Sustaining COVID-19 pandemic response gains in the WHO Eastern Mediterranean Region: mapping strategic opportunities and ways forward WHO Library Cataloguing in Publication Data Names: World Health Organization. Eastern Mediterranean Region Title: Sustaining COVID-19 pandemic response gains in the WHO Eastern Mediterranean Region: mapping strategic opportunities and ways forward / World Health Organization. Eastern Mediterranean Region Description: Cairo: World Health Organization. Eastern Mediterranean Region, 2024 Identifier: ISBN 978-92-9274-329-1 (pbk.) | ISBN 978-92-9274-330-7 (online) Subjects: COVID-19 — prevention & control | COVID-19 — epidemiology | Emergency Medical Services — organization & administration | Health Care Surveys | Betacoronavirus | Disease Outbreaks | | Pandemic Preparedness | Health Priorities | Institutionalization | Eastern Mediterranean Region Classification: NLM WC 506 © World Health Organization 2024 Some rights reserved. 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SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward iii DHIS2 FCV GEHR ICU IDS IHR IPC NCD PHEOC RCCE District Health Information Software fragile, conflict-affected and vulnerable gender, equity and human rights intensive care unit integrated disease surveillance International Health Regulations infection prevention and control noncommunicable disease public health emergency operations centre risk communications and community engagement ABBREVIATIONS SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward iv EXECUTIVE SUMMARY The global COVID-19 pandemic, responsible for millions of infections and deaths, had a far-reaching impact on societies, health systems and economies. The World Health Organization’s Eastern Mediterranean Regional Office commissioned an independent review of the response to the pandemic in the Eastern Mediterranean Region. This analysis and initial recommendations advocate “capitalizing on the momentum from the COVID-19 response by turning temporarily scaled-up capacity in Member States into permanent capacities, agendas and networks”. The present report describes a mapping of gains initiative undertaken by WHO to address the Dalberg Advisors’ recommendations of the abovementioned review, signifying a forward-looking strategy to sustain progress made in the COVID-19 pandemic response for future public health events. WHO’s Eastern Mediterranean Region is home to 22 countries and territories, nine of which are classified as fragile and conflict-affected (FCV) and in 2023, almost 19% of the Region’s population were estimated to need humanitarian assistance. Given the diversity and large number of FCV countries in the Region, a mapping initiative to better understand capacity gains was undertaken to support the development of strategic options to sustain the gains. The key objectives of the mapping initiative were to develop common themes emerging from the pandemic response and proposed solutions, document new capacities, understand successful coordination and collaboration, and support future preparedness. The exercise was accomplished through a combination of methods. A desk review was conducted to develop a contextual foundation and maintain alignment with global and regional initiatives. The review took into consideration key recommendations from the WHO International Health Regulations Emergency Committee, commitments under the Regional Committee for the Eastern Mediterranean, as well as future health emergency preparedness and response agendas such as Health Emergency Preparedness, Response and Resilience (HEPR). Interviews with technical experts across the COVID-19 response provided insights on key areas to include in the development of an online survey tool. Such a tool, which covered core capacities from the IHR and HEPR, was administered to all 22 countries and territories through their ministries of health and WHO Country offices. Finally, an online consultation with stakeholders and partners provided feedback and thoughts on preliminary findings. Preliminary findings were also shared with internal WHO stakeholders and further inputs were gathered. Ultimately, 19 out of 22 countries and territories participated in the online survey or key informant interviews. Rich information was collected and analysed in all areas of the 5 Cs outlined in the HEPR: (1) emergency coordination; (2) collaborative surveillance; (3) access to countermeasures; (4) safe and scalable care; and (5) community protection. The report documents the findings in each area and outlines key gains, new and enhanced capacities and what countries prioritized maintaining for long-term sustainability. Some limitations of this initiative include the short time-frame given to conduct the survey, incomplete data for some countries, country staff turnover and not reverifying data beyond submission. All reporting countries, regardless of income status, documented new gains or enhancements in various areas such as added laboratories, surveillance sites, establishment of IPC or risk communication and community engagement (RCCE) units, new or enhanced databases, new outreach strategies for vaccination, surges in capacity for clinical care and oxygen production, and improved communications, to name a few. Low-and-middle-income countries and FCV countries likewise reported meaningful gains, but may have the most to lose if support to sustain the gains in capacity is not realized. Many countries identified integrating and institutionalizing new or enhanced capacities into routine systems as a way to maintain gains. The desires to maintain new laboratories, surveillance site or new clinical care capacity were measured for some countries but not for others, and it is clear that guidance for right-sizing is lacking. The importance of leadership, coordination and partnerships was evident throughout the responses. Very few countries had examined the costs of maintaining gains and few strategies for long-term sustainability were reported. To sustain gains, priority should be given to integrating and institutionalizing new or enhanced capacities in routine health systems and country budgets. Developing supportive systems such as training, promoting a culture of preventive maintenance, guidance on right-sizing and plans for continued networking with partners for research and leadership will facilitate maintaining gains. The closing section of this report summarizes six strategic recommendations along with priority recommended actions for WHO, partners and countries to pursue for maintaining gains realized during the COVID-19 pandemic response. Cementing these gains will support routine resilience in countries, which will translate into better health systems for their populations. It will also translate into better preparedness and health security to respond to future public health emergencies. Every country should prioritize the new or enhanced systems set up in response to COVID-19 and develop plans for maintaining those that support routine resilience of their public health systems. WHO will work with Member States and territories, regional leaders and partners to support prioritization and actions that will maximize the long-term sustainability of gains made during the COVID-19 response. SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward v 1. Background Regional context The COVID-19 pandemic Pandemic preparedness: Existing initiatives and priorities Mapping initiative: Understanding gains made during the COVID-19 pandemic response in the Region 2. Objectives 3. Methodology Country survey Limitations Survey response rates by country and income status 4. Survey findings Emergency coordination and leadership Collaborative surveillance: Integrated surveillance, laboratory diagnostics and research Vaccines Essential health services, infection prevention and control and clinical care Risk communication and community engagement, communication and outreach, GEHR 5. COVID-19 gains and opportunities in FCV countries 6. Requests of WHO and partners 7. Country priorities for maintaining in the ongoing COVID-19 context 8. Key themes from findings Integration Prioritizing institutionalization of new capacities Financing: Costing and analysis Right-sizing Coordination and leadership Partnerships 9. Conclusions 10. Recommendations and priority actions for sustainability References 1 1 2 2 3 3 4 5 5 6 8 8 10 13 14 16 17 18 19 20 20 21 21 22 22 22 23 24 29 TABLE OF CONTENTS 1SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward 1. BACKGROUND The global COVID-19 pandemic, responsible for millions of infections and deaths, has had and continues to have far-reaching impacts on societies, health systems and economies. The World Health Organization’s Eastern Mediterranean Regional Office commissioned Dalberg Advisors to conduct an independent review of the response to the pandemic in the Eastern Mediterranean Region. The review highlighted the successes and challenges that countries faced during the response (1). The purpose of the review was to provide actionable recommendations, based on lessons learned, to improve WHO’s prevention of, preparedness for, detection of, response to and recovery from ongoing and future health emergencies. The Dalberg Advisors review’s analysis and initial recommendations advocates “capitalizing on the momentum from the COVID-19 response by turning temporarily scaled-up capacity in Member States into permanent capacities, agendas, and networks”(1). This report describes a mapping of gains initiative undertaken by WHO to address the Dalberg Advisors review’s recommendations, signifying a forward-looking strategy to WHO’s Eastern Mediterranean Region is home to 22 countries and territories, nine of which are classified as fragile and conflict-affected (3); in 2023 almost 19% of the Region’s population were estimated to need humanitarian assistance (4). Recent years have demonstrated the detrimental health consequences of emergencies and disasters caused by natural hazards, such as floods in Pakistan, earthquakes in the Syrian Arab Republic and conflicts in several countries in the Region. The Region faces emergencies on a scale that is perhaps unprecedented in its history (5). The recent large-scale events resulting from natural and technological hazards in various countries have underlined the fact that no country is immune to emergencies and disasters. Direct health consequences include trauma-related deaths and disability, gender-based sustain progress made in the COVID-19 pandemic response for future public health events. This report details the process used to evaluate capacity gains in countries and highlights the results of the mapping initiative undertaken by WHO. Additionally, global consensus (2) called for WHO’s support of respiratory pathogen pandemic preparedness, emphasizing the integration of efforts to address respiratory viruses with epidemic and pandemic potential. Given the significance of these recommendations, WHO’s Health Emergencies Programme is embarking on a series of activities in the Region to develop post-COVID-19 strategic options to strengthen health security. These efforts aim to provide guidance for Member States in the Region, supporting them in developing country-specific strategies and plans that will assist in sustaining gains made during the COVID-19 pandemic response and fortify health security and systems for the future. This report explores the strategic opportunities and recommends ways forward that will pave the way for lasting health security in the Region’s Member States and territories. violence and mental disorders. Disruption of health systems contributes to increased morbidity and mortality from infectious diseases, malnutrition, obstetric complications and noncommunicable diseases (NCDs). The Region has also historically been vulnerable to the emergence and spread of pandemics and respiratory diseases due to its unique blend of demographic, environmental and socioeconomic factors. With densely populated urban centres, porous borders and a history of conflicts, the Region presents an environment conducive to rapid disease transmission, demonstrated by recent outbreaks of diseases such as Middle East Respiratory Syndrome (MERS), H5N1, cholera and dengue. Regional context 2SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward As this report is intended to complement and supplement existing WHO and partner initiatives on strengthening pandemic preparedness, including national action plans for health security (NAPHS), pandemic preparedness and response plans, national deployment and vaccination plans, relevant initiatives and priorities are described below. The COVID-19 pandemic sparked global interest and investment in pandemic preparedness. During the 75th World Health Assembly in May 2022, several strategic initiatives were launched, including a proposal from the Director-General on Strengthening the Global Architecture for Health Emergency Preparedness, Response and Resilience (HEPR), which serves to guide the future direction for health emergency preparedness and response (7). HEPR focuses on three key areas for strengthening this global architecture, namely: governance, systems and financing and five cross-cutting systems (the five Cs) (Fig. 1). The Pandemic Preparedness and Resilience for Emerging Threats initiative builds on current momentum and is an application of current efforts to strengthen the HEPR and its cross-cutting systems. The initiative was launched in Geneva in April 2023 (8). It calls for updating pandemic preparedness plans by mode of transmission and initially focusing on respiratory pathogens. This new guidance supports strengthening preparedness and updating response plans. The WHO guidance (9) provides key actions, organized in five subsystems aligned with HEPR and IHR core capacities, to strengthen respiratory pandemic preparedness. Finally, the fourth WHO Strategic Preparedness and Response Plan (10), launched since the start of the COVID-19 pandemic, provides a two-year guide for countries to transition from an emergency response to the long- term, sustained management of COVID-19. Guidance on key actions, activities and approaches to end the COVID-19 emergency and transition to longer-term disease management are available for Member States (11). Pandemic preparedness: Existing initiatives and priorities Fig. 1. The five systems components of HEPR Community protection Collaborative surveilance Access to countermeasures Safe and scalable care Emergency coordination The Eastern Mediterranean Region has been navigating the complex landscape of pandemic response since the emergence of the novel coronavirus, SARS-CoV-2; this global health crisis has profoundly impacted it. The Region experienced a swift and widespread outbreak, straining health care systems and exposing vulnerabilities in disease surveillance, laboratory capacity and health care workforce readiness. The pandemic was responsible for about 23 million cases and 351 000 deaths in the Region as of 31 March 2024 (6). The socioeconomic toll was substantial, with disruptions to trade, tourism and daily life exacerbating existing inequalities in countries. However, it was also seen that the response to the COVID-19 pandemic necessitated unprecedented levels of collaboration among countries, international organizations and stakeholders. THE COVID-19 PANDEMIC 3SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Learning from the COVID-19 pandemic response is a vital regional priority. The 2022 Regional Committee (EM/RC68/ R2) recommended health emergency preparedness to be integrated into health system (12). To ensure health security and universal health coverage, a plan of action for accelerated preparedness and response was devised. The plan of action highlights reassessment based on the COVID-19 pandemic response and other emergencies. The present report provides recommendations to further this goal. Moreover, the 11th (13) and 14th (14) statements of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic urged WHO to aid respiratory pandemic preparedness. Member States, at the 150th executive board, endorsed integrated respiratory pandemic preparedness and enhancing global influenza surveillance for broader virus monitoring, for example, for coronaviruses (such as SARS- CoV-2 or MERS) and respiratory syncytial virus. Learning from the COVID-19 pandemic response This mapping initiative addresses the Dalberg Advisors report’s first recommendation and supports the Regional Committee’s recommendation (EM/RC68/R2) (12). This comprehensive exercise involved evaluating capacity gains in countries, documenting interventions, data-driven analysis and cross-sector stakeholder engagement. Mapping initiative: Understanding gains made during the COVID-19 pandemic response in the Region 2. OBJECTIVES The primary objectives of this report and activities were to systematically gather information, insights and data necessary to achieve the following key outcomes: In summary, this report serves as a strategic review to guide efforts to ensure the long-term sustainability of newly established priority capacities, systems and innovations. By aligning objectives with regional considerations, documenting processes, facilitating collaboration and providing essential data, the report strives to contribute to a future characterized by resilience, preparedness and success in addressing health emergencies. 1. Development of common themes and proposed solutions: The core aim is to collect comprehensive information that will serve as the foundation for identifying common themes and proposing recommendations for sustainability. The report will facilitate the creation of a cohesive approach towards sustainability that spans regional and country considerations. 2. Documentation of new capacities, enhanced capacities, gains and lessons learned: A significant facet of this report is to document the overall gains in various capacities, infrastructure, systems, policies, procedures and other innovations. This documentation will serve as a valuable repository of knowledge, aiding in the sustained maintenance and enhancement of these elements over time. 3. Enhanced collaboration and coordination: By identifying and highlighting successful coordination mechanisms, the report will enable better preparedness and response to emergencies by global, regional and country levels. 4. Support future pandemic preparedness with data and information: The report findings can be leveraged to support applications for funding opportunities, including initiatives such as the new Pandemic Fund and other potential donors. 4SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward 3. METHODOLOGY The information presented in this report was gathered in a comprehensive approach encompassing four primary components: (i) desk review, (ii) key informant interviews (KIIs), (iii) consultations with partners and stakeholders and (iv) a Member State survey exercise. These are summarized in Table 1. Table 1. Data sources for the mapping exercise Data sources Desk review KIIs Consultation with partners and stakeholders Online survey of countries A desk review of the literature was conducted to establish a contextual foundation for the mapping exercise. This process involved collecting, analysing and synthesizing existing research, reports and relevant literature pertaining to the subject matter. The insights from this review informed the subsequent stages of the exercise. KIIs were conducted with 23 stakeholders of the WHO Regional Office for the Eastern Mediterranean, largely representing the technical leads during the COVID-19 pandemic response efforts. These interviews provided qualitative insights, contextual understanding and expert opinions related to the mapping exercise’s objectives across all functional emergency response areas. These KIIs were key to informing development of the online survey tool to engage Member States. Online consultations were held with WHO’s partners and stakeholders, both internal and external, to share preliminary findings and to gather feedback and input about the findings and the way forward. An electronic, online survey tool was developed, considering the insights gleaned from the literature review and KIIs. The survey was disseminated to all 22 Member States and territories. National focal points were assigned to collect information for relevant national stakeholders involved in the national COVID-19 pandemic response efforts. Focal points underwent comprehensive training to ensure consistency, proper survey administration techniques and gain buy-in to exercise objectives. 5SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward C. Access to countermeasures: • COVID-19 vaccine deployment • regulatory procedures • procurement. D. Safe and Scalable Care: • essential health services • case management • clinical operations • infection prevention and control. E. Community protection: • RCCE • communication and outreach • gender equity and human rights (GEHR). The inclusion of the aforementioned components aimed to ensure a well-rounded approach to the mapping exercise and covering the 5 Cs in the HEPR. The integration of the desk review, expert interviews and a carefully designed survey tool enhanced the validity and reliability of the exercise’s findings, enriching the overall analysis to support conclusions drawn. It should be noted that KIIs containing Although our exercise achieved a high level of representation across income levels and political settings, it is important to note that three Member States did not participate (see section 4: Survey findings). Further, while senior governmental technical leads involved in the COVID-19 response predominantly completed the survey, we cannot guarantee this consistency across all countries. Some variations in respondent roles existed. a subset of the 60 questions were offered instead of the electronic survey tool to countries that did not respond, to increase data collection. Two countries requested to participate using this option and where specific information was supplied in line with survey questions, the data is integrated into the text and figures. Additionally, the use of open-ended questions in the survey might have led to varying levels of detail and completeness in the responses, potentially affecting the comparability and comprehensiveness of the data collected. Finally, the exercise was conducted within a relatively short period, limiting the depth of data analysis for this report, and country data was not re-verified beyond the submission of the survey responses. Further exploration and analysis of the data may be warranted in the future. Limitations Country survey The survey was structured in five sections, grouping similar thematic areas, to gather relevant data in a coherent manner aligned with WHO COVID-19 operational pillars, and contained over 60 questions covering the following areas: A. Emergency coordination including: • partnership and coordination • operations supplies and logistics • programme management • resource mobilization • International Health Regulations (IHR) 2005 and public health and social measures. B. Coordinated surveillance: • surveillance systems • laboratory diagnostics • information management • research and knowledge management. 6SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward 17 2 3 Survey Key informant No response The survey was administered to all 22 Member States and territories within WHO’s Eastern Mediterranean Region through an online format. For non-responding countries, an alternative approach was offered and involved conducting KIIs with stakeholders directly involved in the COVID-19 response efforts. The survey’s outcome demonstrated a notably robust response rate, with 17 of 22 countries and territories (77%) participating in the online survey (see Fig. 2). When considering both the survey responses and the additional insights gathered through two country KIIs, the overall response rate increased to 19 countries and territories of 22 (86%). The responses reflect a diverse range of income levels classified according to the World Bank criteria (see Fig. 3). It is particularly noteworthy that all nations designated FCV – including Afghanistan, Iraq, Lebanon, Libya, Somalia, Sudan, the Syrian Arab Republic, the occupied Palestinian Survey response rates by country and income status territory and Yemen – participated in the survey exercise. At the time of the survey, conflict had erupted in Sudan. Despite this, we were able to receive information on the actions taken at a subnational level and have included these results. It should be noted, however, that some countries only completed selected sections of the survey (see Table 2). For this reason, the denominators differ in the various results sections and are reflected both in the percentages and numbers. In addition, occasionally a country did not answer every question in a section of the survey. In these cases, this is reflected in the charts as no response. When either of the two country KIIs provided additional information specific to a question, they are included in the responses and denominators in both text and figures. Fig. 2. Member State participation 7SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Fig. 3. Response rate by income level 5 3 4 5 2 1 2 0 1 2 3 4 5 6 7 8 9 High income Upper middle income Lower middle income Low income Survey Key informant No response Table 2. Survey completion by participating countries (n = 17)* Survey section Completed No response Section A: Emergency coordination Section B: Collaborative surveillance (integrated surveillance, laboratory diagnostics and research) Section C: COVID-19 vaccine Section D: Essential health services, clinical care and IPC Section E: RCCE, communication and outreach and GEHR 14 13 16 14 17 3 4 1 3 0 * This does not include KIIs 8SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward 4. SURVEY FINDINGS Emergency coordination serves as the central point for all operations during an emergency and was essential to the pandemic response. We asked a series of questions to understand what systems and structures existed prior to the pandemic and what were built to respond to the pandemic and to understand what countries deemed important to continue post-pandemic. 14 countries responded to this Public health emergency operations centres (PHEOCs) were reported as having been established prior to the COVID-19 pandemic in 14 out of 16 (88%) of the countries but roughly two fifths of them, i.e. six out of 16 (42%), reported rarely activating the PHEOC prior to it (Fig. 4). Eight out of nine (89%) of FCV countries responded and two of them (22%) reported having no prior PHEOC and five (56%) of the six others had an established PHEOC that was rarely activated. section of the survey, of which eight countries were FCV. Where direct information from one or both of the two country KIIs is also available, this is included in the data for a potential total of 16 country responses. Summary data of select inputs for this section of the survey is provided in Fig. 4. Nine countries (56%) plan to maintain their PHEOC; three (19%, two of which are FCVs) reported they would activate the PHEOC only when necessary. Interministerial, cross-sectoral coordination was extremely important and 15 out of 16 countries (94%) reported setting up such a structure for coordination of the overall response (Fig. 4). 13 out of 16 countries (81%) also found it important to set up interdepartmental emergency management and coordination structures to manage the overall health components of the COVID-19 pandemic response. Emergency coordination Emergency coordination and leadership Fig. 4. Emergency coordination: New or enhanced activities and existence of the PHEOC prior to the COVID-19 pandemic 14 15 11 11 2 1 4 5 1 0 2 4 6 8 10 12 14 16 18 PHEOC existsed prior to Pandemic Inter-ministerial/ inter- sectoral structure (overall national response) New or enhanced procurement activities New or enhanced supply chain activities Yes No Don't know 10 out of 16 countries (63% ) reported new or enhanced risk-based approaches to adopting public health and social measures. Four out of 16 countries (25%) reported “no” or “don’t know” to new or enhanced approaches to public health and social measures. Reported approaches to adopting a risk-based approach to public health and social measures in response to the pandemic included: employing risk assessment methodologies to categorize regions or areas based on COVID-19 transmission risk levels and implementing zoning strategies to identify and contain outbreaks or hotspots. In this study, one country (6%) reported developing contact tracing apps. IHR (2005) and public health and social measures Countries requested assistance in areas such as multisectoral coordination, capacity enhancement and the establishment of standardized best practices and measures. 9SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Nearly three quarters of countries, that is, 11 out of 16 (69%) adapted their procedures and procurement strategies for a more agile logistic response (Fig. 4). Notably, central procurement bodies were established, linked directly to finance ministries with expedited approvals. One country reported emphasizing local manufacturing of essential materials and vaccines, while others optimized supply chains, using real-time tracking and improved inventory management to prevent shortages. Collaborative partnerships were forged with private entities and international organizations to enhance logistic capacities, and logistics infrastructure was reinforced through storage expansions and transportation enhancements. Data analytics informed decision- making and improved coordination among stakeholders’ streamlined response efforts. Emergency procurement mechanisms and tax exemptions expedited acquisitions guided by national emergency committees operating under revised procedures. Notably, national and international cooperation played a pivotal role in shaping procurement strategies. Reprioritization exercises, customs facilitation and donations further bolstered logistic agility. Operations support and logistics and supply chain management 11 out of 16 countries (69%) reported the establishment of new systems or improvements to support supply chain activities (Fig. 4). A range of critical strategies and adaptations in supply chain management procedures and infrastructure were pivotal during the COVID-19 pandemic response. These included: setting up central coordination units or task forces to manage the supply chain for COVID-19-related medical equipment and supplies, streamlining procurement processes to expedite supply acquisition, implementing inventory management and forecasting, optimizing transportation and logistics, decentralizing materials and equipment to enhance response capabilities, utilizing existing infrastructure such as the expanded programme of immunization for supply distribution, and mobilizing resources across different levels of governance. Some countries actively engaged in global collaboration through multilateral forums (regional and global) during the pandemic to strengthen their pandemic response. For instance, several countries noted that participation in Gulf Cooperation Countries’ regular meetings aimed to unify cross-border procedures, enabling a coordinated approach within the Gulf Region. Additionally, two countries (13%) reported participation in Access to COVID-19 Tools Accelerator and G20 meetings facilitating international cooperation on health and finance matters, promoting a unified global response to the pandemic. These forums served as platforms for sharing experiences, aligning strategies and mobilizing resources, ultimately contributing to a more effective pandemic response. Further, bilateral and multilateral partnerships for collaboration with various international organizations and countries played a vital role in pandemic response efforts, especially for low-and middle-income countries as well Partnerships as FCV countries. Examples include cooperation with WHO and also with UNICEF, UNDP, World Bank, Gavi and others, showcasing a multifaceted approach to addressing the crisis. These partnerships allowed countries to leverage expertise, resources and best practices, aiding in the deployment of critical equipment, medicines and support for health care infrastructure. These points highlight the significance of regional and global collaboration in supporting pandemic responses. Engaging in forums, partnerships and virtual activities facilitated the sharing of experiences, resources and expertise, reinforcing the global effort to address the challenges posed by the pandemic. Three quarters of countries, or 12 out of 16 (75%), reported involvement in regional or global forums, but the types of participation varied among countries. 10SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward The majority of countries built upon the surveillance systems they already had to respond to the COVID-19 pandemic (Fig. 5). 15 of 18 countries (83%) used their sentinel surveillance sites to support the pandemic response with 13 of 18 countries (72%) adding additional sentinel sites (Fig. 5). The average number of sentinel sites increased from 51 to 81 in the 15 out of 18 countries (83%) reporting numbers of sites before and after the COVID-19 pandemic. One low-income country (6%) developed sentinel sites for the first time to support the response, three countries (17%) used their sentinel sites but did not add new sites (2 high- income, 1 low-and-middle-income countries) and lastly, one country (6%), which was high income, had sentinel sites, but did not use them for the pandemic response. 12 out of 17 of countries (71%) (two high income, three middle income and seven low income) that added sentinel sites plan to sustain all or some of the sites post-pandemic and incorporate them into routine surveillance. Eight out of 17 countries (47%) reported having an epidemic intelligence from open sources or event-based surveillance system prior to the pandemic, though two countries reported not using these systems to support the pandemic response. Five countries (29%) reported developing such a system to support the pandemic response for a total of 11 out of 17 of countries (65%) that utilized event-based surveillance systems (EBSs) as part of their response (Fig. 5). Integrated surveillance Often the abovementioned systems were used to incorporate non-health-related data into the information gathered. To maintain surveillance and monitoring for SARS-CoV-2, integration of sentinel surveillance to include SARS-CoV-2 on a country’s influenza platform is a recognized strategy. Several countries also mentioned adding the surveillance of other respiratory viruses, such as respiratory syncytial virus, to their influenza platforms. At least 11 countries (65%) have already integrated SARS-CoV-2 into their routine sentinel surveillance for respiratory viruses and are reporting it through the Global Influenza Surveillance and Response System (GISRS). This section of the survey covered information management and surveillance, including any new or improved infrastructure, expansion of sentinel sites or laboratories, sources of data or data collection methods, improved data analytics, forecasting methods, information sharing, reporting and monitoring and evaluation (Fig. 5). We captured the use of new molecular or diagnostic tools that were added and any enhancements to the national and/ or subnational lab network. Early data from key informants suggested the importance of private–public partnerships, so questions were included to capture the types of partnerships developed. Lastly, questions to understand the types of research countries participated in were included. For this section of the survey, 16 countries responded. Where direct information from one or both of the two country KIIs is also available, this is included in the data for a potential total of 18 responses in some cases (Figs 5 and 6). Collaborative surveillance: Integrated surveillance, laboratory diagnostics and research 11SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Of 18 countries reporting, only two (11%), did not report adding new laboratories to their systems in order to carry out laboratory diagnostics for the COVID-19 pandemic response (Fig. 6). In the 16 countries (89%) reporting on the number of their laboratories, the average number of laboratories increased from 25 to 110. Many of these added laboratories were at regional, governate or even community levels. 15 out of 18 countries (83%) added new laboratory techniques including additional RT-PCR capacity, RNA automated extraction and GeneXpert. 14 of 17 countries (82%), reported enhancing or adding genomic sequencing for SARS-CoV-2 (Fig. 6). Four of the 14 countries (29%) explicitly stated they added sequencing to their laboratory diagnostics for the first time. Enhanced or new laboratory data reporting systems were developed in 13 of 17 countries (76%) (Fig. 6). Laboratory diagnostics Other strategies to maintain surveillance for SARS-CoV-2 are to designate COVID-19 a priority disease and incorporate this into integrated disease surveillance and response (IDSR), electronic disease early warning system (eDEWS), district health information software (DHIS2) or other integrated surveillance systems. Laboratory capacity is high on the priority list for sustainability. Of the 16 countries that added new laboratories, 13 (81%) want to maintain them, with nine (56%) hoping to maintain all new laboratories and four (25%) hoping to maintain a subset based on criteria such as population density, political will, geographical access and the ability to function as a regional reference laboratory. New or enhanced genomic sequencing and data systems and reporting are regarded by 13 countries as priority gains and important to maintain. The development of national laboratory strategies and expanding the list of priority pathogens the new laboratories can diagnose is a key strategy several countries mentioned to support sustainability. Three countries specifically mentioned developing a national laboratory strategy to outline the responsibilities of these new laboratories. Fig. 5. Existing surveillance capacities before COVID-19 and their utilization, expansion and/or enhancement during the pandemic 15 13 8 11 17 2 5 9 6 11 0 2 4 6 8 10 12 14 16 18 20 Sentinel sites used for response Added sentinel sites EBS sytem prior to pandemic EBS system used in pandemic response New or enhanced surveillance systems Yes No Don't know 12SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Development of consortia or support for sequencing in countries is one of the most commonly listed benefits of partnering with academia. Four of the five countries that did not highlight partnerships with academia as important Research were low-income countries. The link with academia was also extremely important to research activities in the Region, not only for analysing gene sequencing results, but also for conducting serosurveys and vaccine effectiveness studies. One country noted that coordination with academia allowed the acceleration of needed studies. The other key area where academia was instrumental was in setting up partnerships for training and capacity-building. 12 of 17 (70%) of countries found partnerships with academia extremely important (Fig. 6). Fig. 6. Expansion or enhancement of laboratory capacities during the pandemic 16 15 14 13 12 1 1 2 3 2 1 2 1 1 3 0 2 4 6 8 10 12 14 16 18 20 Added labs during pandemic New or enhanced lab techniques New or enhanced genomics New or enhanced lab reporting Partnered with academia Yes No Don't know 13SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward 13 of 17 countries (76%) reported new or enhanced activities or procedures for rolling out vaccines. 12 of 16 countries (75%) reported new or enhanced activities for increasing uptake (Fig. 7). Common activities for rolling out vaccines included setting up new vaccination centres and deploying mobile teams for various special populations such as the elderly and persons with NCDs. Many countries established drive- through vaccination sites and set up helplines to address public questions or concerns. To increase uptake, nearly 15 of 18 countries (83%) reported new or enhanced activities in the area of procurement procedures. 14 of 17 (82%) mentioned new or enhanced digital systems related to vaccines (Fig. 7). For procurement, increased storage, new cold chain capacity, use of thermal shippers, engaging new partners and conducting negotiations with new partners were some of the more commonly mentioned gains. Most countries developed new electronic digital platforms that supported various tasks such as tracking vaccinations and adverse Most countries integrated vaccination for COVID-19 into routine or expanded immunization programmes early in the pandemic or are now in the process of doing so. With regard to sustainability, integration into routine or expanded immunization programmes is overwhelmingly the consensus from most respondents on how to move forward. As part of the larger plan for sustainability, many Vaccine deployment Vaccine procurement and regulatory procedures COVID-19 vaccines in the future all countries employed vaccine campaigns and community awareness activities, often using various types of media, video clips, FAQs and social media. Many countries conducted workplace and/or school vaccine clinics to increase convenience. Setting up community health committees and engaging community leaders to develop strategies for increasing uptake was mentioned by seven countries. Lastly, at least six of the 18 countries employed negative consequences for people who were not vaccinated by restricting or limiting access to public places and events. events following immunization, setting up appointments, printing vaccine certificates, tracking laboratory results and patient disease history for COVID-19 infection. 12 of the 18 countries (67%) completing the survey or participating in KIIs mentioned the use of emergency use authorization to approve vaccines for use in the country. Seven countries (39%) reported setting up new committees or subcommittees to address vaccine issues and vaccine policies. countries mentioned integrating COVID-19 vaccination into their national immunization strategies. The other theme with regard to supporting the pandemic response and for future sustainability was integrating immunization services into routine health services. Maintaining new cold chain capacities is another area where most countries plan to maintain gains. The COVID-19 pandemic response required a massive vaccine rollout to all populations at an unprecedented scale and pace. Questions to understand gains regarding all facets of COVID-19 vaccine programme implementation were included in the survey. These included specific prompts around new activities or innovations for vaccine procurement, vaccination programmes and regulatory vaccine approval processes during the pandemic. For this section of the survey, 16 countries responded. Where direct information from one or both of the two country KIIs is also available, this was included in the data for a potential total of 18 responses in some cases (Fig. 7). Vaccines 14SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Fig. 7. Introduction of new and/or enhanced vaccine-related activities To understand the gains made in the areas of health services, clinical care and infection prevention and control (IPC), we asked a series of questions to understand the status before the pandemic and after the pandemic had ceased to be considered a global emergency. Perhaps universally, due to the huge surge in cases and the severity of the illness, countries had to grow and expand their health systems in order to respond to the huge caseloads. For this section of the survey, 14 countries responded. Where direct information from one or both of the two country KIIs is also available, this is included in the data for a potential total of 16 responses in some cases. Essential health services, infection prevention and control and clinical care 15 of 16 countries (94%) reported expanding ICU capacity to enhance health services (Fig. 8). Expansion of ICU capacity was established in several ways. Countries may have added ICU beds to every hospital, in each province or in specially set up COVID-19 treatment centres and field hospitals. Contracting for ICU care through the private sector was also mentioned as a strategy for increasing ICU capacity. Many countries noted the importance of training to support health care workers in gaining necessary skills to provide critical care. Obtaining critical care equipment for the treatment of severe patients was often a problem initially, with most countries eventually obtaining the needed equipment. ICU capacity and essential health services 15 out of 16 countries (94%) employed various new or enhanced strategies to support the continuity of essential services (Fig. 8). Some common activities to maintain essential services for NCD patients, elderly and pregnant women included the use of telemedicine and provision of home care. Many countries extended the prescription of routine medicines to three months and some countries provided home delivery of medicines. Most countries mentioned setting up triage systems and developing dedicated COVID-19 treatment centres. Some of these COVID-19 treatment centres integrated essential routine services into their care so that patients could receive all needed medical care at a single appointment. Lastly, an important strategy that was employed by a few countries was the establishment of a package of essential services, including routine immunization, for specific populations such as those with NCDs or pregnant women to maintain essential services. Most countries developed clinical treatment guidelines for the care of COVID-19 patients, which they plan to maintain and update as needed. 15 13 12 14 10 3 3 2 2 5 1 2 1 1 0 2 4 6 8 10 12 14 16 18 20 New or enhanced procurement activities New or enhanced rollout New or enhanced activities uptake New or enhanced digital systems Integrate vaccination into health services Yes No Don't know 15SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward 15 of 16 countries (94%) reported new or enhanced oxygen production capacity (Fig. 8). Prior to the pandemic only 8 of 16 countries (50%) had an IPC unit or programme in their country and only 10 of 16 (63%) had IPC guidelines (Fig. 9). IPC is another area where huge gains were made during the COVID-19 pandemic. During the acute phase of the COVID-19 pandemic, four of the eight countries without IPC programmes or units added them to the programmes of their ministry of health and five out of six countries (83%) without IPC guidelines developed them (Fig. 9). Like the plans for maintaining Oxygen capacity IPC and clinical care oxygen capacity, nearly all countries want to maintain the new capacities developed in the area of IPC. Essential health services and clinical care is another area where public–private partnerships proved critical, with 85% of countries outlining important activities supported through such partnerships. Most often, provision of care to patients, including ICU support, was cited. Provision of support for oxygen therapy, conducting diagnostics, isolation and quarantine units, development and running of field hospitals and procurement of medicines were some of the other critical activities supported through public–private partnerships. Fig. 8. Clinical case management capacities: prior and new or enhanced health service activities Fig. 9. Existing IPC capacities and new or enhanced activities Another area of almost universal gain in the response to the pandemic was the addition of new or enhanced oxygen production capacity. Three countries mentioned that they plan to maintain their expanded oxygen production capacity and ICU capacities as they have already proven lifesaving beyond the COVID-19 pandemic. 15 15 15 1 1 1 0 2 4 6 8 10 12 14 16 18 Enhanced ICU capacity New or enhanced health services New or enhanced O 2 supply Yes No Don’t know 8 10 4 5 4 1 0 2 4 6 8 10 12 14 16 18 IPC Units/Programmes IPC Guidelines Existed prior to pandemic Added due to pandemic No units/programmes or guidelines 16SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Effective communications and engagement between health experts and communities was considered crucial during the COVID-19 pandemic, ensuring that communities understood, accepted and were able to adopt recommended and public health and social measures and risk-reducing behaviours to protect themselves and their families. This section of the survey sought to understand gains in these areas along with reaching all populations through consideration of GEHR. This section of the survey had the most respondents, namely 17 countries. Where direct information from one or both of the two country KIIs is also available, this is included in the data for a potential total of 19 responses in some cases. Risk communication and community engagement, communication and outreach, GEHR 13 of 18 countries (72%) established new risk communication and community engagement (RCCE) units or teams in their country in response to the pandemic (Fig. 10). 16 of 18 countries (89%) developed new or enhanced capacities to handle communications and outreach. 15 of 18 countries (83%) developed new or enhanced RCCE strategies to support the COVID-19 pandemic response (Fig. 10). Several countries stated that all services were free for all people. A common approach by countries was to develop communications tailored to women, the vulnerable and special populations. With regard to sustaining gains, a few countries explicitly noted that using these capacities more to promote routine preventive measures and for health promotion is a future strategy to sustain these capacities. RCCE and communication and outreach GEHR A common strategy was for countries to adapt the WHO Global Communications Guidelines for their country. Some of the activities highlighted in the responses include the development of RCCE working groups, use of rapid response teams and health care workers and social mobilizers to deliver messages, use of helplines and hotlines, mass media campaigns and translation of materials to all local languages. 12 of 18 countries (66%) reported the implementation of enhanced GEHR strategies (Fig. 10). 7 of 16 countries (43%) are considering incorporating GEHR into their RCCE strategy (Fig. 10). 13 out of 18 countries (72%) would like to sustain the gains made in the area of RCCE, community outreach and GEHR (Fig. 10). Fig. 10. RCCE, communications and outreach, and GEHR capacities: new and enhanced activities 13 15 16 12 13 5 1 1 4 2 2 1 2 3 0 2 4 6 8 10 12 14 16 18 20 New RCCE unit New RCCE strategies Comms/outreach New or enhanced GEHR Maintain new activities Yes No Don't know 17SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward It is interesting to note that all FCVs submitted the survey on time with little prompting and eight out of nine countries (88%) filled in all sections of the survey, while the remaining country filled four of five sections. Eight of nine countries (88%) added new sentinel sites and ICU beds. The average increase in the number of sentinel sites for these countries was 28, with seven of the eight countries (88%) who added sentinel sites desiring to maintain them. All nine countries (100%) added laboratories and new or enhanced oxygen sources. The average number of laboratories reported as being added in FCV countries was 17, with seven of nine countries (77%) wanting to maintain the laboratories they have set up. Of the seven who want to maintain the new laboratories, four countries (57%) want to maintain all of them, two (29%) are targeting about 25% to maintain and the final country (14%) wants to make sure to maintain its national influenza centre. With regard to exploring the costs of maintenance, three out of 19 countries said they have looked at costs related to laboratories and surveillance. With regard to IPC, four out of eight countries had IPC units before the pandemic, three countries added IPC units during the pandemic and two countries still have no IPC unit. Though two of the countries do not have IPC units, they did develop IPC guidelines for the pandemic. This means all countries developed new or enhanced activities around 5. COVID-19 GAINS AND OPPORTUNITIES IN FCV COUNTRIES IPC, even if they did not develop an IPC unit. As mentioned above, four of the 22 countries or territories (18%) developed IPC units for the pandemic, meaning that 75% of the new units developed were in FCV countries. Lastly, if we look at emergency coordination, only two countries did not have a PHEOC before the pandemic. They were both FCV countries and both established PHEOCs to manage the response. Additionally, six out of 14 countries with PHEOCs established priorly (43%) reported rarely activating their PHEOCs before the pandemic. Five of these (83%) were FCV countries. With regard to maintaining the PHEOCs, nine countries out of 16 expressed a wish to maintain them. Four of these were FCVs, including one of the two countries with newly established PHEOCs. Two of the three countries responding that they would only activate the PHEOC when necessary were FCV countries. Lastly, only one of the four FCV countries wishing to maintain the PHEOC mentioned considering a cost analysis. As described above, a large proportion of the countries that added new units, sites and PHEOCs during the pandemic were FCV countries. It was also clear that costing and planning for sustainability were mostly absent. FCV countries will likely need dedicated support for planning and maintaining gains and guidance for institutionalizing and integrating them into routine systems and national budgets. 18SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward For each section of the survey, countries were asked what support they needed from WHO and its partners. Between eight and 13 countries responded to the question about needed support in the five sections of the survey. While the requests varied for each country, some common themes emerged. Countries of all income levels noted that updates on guidance and/or guidelines from WHO was important, both periodically and as needed. This was highlighted especially in the areas of essential health services, clinical 6. REQUESTS OF WHO AND PARTNERS care, treatment guidelines and IPC sections as well as the RCCE section. Training from WHO and partners was highlighted as a critical need for maintaining gains and sustaining programmes, especially to keep health care workers up to speed on IPC, critical care, health promotion, RCCE and vaccination programmes. Training was also noted for rapid response teams, laboratory techniques and genomics. Lastly, financial support was often requested from LMICs and FCVs. 19SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward By and large, every country highlighted some capacities and activities that they plan to maintain and sustain. For the most part, new or enhanced capacities fell into two categories. The first area for the development of new or enhanced capacities was generally activities that involved scaling up existing systems, programmes or infrastructure to meet the needs of the population during the COVID-19 pandemic. This generally came in the form of new or surge capacity such as laboratories for diagnostics, surveillance sites to enhance monitoring, additional ICU beds, field hospitals and vaccination, isolation and quarantine centres. Countries that scaled up various systems differed in their response regarding the need for sustainability. Some countries wanted to maintain all of the new laboratories, sites or ICU beds, while others noted that they would maintain a portion and yet others said they would scale back up in the future if needed. Those indicating they would resurge if needed were generally countries that already had good infrastructure. The second area is the development of new units, groups or activities that were absent prior to the COVID-19 pandemic, but for which WHO guidance and good practices already existed; for example, the development of an IPC unit or team and the development of oxygen production facilities. Another example is the area of RCCE where several countries developed new RCCE units or workgroups to enhance awareness and outreach where none previously existed. The pandemic presented the necessity to develop these capacities where they were not present, even though they were already widely regarded as core capacities noted in IHR and HEPR. Where these capacities were completely new, most countries highlighted the desire to maintain and sustain these gains. In countries where these capacities were enhanced, the desire to sustain the enhancement varies by country, with several countries noting they would scale back up as needed and may maintain a portion of the gains continuously, but not at the acute-phase level. 7. COUNTRY PRIORITIES FOR MAINTAINING IN THE ONGOING COVID-19 CONTEXT While we asked about innovations, these were less often highlighted. For most countries, innovation came through new or enhanced data systems to capture a variety of necessary information to respond to the pandemic. The new or enhanced data systems appear to be tailored to each country’s needs and included a variety of information and functions such as vaccination and booster status, appointment generation, disease status, laboratory results, adverse events following immunization and ability to print vaccination certificates. Some countries had electronic data systems for the first time and new linkages to other data systems were often mentioned. Data systems seemed to vary widely between countries. Most countries stated that they would like to maintain and sustain these new data systems. By understanding the systems in various countries and the data that was useful for national and regional response, we can use these insights as an important starting point to develop minimum data needs and standards for necessary support to countries. Such information would position countries and the Region well for future data collection needs in another emergency response and contribute to routine reporting systems. Lastly, in a few areas, new technology was mentioned. Nearly all countries developed or enhanced genomic sequencing capacities. Four countries explicitly stated that they implemented sequencing for the first time. Other new or enhanced laboratory capacities included widely expanded PCR capabilities, automated extraction systems and GeneXpert. The addition of capabilities to support new or enhanced production of medical oxygen was almost uniformly noted. Where countries added these new capacities, maintaining and sustaining them was noted as a priority. It was also noted during consultations with key stakeholders that without ongoing continuation and practice of systems such as sequencing or producing oxygen, the skills will not be maintained. Equally critical is a need to promote a culture of preventive maintenance instead of corrective maintenance after systems are broken. This has major significance for expanding country-level capacities in biomedical engineering. 20SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward If there is one word to sum up the greatest movement countries have made towards sustainability, it is integration. This recurring theme applied to the integration of surveillance systems into systems that already exist and are institutionalized within countries. Over half the reporting countries have already integrated monitoring of SARS-CoV-2 into their routine sentinel sites and laboratory systems for influenza. A few countries have integrated COVID-19 into their IDSR and formally named SARS-CoV-2 as a priority reportable pathogen. Laboratory expansion during the pandemic was unprecedented and often extended all the way to the community level. Strategically prioritizing the number of laboratories to maintain and integrating them into national laboratory networks will be critical to long-term sustainability. Defining the role of these laboratories as part of a national laboratory strategy, with responsibilities beyond diagnosing SARS-CoV-2, such as training to diagnose other priority pathogens, will support gains made in laboratory capacity development. Likewise, for COVID-19 vaccination, many countries integrated the provision of COVID-19 vaccines into the routine immunization systems early on. Almost all other countries are in the process of integrating COVID-19 vaccination into routine immunization or expanded programmes of immunization with guidance already published (15). This comes at a unique time and is consistent with the life course focus on integrating vaccinations across the life course into country immunization programmes (15). Clearly, there was increased capacity for adult and life course immunizations during the pandemic. Thought should be given to capitalizing on these gains by incorporating other routine immunizations such as influenza into these new life course systems. Guidance for decision- makers on seasonal influenza vaccines is available (16). Similarly, gains made through understanding the importance of health workers as both givers and receivers of vaccines should be explored more fully to better capitalize on their roles in the interim and for the next emergency. 8. KEY THEMES FROM FINDINGS Essential health services are often interrupted during pandemics due to the overwhelming surge in patient cases and the redirection of health care resources and personnel to address the immediate crisis, an expected outcome given the sudden and extraordinary demands on the health care system during such events. Indeed, disruptions to essential health services during the COVID-19 pandemic were widely reported were not unique to the countries of the Region, and highlighted the need for comprehensive packages of services that seamlessly integrate routine care with critical care components. This is particularly important for patients with NCDs, who are often most vulnerable and at greatest risk for excess morbidity and mortality. An integrated approach, including the most vulnerable, such as NCD patients, enhances health care system resilience, including hospital resilience, and adaptability, ensuring the uninterrupted provision of essential services during pandemics and emergencies. By embedding critical care elements into routine care, health systems become better equipped to manage surges in demand while promoting universal health coverage and equitable access to high- quality care. Lastly, it was clear that IPC and essential health services are sometimes thought of separately and not always linked as part of essential health systems. The addition and integration of new IPC units into health systems in several countries offers the opportunity to make sure the programmes are appropriately linked and integrated into routine standards at both the system level and the service level. Integration 21SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward It is important to highlight that, although most countries expressed an interest in sustaining newly developed or improved capacities and systems through integration into routine, they have seldom undertaken comprehensive costing exercises or made efforts to integrate these requirements into their NAPHS or government budgets. This observation suggests a need for increased technical support and advocacy in this specific domain. While many countries highlighted new units, laboratories or sites that they want to maintain, there has been very little analysis of the long-term costs of maintaining the gains. For example, only 2 of 14 countries (14%) mentioned conducting a costing analysis for maintaining new PHEOC systems. A few countries mentioned incorporating the new costs into the annual health budget. By and large, these were the high-income countries. Other countries specifically noted that they would maintain the current system until a certain date, for example, December 2023, when donor funds would run out. Lastly, some countries seem to allude to the fact that they will keep the new units, laboratories or activities without any consideration of the funding and resources they might need. There is a need to understand the financing for the gains and to provide support for countries in the development of sustainable financing plans within governments and, where needed, in collaboration with donors including the new Pandemic Fund. Financing: Costing and analysis All reporting countries documented enhancements in areas including new laboratories, surveillance sites, IPC or RCCE units, databases, vaccination strategies and capacities for clinical care and oxygen production (Fig. 11.) Some countries set up new units or programmes in their ministry of health infrastructure to address critical needs during the pandemic. A key example, mentioned above, is the addition of units to conduct IPC activities. The utility of these new units and the programmes of work they encompass has already been Prioritizing institutionalization of new capacities noted as game-changing for patient outcomes beyond the pandemic. For example, one country noted that setting up the IPC has already provided benefits to health outcomes for routine health care. Support and best practices to institutionalize and integrate these units into routine health care services and structure is critical. Another example for which similar considerations need to be thought through is new RCCE units. Fig. 11. Number of countries with selected gains or enhancements 15 13 17 16 15 15 15 1 5 1 1 3 1 1 1 1 0 2 4 6 8 10 12 14 16 18 20 New Inter- ministerial/ inter- sectoral structure Added surveillance sites New or enhanced surveillance systems Added labs Enhanced vaccine procurement New or enhanced O 2 system(s) New RCCE strategies Yes No Don’t know 22SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Partnerships with academia, nongovernmental organizations and the private sector were all deemed critical by the responding countries. The partners varied by country, as did the main roles and functions they supported. In many cases, they were an extension of the local governments, fulfilling critical roles such as patient care, vaccination, surge capacities, distribution of meds and services, among some frequently mentioned. Partnerships allowed the rapid scale up of needed training for health workers and laboratories. Partnerships decreased the time needed to set up research studies and gain needed information to drive policy. Likewise, partners were critical to innovations such as adding genomic sequencing capacities. It is key to understand how to keep these partnerships active at country and regional levels. It is important to capitalize on the strengths of the regional and/or global partnerships to address the routine research and training needed to support sustaining gains. Partnerships The Dalberg Advisors’ report considered the Region’s success during the COVID-19 pandemic to have been underscored by exceptional coordination and leadership, and these two factors were also crucially important at the country level. The establishment of national interministerial and cross-sectoral coordination mechanisms was a pivotal achievement across most countries, and countries similarly recognized the significance of interdepartmental emergency management structures for overseeing the comprehensive health aspects of the COVID-19 response. Countries should develop plans and strategies to maintain both interdepartmental linkages between essential health services and emergency response as well as maintaining linkages across sectors. The pandemic’s impact highlighted the vital role of PHEOCs, and a strong willingness to uphold them was apparent among the responding countries. Much consideration needs to be given to ensuring these structures (interministerial, interdepartmental, PHEOC and other multisectoral coordination structures) remain in place and are optimized and that staff be appropriately available and trained. If unavailable, standard operating procedures should be developed to standardize the activation and maintenance of coordination structures. Simulation exercises are also another way to support country preparedness for the next pandemic and should be prioritized. Coordination and leadership A corollary to the costing analysis is the concept of right- sizing. While many countries wanted to keep all their new laboratories, sentinel sites or ICU beds, some were more measured in their approach. Various rationales were applied to the determination of what level of new laboratories to keep or how many sentinel sites to maintain. Many countries wanted to maintain enough laboratories or sites to make sure each province (or country-level unit, such as governate) continued to have services. Other criteria included local epidemiological needs, population density, geographical access and political will. Similarly, many countries added new sequencing activities. In the absence of major donor funding, understanding the proper level of work or number of specimens to maintain meaningful sequence activity to contribute to country, regional and global efforts is needed. Where countries did not apply any rationale nor budgeting considerations, it would be important to develop guidance on the optimal laboratory, sentinel site, expanded ICU or sequencing capacity to guide countries with rationale and minimum standards for the routine maintenance of systems and skills that can be flexibly surged for future response. Right-sizing 23SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward The acute response phase of the COVID-19 pandemic, though devastating, presented unique opportunities to sustain the progress made in building health systems and response systems. It is clear that the quickest response was and is rooted in building on existing capacity. Given all the gains, prioritizing and sustaining certain gains at optimal levels will enhance current health services, systems and preparedness for future responses, thereby reinforcing the resilience of the health systems. The results from this exercise show that substantial gains were made across all countries, from high income to low income, and in fragile and conflict-affected countries. WHO launched the HEPR in 2022 and it strives to support “core national capacities and capabilities that sit at the intersection of health security, primary health care, and health promotion” (8). By capitalizing on the results of this exercise there is an opportunity to cement the gains that countries made in enhancing IHR core capacities and to translate the HEPR into reality. While the Dalberg Advisors’ report highlighted that coordination across sectors, systems and countries was a strength displayed by WHO and its Regional Office during the pandemic, this exercise highlighted that health security is often considered separately from health systems in normal circumstances. The findings from this exercise confirm what the Regional Committee for the Eastern Mediterranean (12) highlighted, that there is a need to bring essential functions of health systems and health security together through planning for routine resilience (11). The time for action is now. The gains built will only be sustained through support and guidance. There is an opportunity to make sure that essential public health functions such as IPC, surveillance and prevention are all integrated and linked to primary care and essential health services systems. This will support high-quality and safe essential health systems for the future as well as enhance preparedness. Furthermore, it involves the development of contingency plans for surging. These plans are critical for responding effectively to sudden spikes in demand, a common occurrence during pandemics. By having well-structured contingency plans in place, the health care system can adapt swiftly and efficiently to evolving circumstances, maintaining its core functions and ensuring resilience in the face of future challenges. Research and knowledge management gains can be sustained through keeping the improvements and gains made in research systems and new data systems active. Capitalizing on partnerships set up and designing ways to address follow on questions from the pandemic, such as operational research, will support keeping the linkages alive and contributing to further knowledge. It is important to support research for best practices for future pandemic response. Research should not be sidelined during a pandemic; rather, as in this case of the COVID-19 pandemic, the efforts invested in research during the acute phase of the pandemic should continue to be built upon to forge longer-term, sustained relationships with academia. Among the key foundational building blocks of health systems are leadership and health system financing (17). Country leadership is needed to develop budgeting and costing strategies. In the context of pandemic preparedness, this involves a balance of securing donor funding for response but also ensuring that this support becomes an enduring part of the government and ministry of health systems for the long term by allocating resources to routine health care systems at an optimal scale (i.e. right-sizing). Sustained leadership and financing at all levels (country and regional) is essential to retain the skills and infrastructure developed during times of crisis while ensuring that everyday health care services continue unhindered. The HEPR highlights the need to develop and maintain both leadership and sustained financing and the critical role partners play in the catalytic and sustainable funding for HEPR core capacities. By prioritizing key gains to be sustained in each country and incorporating them into routine systems, essential core capacities will be enhanced and can support the routine resilience of health systems. Likewise, this will put each country and the Region in a better place for future public health emergency responses. 9. CONCLUSIONS 24SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Based on the findings from the survey, KIIs and discussions with stakeholders, the present report makes the following recommendations to support the ongoing sustainability of gains in capacities, systems and networks made during the COVID-19 pandemic. These recommendations are targeted for action at various global, regional and/or country levels, as appropriate. WHO, Member States and partners will need to work collaboratively to support progress in sustaining gains. See Table 3 for a summary of recommendations and priority actions mapped to related HEPR pillars. 10. RECOMMENDATIONS AND PRIORITY ACTIONS FOR SUSTAINABILITY Recommendation 1 Institutionalization and integration of new or enhanced capacities into routine systems is the major strategy for sustainability and for maintaining gains in the areas of surveillance, laboratory, immunization and health services. To maintain ongoing monitoring and reporting of SARS-CoV-2, the WHO Regional Office for the Eastern Mediterranean and the Member States of the Region should continue to develop and fine tune guidance to support integrated respiratory virus surveillance in the GISRS. Current guidance for country implementation is available (18). Countries should also assess how the surveillance systems work together as a whole to provide the big picture and needed components to monitor respiratory viruses and integrate into GISRS or other institutionalized systems such as IDSR. WHO has developed guidance (19) to support countries in these efforts. Guidance on the WHO Mosaic Respiratory Surveillance Framework is also a useful tool (20). Countries should develop a national laboratory strategy that clearly outlines roles and responsibilities for all the laboratories at different levels in their systems, including testing for additional priority pathogens, and how they are networked with in a country. The strategy should meet any minimum criteria outlined by WHO. Countries should integrate COVID-19 vaccination into routine immunization systems or expanded programmes of immunization in line with the WHO immunization guidance (15). Countries should prioritize development packages of essential health services for routine resilience and for use during health emergencies to mitigate preventable deaths and diseases in line with Resolution WHA76.2. of 30 May 2023 (21), which emphasized the significance of strengthening routine integrated emergency, critical and operative care for universal health coverage and protection from health emergencies. Countries can consider prioritizing the actions outlined in published guidance (21, 22). Countries should assess the utility of new or enhanced data systems developed during the pandemic and integrate them into their systems for routine use, such as immunization and surveillance data systems, as appropriate. WHO and partners should work together to support countries that added new core capacities in line with those highlighted in HEPR and IHR, such as IPC (23), RCCE and PHEOCs, to conduct a costing analysis and develop a strategy to institutionalize the new units. Where feasible, WHO should work with partners and donors to develop a long-term strategy for institutionalization and financing within the countries. 25SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Recommendation 2 Develop supportive systems and programmes to foster best practices, long-term sustainability and maintenance of capacity for routine resilience. Recommendation 3 WHO should work with partners to develop priorities for interim and longer-term targets for right-sizing activities and infrastructure that was scaled up during the pandemic to support routine resilience and flexible surge capacity. WHO should develop a training strategy to support the ongoing needs for IPC, essential health services and ICU care for the health workforce. This should include routinely assessing and updating training programmes and materials to make sure they support country needs. Monitoring and evaluation to assess impact should be incorporated as a critical part of the strategy. WHO should consider working with partners to setup a peer- to-peer training and learning network within the Region so countries can share experiences and support other countries with training strategies and materials. WHO and countries should support programmes that promote a culture of preventive maintenance by integrating preventive activities into appropriate guidance documents, supporting resources and contracts for routine maintenance of lab equipment, oxygen production facilities and other new systems as needed. Interim guidance should be issued on how countries should consider the number of new (additional) laboratories, sentinel sites and ICU beds that should be maintained as an immediate priority. WHO should provide guidance of the ideal attributes of a laboratory structure at the country level including recommendations on minimal capacities and levels of laboratories in a network to support decisions on the number of laboratories and items of equipment to maintain. WHO should work with partners to develop longer-term guidance on the optimal size of systems and strategy for routine surveillance and laboratory systems, and essential health systems including ICUs. The strategic maintenance of oxygen production capacities with potential need to surge in the future should be prioritized. WHO resources are available (24). Countries should expand their country-level biomedical engineering capacity to support the routine maintenance of new systems and future flexible surge capacity for health facilities. WHO should consider conducting a review of the data systems set up during the pandemic, especially in FCVs and low resource countries, to understand their commonalities and attributes. It should assess the systems to make sure all new systems meet minimum data requirements for reporting in routine regional and global systems such as the electronic joint reporting form (eJRF), surveillance platforms and others to enhance routine reporting and future preparedness. Similar guidance should be issued for how many specimens and genomic sequences should be carried out for optimal monitoring of SARS-CoV-2 to maintain routine functioning of lab systems and skills and support future surge if needed. WHO and partners should work with countries to document lessons learned and best practices for surging capacities needed for scale up during future public health events. 26SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward Setting up a regional network of PHEOCs to maintain routine connections to key emergency management leaders in countries through occasional webinars to update on new guidance, share experiences from simulation exercises or similar. WHO and partners should develop strategies to keep PHEOC staff and key leaders connected to country, regional and global systems to facilitate rapid future scale up and communications. They should provide tools and updates for countries to use nationally to maintain cross- sectoral and cross-ministerial leadership connected and engaged, as appropriate. Building and strengthening leadership capacities at national, subnational and facility-level, particularly technical capacities in managing multisectoral and interdisciplinary centres and committees (i.e. PHEOC). Consider developing a cross-sectoral key leaders forum or network with broad membership to maintain contact Recommendation 5 Provide strategic and technical support for developing costing tools and proposals for financing of key gains, to support integration into national budgets, such as NAPHS, and support development of donor funding proposals, including for the Pandemic Fund. WHO should work to develop tools that support costing analyses of adding new laboratories, sentinel sites or units to support forecasting and integration. Recommendation 6 Countries should update preparedness plans and include in NAPHS, pandemic preparedness plans and other relevant national contingency plans for preparedness and response. They should routinely update and exercise plans through simulation exercises or regular conduct of in- and after-action reviews during public health events. As part of the exercises, countries should make sure to engage multiple sectors and key leadership. Recent resources such as the PRET module 1 (9) are available. with key leaders and partners and engage in virtual and or newsletter updates with engaging topics a couple of times a year. Consider developing a regional research working group to summarize regional research learning during the COVID-19 pandemic and to develop a targeted research agenda with a few priority regional topics to address unanswered questions from the pandemic. This could potentially be Member-State-led with minimal WHO Secretariat support. Strategies to maintain the function and utility of all the genomic sequencing consortia set up during the pandemic should be explored to support future responses and foster continuity of the new partnerships and linkages forged during the pandemic. This could potentially be Member-State-led with minimal WHO Secretariat support. Consider developing country or regional funding proposals to support the institutionalization of IPC (or other key gains) in countries where IPC was added during the pandemic and in countries that still lack IPC programmes. Consider developing other national or regional funding proposals to support targeted recommendations in this report. Recommendation 4 The Dalberg Advisors’ report mentioned key gains in the area of leadership. Likewise, this exercise found that interministerial committees, interdepartmental committees and public health emergency operation centres were key both to managing activities within countries and to coordinating with partners. To maintain the strong sense of leadership and coordination within the Region and capitalize on momentum, WHO and partners have been advised to consider the following networking activities: 27SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward HEPR pillar Priority recommended actions Strategic recommendation No. 2: Develop supportive systems and programmes to foster best practices, long-term sustainability and maintenance of capacity for routine resilience. Safe and scalable care Safe and scalable care Safe and scalable care Collaborative surveillance Access to countermeasures Develop training strategy that includes routinely assessing and updating training programmes with an monitoring and evaluation component to support the ongoing needs for IPC, essential health services and ICU care for the health workforce. Support programmes that promote a culture of preventive maintenance by integrating preventive activities into appropriate guidance documents, supporting resources and contracts for routine maintenance of lab equipment, oxygen production facilities and other new systems as needed. Expand national biomedical engineering capacity to support the routine maintenance of new systems and future flexible surge capacity for health facilities. Conduct a review of the data systems set up during the pandemic to meet future preparedness needs and prioritize support to countries for maintaining and integrating new systems into routine use. Table 3. Summary of recommendations and key priority actions HEPR pillar Priority recommended actions Strategic recommendation No. 1: Institutionalize and integrate new or enhanced capacities into routine systems in the areas of surveillance, laboratory, immunization and health services. Collaborative surveillance Collaborative surveillance Access to countermeasures Safe and scalable care All 5 Cs All 5 Cs Maintain ongoing monitoring and reporting of SARS-CoV2 by integrating respiratory virus surveillance into the GISRS or other institutionalized systems such as IDSR. Current guidance for country implementation is available End-to-end integration of SARS-CoV-2 and influenza sentinel surveillance: revised interim guidance (who.int).16 Develop a national laboratory strategy which clearly outlines roles and responsibilities for all the laboratories at different levels in the system, including the testing of additional priority pathogens, and how they are networked within a country. Integrate COVID-19 vaccination into routine immunization systems or expanded immunization programmes in line with the WHO Immunization IA2030 guidance.13 Prioritize development packages of essential health services for routine resilience and for use during health emergencies to mitigate preventable deaths and diseases. Assess the utility of new or enhanced data systems developed during the pandemic and integrate them into systems for routine use, such as immunization and surveillance data systems, as appropriate. Support costing analysis and national long-term strategy and financing to institutionalize new core capacities developed in the context of COVID-19 (IPC Infection Prevention and Control, RCCE and PHEOCs). 28SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward HEPR pillar HEPR pillar Priority recommended actions Priority recommended actions Strategic Recommendation No. 5: Provide strategic and technical support to develop costing tools and proposals for financing of key new gains Strategic Recommendation No. 6: Update preparedness plans Safe and scalable care Emergency coordination Emergency coordination All 5 Cs All 5 Cs All 5 Cs Develop national or regional funding proposals to support the institutionalization of IPC (or other key gains) in countries where IPC was added during the pandemic and in countries that still lack IPC programmes. Develop additional national or regional funding proposals to support targeted recommendations in this report. Include updates in NAPHS, pandemic preparedness plans and other relevant national contingency plans for preparedness and response. Plan to routinely update and exercise plans through simulation exercises or regular conduct of intra- and after-action reviews during public health events. HEPR pillar Priority recommended actions Strategic recommendation No. 4: Maintain leadership and coordination within the Region and capitalize on momentum gained during the pandemic through the development of strategic networks Emergency coordination Emergency coordination Emergency coordination All 5 Cs Collaborative surveillance Emergency coordination Set up regional network of PHEOCs to maintain routine connections to key emergency management leaders in countries. Develop strategies to build and strengthen leadership capacities at national, subnational and facility-level, particularly technical capacities in managing multisectoral and interdisciplinary centres and committees (i.e. PHEOC) through training, tools and technical guidance. Consider developing a cross-sectoral key leaders forum or network with broad membership to maintain contact with key leaders and partners. Consider developing a regional research working group to summarize regional research learning during the pandemic and to develop a targeted research agenda. Explore strategies to maintain the function and utility of all the genomic sequencing consortia set up during the pandemic to support future responses and foster continuity of the new partnerships and linkages forged during it. HEPR pillar Priority recommended actions Strategic recommendation No. 3: Develop priorities for interim and longer-term targets for right-sizing activities and infrastructure that was scaled up during the pandemic to support routine resilience and flexible surge capacity. Collaborative surveillance Collaborative surveillance Collaborative surveillance Safe and scalable care Collaborative surveillance All 5 Cs Interim guidance should be issued on how countries should consider the number of new (additional) laboratories, sentinel sites and ICU beds that should be maintained as an immediate priority. Provide guidance on the ideal attributes of a laboratory structure at the country level including recommendations on minimal capacities and levels of laboratories in a network to support decisions on number of laboratories and equipment to maintain. Develop longer-term guidance on the optimal size of systems and strategy for routine surveillance and laboratory systems and essential health systems including ICUs. Develop guidance on number of specimens and genomic sequences needed for optimal monitoring of SARS-CoV-2 to maintain routine functioning of lab systems and skills and support future surge if needed. Document lessons learned and best practices for surging capacities needed for scale up during future public health events. 29SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward 1. Dalberg Advisors. WHO’s response to COVID-19 in the Eastern Mediterranean Region. Geneva, World Health Organization, 2023 (https://www.who.int/publications/m/item/independent-review-of-who-s-response-to-covid-19- in-the-eastern-mediterranean-region, accessed 18 August 2023). 2. COVID-19: Make it the last pandemic. Geneva: The Independent Panel for Pandemic Preparedness and Response; 2021 (https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-Make-it-the-Last-Pandemic_final.pdf, accessed 25 September 2023). 3. FY23 list of fragile and conflict-affected situations. Washington, DC: World Bank; 2023. (https://thedocs.worldbank.org/ en/doc/69b1d088e3c48ebe2cdf451e30284f04-0090082022/original/FCSList-FY23.pdf). 4. Global Humanitarian Overview 2023, August Update (Snapshot as of 31 August 2023). New York: Office for the Coordination of Humanitarian Affairs; 2023 (https://www.unocha.org/publications/report/world/global-humanitarian- overview-2023-july-update-snapshot-31-august-2023, accessed 28 September 2023). 5. Brennan R, Hajjeh R, Al-Mandhari A. Responding to health emergencies in the Eastern Mediterranean region in times of conflict. Lancet 2022;399:e20–e22. 6. Corona virus [web site]. Cairo: WHO Office for the Eastern Mediterranean; 2023 (http://www.emro.who.int/health- topics/corona-virus/index.html, accessed 18 August 2023). 7. Preparedness and Resilience for Emerging Threats (PRET) [web site]. Geneva: World Health Organization; 2024 (https:// www.who.int/initiatives/preparedness-and-resilience-for-emerging-threats, accessed 9 September 2023). 8. Strengthening the global architecture for health emergency prevention, preparedness, response and resilience. Geneva: World Health Organization; 2023 (https://www.who.int/publications/m/item/strengthening-the-global-architecture- for-health-emergency-prevention--preparedness--response-and-resilience, accessed 18 August 2023). 9. Preparedness and resilience for emerging threats, Module 1: Planning for respiratory pathogen pandemics. Geneva: World Health Organization; 2023 (https://www.who.int/publications-detail-redirect/9789240084674, accessed 11 September 2023). 10. From emergency response to long-term COVID-19 disease management: Sustaining gains made during the COVID-19 pandemic [web site]. Geneva: World Health Organization; 2023 (https://www.who.int/publications/i/item/WHO-WHE- SPP-2023.1, accessed 14 September 2023). 11. Ending the COVID-19 emergency and transitioning from emergency phase to longer-term disease management: guidance on calibrating the response [web site]. Geneva: World Health Organization; 2023 (https://www.who.int/ publications-detail-redirect/WHO-WHE-SPP-2023.2, accessed 18 August 2023). 12. Accelerating health emergency preparedness and response – a plan of action. Cairo: WHO Office for the Eastern Mediterranean; 2021. 13. Statement on the eleventh meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic. Geneva: World Health Organization; 2022. (https://www.who.int/news item/13-04-2022-statement-on-the-eleventh-meeting-of-the-international-health-regulations-(2005)-emergency- committee-regarding-the-coronavirus-disease-(covid-19)-pandemic, accessed 9 September 2023). 14. Statement on the fourteenth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic. Geneva: World Health Organization; 2023. (https://www.who.int/news/ item/30-01-2023-statement-on-the-fourteenth-meeting-of-the-international-health-regulations-(2005)-emergency- committee-regarding-the-coronavirus-disease-(covid-19)-pandemic, accessed 9 September 2023). REFERENCES 30SUSTAINING COVID-19 PANDEMIC RESPONSE GAINS IN THE WHO EASTERN MEDITERRANEAN REGION mapping strategic opportunities and ways forward 15. Immunization agenda 2030: A global strategy to leave no one behind. Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/item/immunization-agenda-2030-a-global-strategy-to-leave-no-one-behind, accessed 18 August 2023). 16. Seasonal influenza vaccines: an overview for decision-makers. Geneva: World Health Organization; 2020 (https://iris. who.int/handle/10665/336951, accessed 19 September 2023). 17. Health system building blocks [web site]. Geneva: World Health Organization; 2010 (https://extranet.who.int/nhptool/ BuildingBlock.aspx, accessed 18 August 2023). 18. End-to-end integration of SARS-CoV-2 and influenza sentinel surveillance: revised interim guidance. Geneva: World Health Organization; 2022 (https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-Integrated_sentinel_ surveillance-2022.1, accessed 9 September 2023). 19. Strategic framework for prevention and control of emerging and epidemic-prone infectious diseases in the Eastern Mediterranean Region. Cairo: WHO Office for the Eastern Mediterranean; 2020. 20. “Crafting the mosaic”: a framework for resilient surveillance for respiratory viruses of epidemic and pandemic potential. Geneva: World Health Organization; 2023 (https://www.who.int/publications-detail-redirect/9789240070288, accessed 9 September 2023). 21. Seventy-sixth World Health Assembly. Agenda item 13.1, 30 May 2023: Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies. Geneva: World Health Organization; 2023 (WHA76.2; https://apps.who.int/gb/ebwha/pdf_files/WHA76/A76_R2-en.pdf). 22. Integrated emergency, critical and operative care (ECO) [web site]. Geneva: World Health Organization; 2023 (https:// www.who.int/teams/integrated-health-services/clinical-services-and-systems/emergency--critical-and-operative-care, accessed 14 September 2023). 23. 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Sustaining COVID-19 pandemic response gains in the WHO Eastern Mediterranean Region: mapping strategic opportunities and ways forward
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