key milestones. These campaigns also linked with regional and international networks of public health experts and other partners to boost engagement and solidarity around health promotion, and amplify the most important messages. The S4H communications projects were organized around a few main focus areas: • supporting healthy lifestyles: promoting activities and choices to improve physical and mental health • keeping safe and building health security, focusing on health and safety at mass gatherings • promoting #HealthForAll through ways for people to lead healthy lives – like physical activity, healthy diets and controlling tobacco use • promoting equity and gender diversity in sport • using the FIFA World Cup Qatar 2022 to build momentum around WHO’s global health agenda to protect the vulnerable and achieve Universal Health Care – making sure that all people around the world can get all the high-quality health services they need, whenever and wherever they need them, without financial hardship. Together, these efforts also supported WHO’s “Triple Billion” campaign targets – the push to get one billion more people benefitting from universal health coverage; one billion more people better protected from health emergencies; and one billion more people enjoying better health and well- being by 2025. There were three main target audiences: • the international general public, with a focus on youth, women, older adults and people with disabilities • football and sports audiences across the world – including spectators, staff, football players, sports stars and fans watching their teams from home • a network of partners that included – among others – health institutions, UN agencies, NGOs, civil society groups, national embassies to Qatar, regional governments, diplomatic missions and private sector and media partners. The media campaigns were tailored. They engaged with carefully chosen outlets in their respective contexts to achieve clear advertising and marketing goals that disseminated targeted health messages to keep people healthy and safe. To increase reach, the Sport for Health partners – FIFA, the SC, the Ministry of Public Health and WHO – promoted campaign messages further through their own media connections, social media channels and press releases. Messages and campaign content were also pitched to major regional influencers and sports and health journalists. 172 Strengthening health and well-being through sport events Changing the game Activities Communications teams at the Ministry of Public Health, HMC and PHCC worked with their colleagues across the health care sector to ensure that everyone attending the FIFA World Cup Qatar 2022 was aware of the full range of health care services available to them. A dedicated website was created to give local and visiting fans information on health services and health advice. Communications teams delivered regular messaging to local and international fans through media including press releases, media interviews and social media messaging (Maya Al Akkawi, Paul Garwood, and Reem Ahmadieh, Ministry of Public Health of Qatar, World Health Organization, Global Health Strategies, unpublished data, 2022), (World Health Organization, unpublished data, 2023). As part of the Sport for Health partnership, Qatar’s health communications teams worked with their peers at WHO, FIFA, and the SC on a wide range of campaigns promoting healthy lifestyles and trying to ensure a safe World Cup. These included: • a dedicated FIFA World Cup Qatar 2022 website highlighting all available services for fans; • listing key medical services and facilities on the Hayya Fan Application; • more than 100 social media posts before and throughout the tournament explaining how to access health care services; • public Sport for Health webinars about the steps in place to ensure a safe and secure World Cup, and ways in which the public could play their part; • a range of S4H messages and videos about health topics including physical activity, mental health, tobacco control nutrition and health security. These were promoted by governmental and private channels including stadium LED screens and scoreboards during FIFA World Cup Qatar 2022 matches, messaging on captains’ arm bands during games, and through channels managed by partners such as Qatar Airways, Hamad international Airport, Qatar Museums, Elan, beIN and others; • multiple local and international media interviews on channels like QTV, Al Rayyan, beIN, Al Kass and others; • updating and launching “Florence, the Artificial Intelligence Hero.” Florence was a digital health promoter that provided counselling in eight languages on health topics like COVID-19, tobacco control, mental health, nutrition and physical activity. Florence has since been renamed by WHO as SARAH, or “Smart AI Resource Assistant for Health,” and uses generative AI “to help you lead a healthier life,” including by sharing tips to prevent some of the biggest causes of death in the world, including cancer, heart disease, lung disease, and diabetes. • internal communications to health care staff across the health care system to keep them up to date on health activities and their roles. These included newsletters, email messages from the Minister of Public Health and the Chair of the FIFA World Cup Strategic Group, a series of text messages, targeted staff webinars and a dedicated intranet site. SARAH can be accessed at https://www.who.int/ campaigns/s-a-r-a-h 1739. Advocating for health Media channels Meeting the campaign’s media goals meant consider not only traditional media (like Al Jazeera, beIN, Al Araby, Abu Dhabi TV, France 24, Radio Monte Carlo, Al Ahram and others) but also social media channels (like Facebook, YouTube, Tiktok and Instagram) and collaborations with popular “influencers” and content creators. The S4H partnership created a list of opportunities to use TV and radio outlets to amplify campaigns across wider audiences, with FIFA and the Supreme Committee supporting engagement efforts by leveraging their connections with sports journalists to elevate campaigns by sharing content like press releases, op-eds and social media content. Journalists were also invited to campaign events, like Walk the Talk, Health Through my Lens, the WISH Forum and others. Campaign press releases were shared with journalists, who were also invited to webinars on media coverage of health topics. A number of pre-identified regional and local influencers, including social media content creators, were contacted and briefed about the campaign. They were asked to share S4H messages, promote events and hashtags like #Sport4Health, #HealthForAll and #REACHOUT through their channels and platforms, and challenge their followers to take part in mass participation campaigns like #BringTheMoves. Advocating for health: reflections Issues, challenges and responses • Coordinating major organizations was a governance challenge. In the high intensity environment of a World Cup, with stakeholders determined to make the most of every opportunity for visibility, it was sometimes difficult to secure timely approvals and ensure inclusive decision- making among stakeholders such as FIFA, the SC, the Ministry of Public Health, and HMC. • Coordination issues also arose from the differing expectations of various partners’, including over project goals and partners’ commercial priorities. It was crucial to gain an understanding of each partners’ needs and wants and manage expectations accordingly. These issues were made worse by the fact that some stakeholders joined projects late: securing their engagement from the outset would have created better alignment. • Monitoring, measuring and evaluating the impact of communications campaigns with a truly global reach is inherently difficult, particularly as regards behaviour change. • Ownership limitations of stadiums in Qatar restricted the scope of initiatives within stadium premises. During most high-profile mega sports events, control of stadiums is usually ceded by the host country to the respective sports federation, which will make all decisions concerning the management of venues. At times this meant that evaluation measures could not be carried out, further hindering the ability to assess behaviour change. • The quality of some initiatives may have suffered from pursuing too many simultaneous projects and goals and overstretching the capacity of communications teams. 174 Strengthening health and well-being through sport events Changing the game • Long term behaviour change requires continuity and sustainability of activities, which is not always compatible with event-driven campaigns unless a sustainability strategy and associated resources are in place. Considerations for future events • It is important to emphasize the value of coordinating the communication efforts of different stakeholders. This requires clear communication and collaboration and involvement of interested parties as early as possible in the process. • This process is easier when communications prioritize initiatives align with overarching goals and objectives, recognize the importance of integrating health promotion messaging and visibility within mega sporting events, and are based on detailed plans and SOPs that ensure readiness and responsiveness for message deployment. Establishing agreements with event organizers, local stakeholders, media channels and outlets early in the planning phase helps achieve more effective outreach and results. • The use of innovative monitoring and evaluation approaches, leveraging technology to capture and analyse data, is a potentially powerful part of any evaluation strategy. • It is easier to implementing capacity building initiatives locally and regionally if a relevant toolkit is available (or can be made in advance), in local languages and adapted to local contexts, to help design and execute effective health promotion campaigns and develop train-the-trainer programmes that ensure sustainability beyond the event. • Prioritizing legacy planning from the beginning creates the greatest chance of obtaining and sustaining resources and initiatives to build longer term capacity that can be used for future events. 175 9.1.1 Advocating for health: reflections; 9.1.2 Issues, challenges and responses; 9.1.3 Considerations for future events Example: #BringtheMoves “Football, music and joy are the perfect ingredients to get people moving for health. WHO’s partnership with FIFA and Qatar Ministry of Public Health on the Bring the Moves challenge is all about connecting World Cup stars with young people globally, to motivate people everywhere to be more physically active for better health.” WHO Director General Dr Tedros Adhanom Ghebreyesus “ We know the negative impact that a lack of exercise can have on children’s health. Football can use the significant platform of this FIFA World Cup Qatar 2022 to spread that message in an exciting and engaging way. This challenge unites children with their heroes and uses the most digital-ever World Cup to send a message: we all need to be active. It also drives awareness for parents that children need 60 minutes of physical exercise a day. At the moment, that is not the case for 80% of adolescents around the world.” FIFA President Gianni Infantino © Supreme Committee for Delivery and Legacy© Supreme Committee for Delivery and Legacy Alisson Becker promotes the “#BringTheMoves” campaign at the FIFA Fan Festival. “#BringTheMoves” and “Be Active” campaigns promoting physical activity displayed in the stadium. 176 Strengthening health and well-being through sport events Changing the game The #BringtheMoves campaign was launched by FIFA, in collaboration with S4H partners, in late 2022. Supported by WHO Goodwill Ambassadors from the world of football like Liverpool and Brazil goalkeeper Alisson Becker and ex-Chelsea and Côte d’Ivoire striker Didier Drogba, the campaign use football to get young people to be more physically active. Before the start of the tournament, S4H partners launched the #BringtheMoves Challenge to stress the importance of exercise for children. The challenge was for fans around the world to invent a dance routine, film it, and challenge players at the FIFA World Cup Qatar 2022 to imitate their routine during their goal celebrations. The campaign was boosted by events during both FIFA World Cup Qatar 2022 semi-final matches. In these games, LED boards and graphics on the team captains’ armbands transmitted the Be Active message to fans in the stadium and global TV audiences. At half-time, The Mad Stuntman and Reel to Real performed the #BringtheMoves campaign theme song, their timeless hit “I like to Move It.” In a fun way, this showed a worldwide audience of over 1.5 billion people that children need 60 minutes of exercise every day. The campaign also encouraged children to download GenMove (check section Implementation of a Global Active Video Game – GenMove) – which was ceremonially launched by Dr Hanan Mohamed Al Kuwari, Minister of Public Health for Qatar and Dr Tedros Adhanom Ghebreyesus, WHO Director-General, at the Walk the Talk – Health for All Challenge in Qatar – and publicized WHO Physical Activity Factsheets. “ Saving goals is my job. But there is another goal I aim for every day: to play my part in helping save lives. I am proud to be a member of Team WHO and its global partners who work day and night to protect and promote the health of people all around the world. On universal health coverage day, let’s all be active and play our part to make health for all our number one goal.” “ I support the Bring the Moves challenge because I really believe kids have to be active. They need to be active for the good of their future as they are growing up. I see that we, football players, can be an inspiration for them as well. So, if we can have fun with them and make them move their bodies a little bit, we’re going to be happy.” Alisson Becker, Brazil goalkeeper www.who.int/news-room/ fact-sheets/detail/physical- activity 1779.1.4 Example: #BringtheMoves “ Everyone knows how important health is. Sports and Health are related. If you’re not in good health, you cannot practice sport. You also need practice to be in good health. So, it goes together and that’s why the World Cup is a great platform to spread the good message about health. “ Being active provides many benefits to everyone, especially for children while they are growing and developing physically, mentally and socially. Being active is good for your body and your mind – mental and physical health.” Didier Drogba, footballer 178 Strengthening health and well-being through sport events Changing the game Example: Fides Fides is a network of health care influencers supported by WHO, dedicated to raising good content and fighting misinformation. At the start of the COVID-19 outbreak, WHO brought technology companies from around the world together in collaboration to promote science, solutions and solidarity. This project used WHO’s convening power to encourage industry partnerships, rather than competition, to provide reliable public health information to people around the world. To help Qatar achieve its primary health goals, and as part of the collaboration with the Ministry of Public Health under S4H, WHO’s Digital Channels team identified digital opportunities to strengthen the S4H health pillars and contribute to a longer- lasting national and regional health legacy. Their aim was to deliver health content to people across the region, in their own languages, addressing health topics like obesity, physical activity, nutrition, mental health, air quality and pollution, respiratory issues, and healthy environments. A key part of this push was project Fides: a growing community of 600 health care influencers producing high quality content and fighting misinformation. Fides was born from the fight against COVID-19 misinformation, when WHO joined forces with health care professionals active on social media. That push grew into the online community that became the Fides network, which now has a collective online reach of over 150 million people globally. The purpose of Fides is to: • facilitate a safe space: where health care influencers come together as a community and elevate their online presence. The community is supported with psychosocial support and protection; • raise good health content: leverage WHO’s science-based health messages through rapid development and sharing of content, as well as coordinated, focused communication; • fight misinformation: target topics, posts, people, channels and work with social media companies to improve their policies; • networking opportunities: due to the global presence and enabling environment of Fides, collaboration and engagement between members thrives; • gain user insights and trends so public health stays ahead of rumours and myths, and to be able to prepare better, tailored content; • build capacity through events and customized training programmes throughout the year that advance knowledge on digital literacy in health care professionals at country and community level. 1799.1.5 Example: Fides Why is the Fides project needed? Health care influencers spend a great amount of time, effort and energy to make science- based content for social media. It takes hours to read guidance and peer-reviewed scientific papers, synthesise the content and translate it into a digestible format, then produce engaging posts for social media. That’s on top of the countless, stressful hours they spend saving lives in hospitals and clinics. Health care influencers often also feel isolated and lonely. They are attacked by trolls and showered with hate and hostility from those with conflicting opinions. It’s a heavy psychological toll to carry, and many have had to step back from their calling just to protect their mental health. Building following and trust is not easy, and more people could greatly benefit from this type of content. It is necessary to support those people brave and driven enough to provide it. Social media companies could do a better job promoting them, and the creation of a community of health care influencers provides a platform for them to promote and support one another. Crucially, regional voices are needed to connect with others who share the same languages, religions and cultures. Goals and achievements Fides’ proposal for S4H was to recruit health care professionals from Qatar and the region to expand the network’s reach in audiences across the Middle East and beyond. Fides wanted Qatari content creators to act as world leaders in public health online. The target was to bring into the network at least 10 doctors, 10 nurses and 10 health scientists from Qatar to build an online Qatari health community who could plan, collaborate and share experiences, then organize and support one another when posting content. This was also a valuable opportunity to link with health care influencers in other countries and share experiences, best practices and pain points; develop joint projects; and follow and promote each other’s work. The period between late 2022 and August 2023 saw significant progress. The network has grown rapidly, with potential for further expansion through new collaborations and an influx of new member requests. Collaboration with the Ministry of Public Health provided greater support for the project, which in turn meant more efficient management, improved asset support, and further possibilities for expansion. Fides has engaged with its members through customised newsletters, social media management, and support for content creation, and set up a partnership with a high profiled technology provider to enhance content management, and collaboration initiatives with social media companies to ensure members’ safety online. A Fides branding and positioning document has been developed, as well as an onboarding manual to help new members transition smoothly into the Fides community. Future activities are promising, with planned workshops, a virtual community of practice, and other initiatives that will amplify Fides’ impact. The rapid growth of the network has also presented challenges, including member engagement, onboarding processes, and monitoring of social media activity. 180 Strengthening health and well-being through sport events Changing the game Addressing these challenges in a rapid, targeted way will help ensure the project’s continued success. The addition of new members to Fides’ core team will increase capacity to drive the project forward. Fides has already demonstrated its potential to be a powerful tool for disseminating accurate health information and fostering a global community of well-supported health care professionals. With the right strategies in place and continued dedication and resources, the network can be strengthened even further, enhancing its impact and its contribution to global health and well-being. Figure 34 Screenshots from Fides newsletter6 6 Fides Newsletter #2 | Sports and physical activity | November 2022 1819.1.6 Why is the Fides project needed?; 9.1.7 Goals and achievements Example: health through my lens photography exhibition In a collaborative effort to promote health awareness and creative expression, the Ministry of Public Health and WHO organized a photography competition and exhibition called “Health Through My Lens” to showcase artistic expression, through photography, of people’s personal views and feelings about health and well-being. The goals of the event were fourfold: 1. promote public awareness of various aspects of health and well-being; 2. encourage creative expression by providing an avenue and a platform for people’s creative expression around health; 3. showcase diverse interpretations, highlighting the many different ways in which people perceive and embody health and well-being in their daily lives; 4. foster community engagement engage in thought-provoking dialogues about health through visual arts. Health Through My Lens exemplified how art can be a powerful tool to promote health awareness and community engagement. By providing a high profile platform for people’s creativity and personal views, it fostered deeper understanding and appreciation of well-being in the communities. “ This exhibition came at the right time with the World Cup and showcased the progress of sports and health in Qatar through the years and the connection between health and sport. We encourage everyone to maintain their healthy life through sports” - Dr. Mohamed Hamad J. Al – Thani, Director of Public Health, Ministry of Public Health – Qatar © Ministry of Public Health One of the entries from the photography exhibition titled “Health Through My Lens” in Oxygen Park. 182 Strengthening health and well-being through sport events Changing the game Example: health in focus filmmaking workshops The first involvement of the Doha Film Institute (DFI) with the FIFA World Cup Qatar 2022 came in May 2022, when it partnered with the Qatar Football Association (QFA) to launch a “Football Filmmaking Challenge” for aspiring filmmakers aged 18-25. Entrants took part in a specialized DFI workshop and created short films on the theme of football. The workshop was designed a well- rounded introduction to the essential tools of filmmaking, and a reflection of the pride in Qatar and the Arab region to be hosting the World Cup. But the workshop – like other DFI workshops – was not just for Qataris or Arabs, but for everyone. The DFI has welcomed participants from all over the world, from places including occupied Palestinian territory, including east Jerusalem, Egypt, Pakistan, India, Sudan, Jordan, Lebanon, Syrian Arab Republic and Kazakhstan.   As part of the legacy of the World Cup, in May 2023 the Ministry of Public Health joined forces with the DFI to organize and host Qatar’s first ever Health in Focus Filmmaking Workshop, the aim of which was to use the storytelling potential of cinema to promote public health and community engagement. Led by experienced filmmaker and mentor Corine Shawi, participants worked on individual projects at various locations throughout Doha. Completed films were given the chance to be screened at DFI’s acclaimed annual film festival. This workshop followed the example of the WHO Health for All Film Festival (HAFF) initiative, which works to create a global movement for health promotion and education, harnessing diverse artistic approaches to film production. The HAFF initiative advocates for the use of all film genres, on the principle that poetic, scientific, journalistic, or personal narratives are all artistic avenues that can carry important messages and raising awareness about health issues. This approach moves beyond the production of conventional “training films,” enabling health promoters to share knowledge rooted in scientific evidence or experiential insights in the field of health. For example: in the short film When It’s Time, directed by Awad Karrar, the director explores an intimate conversation with his father as they navigate the complexities of their perspective on mortality in the face of a life-altering challenge. The documentary provides a glimpse into the impact of illness on familial bonds, ultimately revealing the love that defines their journey. This short film won a Special Jury Mention award in the 2023 “Made in Qatar” Competition Screenings.  The Football Filmmaking Challenge and the workshops that followed achieved their goals, demonstrating both the power of cinema for health advocacy and the importance of multisectoral collaboration – most notably through identifying and using creative outlets to promote health. Participants’ projects were featured at the Eastern Mediterranean Healthy Cities Conference Qatar 2023 and the 3rd Qatar Public Health Conference. Following the screenings, panel discussions explored the significance of film as a medium for promoting health and well-being. Selected works from the workshop were also featured in esteemed film markets and festivals like the Short Film Market of the Clermont- Ferrand International Film Festival and the European Film Market at Berlinale. Building on the success of 2023, the workshop took place again in 2024, starting in February. The hope is that this valuable collaboration between WHO, the Ministry of Public Health and the DFI proves sustainable, continuing to advance public health awareness through cinematic storytelling, expanding its impact and engaging an ever- wider audience. 183 9.1.8 Example: health through my lens photography exhibition; 9.1.9 Example: health in focus filmmaking workshops Lowest intoxication rate 0.4% Tobacco free policy 20% healthier food options in FIFA fanfest and fanzone 30% healthier food offer in stadiums 32 physical activity and mental health benches launched 18 645 violations reported 80 trained inspectors 184 Strengthening health and well-being through sport events Changing the game The “Be Active” campaign reached a worldwide audience of 1.5 billion people (according to FIFA estimates) 37 metro stations across 76km 1 745 457 rides during tournament 50-70% of transport to stadium used Metro 7 out of 8 stadiums could be reachable by metro 1859.1.10 Summary Building a global movement for sport for health At the Seventy-sixth World Health Assembly in Geneva in 2023, Qatar and the United States of America co-hosted a side event entitled “Building a Legacy for Sport and Health Post Mega Sporting Events.” This event gathered representatives from Qatar, WHO, various host countries of major sports events (including the United States of America, France and Ghana) and sporting federations (including the International Olympic Committee) to discuss the experiences and planning approaches involved in hosting mega sports events. Topics addressed at the meeting included health security during mass gatherings; promoting physical activity and mental health; and using digital technology in health communication and advocacy. Special attention was given to how mega-events like the FIFA World Cup and the Olympics can be leveraged to promote healthier lifestyles and inclusive, sustainable development in host countries. Speakers discussed the lessons of past events and the importance of partnerships and knowledge-sharing in enhancing the positive health impacts of future sporting events. The event highlighted the critical role of partnerships across different sectors and regions. The event’s purpose was fourfold: firstly, to highlight the core activities and components needed to create meaningful health legacy through such events; secondly, to begin the process of creating and fostering a global movement for health promotion and health protection through sport; thirdly, to call for as commitment to sustained improvements to health and safety practices for future mega events; and fourthly, to gather support for a draft resolution for presentation at the Seventy-seventh World Health Assembly the following year, in 2024. “As a project coordinator at the Ministry of Public Health, working on this initiative from the inception of S4H was an incredible learning experience. I take great pride in the project’s success, particularly in seeing its implementation during the FIFA World Cup 2022 in Qatar and in the ongoing knowledge sharing and potential replication efforts at other major sporting events worldwide. Even after the project concludes, we will continue to work towards the same goals, focusing on the implementation of the WHO resolution on strengthening health promotion and well-being through sporting events, with Qatar leading the way—one of the most significant outcomes of the project.” Bothayna Al-Emadi, International Relations Coordinator, International Health Relations Department, Ministry of Public Health 186 Strengthening health and well-being through sport events Changing the game Resolution WHA77.12 of the Seventy-seventh World Health Assembly The S4H project broke ground in many areas. It challenged expectations around what is possible for health promotion at major sports events; it challenged sensitive areas like food and alcohol consumption; it introduced new services to Qatar and expanded and improved existing systems; it capitalized on major World Cup-inspired infrastructural improvements like the country’s first ever subway system; and it moved the needle for national and regional public health in many other areas. It also highlighted the challenges inherent in such an ambitious project, and cast a spotlight on areas where data gathering, monitoring, analysis and evaluation could have been better – and what needs to be done in the future. In the hope this test case is helpful for other countries planning large sporting events and wanting achieve the greatest possible health and social benefit, and on the basis of the experiences outlined in this report, in May 2024 Qatar, together with Belarus, China, Egypt, European Union and its 27 Member States, Iraq, Japan, Saudi Arabia, Malaysia, Mexico, Morocco, Oman, Serbia, Sri Lanka, Thailand, Türkiye, United Arab Emirates, and Yemen, submitted resolution WHA77.12 to the Seventy-seventh World Health Assembly on strengthening health and well-being through sport events. The resolution, which was approved by consensus by all WHO Member States, strengthens the foundations of the Sport for Health model. It urges WHO Member States to use sport as a lever for a range of actions addressing public health and social challenges including non-communicable disease, preparedness for health emergencies, violence and injury, mental health, and social inclusion. We truly hope that the experience of the FIFA World Cup Qatar 2022 can be seen as an extended case study showing that the S4H model can and should be replicated elsewhere. Sport already offers so many opportunities to promote respect for human rights and bridge cultures in service of dialogue, mutual understanding, fairness, non-discrimination, respect, inclusion and equal opportunity. Now, we hope, it can also offer platforms for public health interventions and improvements around the world. The full text of resolution WHA77.12 is available at this link: https://rb.gy/695i80 (1) More information on the WHO S4H programme can be found at https://www.who.int/ initiatives/sports-and-health © World Health Organization© World Health Organization WHO Director General and the Qatar Minister of Public Health at the second Steering Committee meeting of the project. 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