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THIS PAPER IS IN THE FOLLOWING E-COLLECTION/THEME ISSUE:

Viewpoint and Opinions on Technology and Innovation in Public Health (52) JMIR
Theme Issue: COVID-19 Special Issue (2458) Public (e)Health, Digital
Epidemiology and Public Health Informatics (743) Infectious Diseases
(non-STD/STI) (1588) E-Health / Health Services Research and New Models of Care
(539) Outbreak and Pandemic Preparedness and Management (1741)

Published on 15.02.2024 in Vol 10 (2024)

Preprints (earlier versions) of this paper are available at
https://preprints.jmir.org/preprint/40491, first published June 23, 2022.

LEARNING FROM COVID-19: WHAT WOULD IT TAKE TO BE BETTER PREPARED IN THE EASTERN
MEDITERRANEAN REGION?

Authors of this article:

Lara Kufoof1 ; Rana Hajjeh2 ; Mohannad Al Nsour3 ; Randa Saad4 ;
Victoria Bélorgeot5 ; Abdinasir Abubakar5 ; Yousef Khader6 ; Salman Rawaf7
Article Authors Cited by Tweetations (2) Metrics
* Abstract
* Introduction
* Challenges-in-the-EMR
* Achievements-and-Lessons-Learned
* COVID-19-Vaccination
* Recommendations-from-the-World-Health-Assembly-That-Benefit-the-EMR
* Reshaping-Public-Health
* Conclusion
* Recommendations-and-Areas-of-Improvement
* References
* Abbreviations
* Copyright

VIEWPOINT

* Lara Kufoof1, MSc ;
* Rana Hajjeh2, MD ;
* Mohannad Al Nsour3, PhD ;
* Randa Saad4, MD ;
* Victoria Bélorgeot5, MSc ;
* Abdinasir Abubakar5, MSc, MD ;
* Yousef Khader6, ScD ;
* Salman Rawaf7, PhD

1Project Management Office, Global Health Development, Eastern Mediterranean
Public Health Network, Amman, Jordan

2Department of Program Management, Regional Office for the Eastern
Mediterranean, World Health Organization, Cairo, Egypt

3Global Health Development, Eastern Mediterranean Public Health Network, Amman,
Jordan

4Department of Research and Policy, Global Health Development, Eastern
Mediterranean Public Health Network, Amman, Jordan

5Regional Office for the Eastern Mediterranean, World Health Organization,
Cairo, Egypt

6Department of Public Health, Faculty of Medicine, Jordan University of Science
and Technology, Irbid, Jordan

7Department of Primary Care and Public Health, School of Public Health at
Imperial College London, London, United Kingdom

CORRESPONDING AUTHOR:

Yousef Khader, ScD

Department of Public Health

Faculty of Medicine

Jordan University of Science and Technology

Alramtha-Amman Street

Irbid, 22110

Jordan

Phone: 962 796802040

Email: yskhader@just.edu.jo

ABSTRACT

The COVID-19 transmission in the Eastern Mediterranean Region (EMR) was
influenced by various factors such as conflict, demographics, travel and social
restrictions, migrant workers, weak health systems, and mass gatherings. The
countries that responded well to COVID-19 had high-level political commitment,
multisectoral coordination, and existing infrastructures that could quickly
mobilize. However, some EMR countries faced challenges due to political
instability and fragile health systems, which hindered their response
strategies. The pandemic highlighted the region’s weak health systems and
preparedness, fragmented surveillance systems, and lack of trust in information
sharing. COVID-19 exposed the disruption of access and delivery of essential
health services as a major health system fragility. In 2020, the World Health
Organization (WHO) conducted a global pulse survey, which demonstrated that the
EMR experienced the highest disruption in health services compared to other WHO
regions. However, thanks to prioritization by the WHO and its member states,
significant improvement was observed in 2021 during the second round of the
WHO’s National Pulse Survey. The pandemic underscored the importance of
political leadership, community engagement, and trust and emphasized that
investing in health security benefits everyone. Increasing vaccine coverage,
building regional capacities, strengthening health systems, and working toward
universal health coverage and health security are all priorities in the EMR.
Emergency public health plays a key role in preparing for and responding to
pandemics and biological threats. Integrating public health into primary care
and investing in public health workforce capacity building is essential to
reshaping public health and health emergency preparedness.

JMIR Public Health Surveill 2024;10:e40491

doi:10.2196/40491

KEYWORDS

COVID-19 (3004); integration (31); pandemic preparedness (11); primary health
care (187); public health (934)
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INTRODUCTION

The World Health Organization (WHO) was first alerted to cases of pneumonia of
unknown origin on December 31, 2019. By January 30, 2020, the WHO had declared
the novel coronavirus outbreak a public health emergency of international
concern [WHO director-general's statement on IHR emergency committee on novel
coronavirus (2019-nCoV). World Health Organization. 2020. URL: https:/ /www.
who.int/ director-general/ speeches/ detail/ who-director-general-s-statement-on
-ihr-emergency-committee-on-novel-coronavirus-(2019-ncov). [Accessed [accessed
2024-01-24] 1]. The WHO’s Director General described this outbreak of COVID-19
as a pandemic on March 11, 2020 [Ghebreyesus TA. WHO director-general's opening
remarks at the media briefing on COVID-19 - 11 March 2020. World Health
Organization. 2020. URL: https:/ /www. who.int/ director-general/ speeches/
detail/ who-director-general-s-opening-re
marks-at-the-media-briefing-on-covid-19---11-march-2020 [accessed 2024-01-24]
2]. Since then, many countries have announced several restrictive public health
measures to contain the virus, such as travel bans, border restrictions,
lockdowns, and mandatory quarantines [Listings of WHO’s response to COVID-19.
World Health Organization. 2021. URL: https://www.who.int/news/item/29-06
-2020-covidtimeline.%5BAccessed [accessed 2024-01-24] 3]. As a result, global
economic growth was severely impacted, with the global gross domestic product
dropping by 6.7% in 2020 [Szmigiera M. Share of Gross Domestic Product (GDP)
lost as a result of the coronavirus pandemic (COVID-19) in 2020, by economy.
Statista. 2024. URL:
https://www.statista.com/statistics/1240594/gdp-loss-covid-19-economy/#statisticContainer.[Accessed
[accessed 2022-01-01] 4,Chi YL, Regan L, Nemzoff C, Krubiner C, Anwar Y, Walker
D. Beyond COVID-19: a whole of health look at impacts during the pandemic
response. Center for Global Development. 2020. URL:
https://www.cgdev.org/sites/default/files/PP1 77-Beyond-COVID-scoping-paper.pdf
[accessed 2024-01-24] 5]. These measures, along with the strain on resources due
to the care of those infected with COVID-19, have disrupted the access to and
delivery of essential health services [In WHO global pulse survey, 90% of
countries report disruptions to essential health services since COVID-19
pandemic. WHO to roll out learning and monitoring tools to improve service
provision during pandemic. World Health Organization. 2020. URL: https:/ /www.
who.int/ news/ item/
31-08-2020-in-who-global-pulse-survey-90-of-countries-report-disruptions-to-
essential-health-services-since-covid-19-pandemic [accessed 2024-01-24] 6]. Even
the strongest health systems were heavily impacted and overwhelmed by the
pandemic.

In 2020, the WHO conducted a global pulse survey to understand the impact of
COVID-19 on health systems. Almost 90% of the 105 engaged countries reported
interruptions in different services, ranging from routine and elective service
delivery to critical care, especially in low- and middle-income countries [In
WHO global pulse survey, 90% of countries report disruptions to essential health
services since COVID-19 pandemic. WHO to roll out learning and monitoring tools
to improve service provision during pandemic. World Health Organization. 2020.
URL: https:/ /www. who.int/ news/ item/
31-08-2020-in-who-global-pulse-survey-90-of-countries-report-disruptions-to-
essential-health-services-since-covid-19-pandemic [accessed 2024-01-24] 6].
Financial constraints, supply chain disruptions, redirection of services to the
care of patients with COVID-19, and workforce unavailability affected access to
essential health services [Chi YL, Regan L, Nemzoff C, Krubiner C, Anwar Y,
Walker D. Beyond COVID-19: a whole of health look at impacts during the pandemic
response. Center for Global Development. 2020. URL:
https://www.cgdev.org/sites/default/files/PP1 77-Beyond-COVID-scoping-paper.pdf
[accessed 2024-01-24] 5]. The pandemic revealed that no country was sufficiently
prepared against biological threats. Many risks and gaps were identified in the
current public health system that hindered countries’ capacities for response.
These challenges and gaps called for increased investments and stronger
political will to enhance health emergency preparedness [Rose SM, Paterra M,
Isaac C, Bell J, Stucke A, Hagens A, et al. Analysing COVID-19 outcomes in the
context of the 2019 Global Health Security (GHS) index. BMJ Glob Health.
2021;6(12):e007581.
[https://gh.bmj.com/lookup/pmidlookup?view=long&pmid=34893478] [CrossRef]
[Medline]7].

In January 2020, the WHO activated its incident management system at all 3
levels of the organization (global, regional, and country levels), in line with
the WHO’s emergency response framework [Listings of WHO’s response to COVID-19.
World Health Organization. 2021. URL: https://www.who.int/news/item/29-06
-2020-covidtimeline.%5BAccessed [accessed 2024-01-24] 3]. This system safeguards
the coordination of response actions during public health emergencies [Listings
of WHO’s response to COVID-19. World Health Organization. 2021. URL:
https://www.who.int/news/item/29-06 -2020-covidtimeline.%5BAccessed [accessed
2024-01-24] 3]. The WHO’s Eastern Mediterranean Region (EMR) Incident Management
Support Team (IMST) for COVID-19 was activated on January 22, 2020, as a
coordination mechanism providing technical, strategic, and operational support
to EMR countries. It has been operational for over 2 years as the WHO’s
longest-running IMST. On January 29, 2020, the first cases of COVID-19 were
reported in the EMR, and by April 10, 2020, all 22 EMR countries and territories
had reported COVID-19 cases [COVID-19 strategic preparedness and response plan:
sustaining an effective response to end the acute phase of the pandemic and
transitioning to recovery in WHO’s Eastern Mediterranean Region – 2022 edition.
World Health Organization Regional Office for the Eastern Mediterranean. 2023.
URL: https://applications.emro.who.int/docs/WHOEMCSR513E-eng.pdf?ua=1 [accessed
2024-01-24] 8].

The EMR is composed of 22 countries, categorized into 3 groups based on
socioeconomic development. Group 1 includes Bahrain, Kuwait, Oman, Qatar, Saudi
Arabia, and the United Arab Emirates (UAE), which have the most resources and
are all high-income countries. Group 2 includes Egypt, Iran, Iraq, Jordan,
Lebanon, Libya, Morocco, Palestine, Syria, and Tunisia, which have the next most
level of resources and are upper-middle– or lower-middle–income countries. Group
3 includes Afghanistan, Djibouti, Pakistan, Somalia, Sudan, and Yemen, which
have the least resources and are all either lower-middle– or low-income
countries [Assessing national capacity for the prevention and control of
noncommunicable diseases: report of the 2019 global survey. World Health
Organization Regional Office for the Eastern Mediterranean. 2019. URL:
https://www.who.int/publications/i/item/9789240002319 [accessed 2024-01-24] 9].
The diversity of country incomes, emergencies, cultures, and health system
capacities in the EMR led to varying response capacities, COVID-19 knowledge and
risk perceptions, and socioeconomic impacts, which have usually been substantial
[Al-Mandhari AS, Brennan RJ, Abubakar A, Hajjeh R. Tackling COVID-19 in the
Eastern Mediterranean Region. Lancet. 2020;396(10265):1786-1788.
[https://europepmc.org/abstract/MED/33220856] [CrossRef] [Medline]10].

This viewpoint highlights the challenges that faced EMR countries and their
achievements and lessons learned during the COVID-19 pandemic. It provides an
overview of the unequal COVID-19 vaccination coverage in the region and
discusses the methods and approaches of how to reshape public health in the
region and strengthen health emergency preparedness, providing recommendations
for the way forward.

CHALLENGES IN THE EMR

Over 50% of the countries in the region are affected by complex emergencies,
either directly or indirectly. The EMR holds 9 major humanitarian emergencies,
102 million people needing humanitarian assistance (37% of the global total),
and over 32 million refugees and internally displaced persons [COVID-19
strategic preparedness and response plan: sustaining an effective response to
end the acute phase of the pandemic and transitioning to recovery in WHO’s
Eastern Mediterranean Region – 2022 edition. World Health Organization Regional
Office for the Eastern Mediterranean. 2023. URL:
https://applications.emro.who.int/docs/WHOEMCSR513E-eng.pdf?ua=1 [accessed
2024-01-24] 8]. Political instability, fragile health systems in some EMR
countries, multiple disease outbreaks, and poor accessibility and availability
of basic health care services have hampered the effectiveness and efficiency of
the strategies adopted to combat COVID-19 [Brennan R, Hajjeh R, Al-Mandhari A.
Responding to health emergencies in the Eastern Mediterranean Region in times of
conflict. Lancet. 2022;399(10332):e20-e22.
[https://europepmc.org/abstract/MED/32135078] [CrossRef] [Medline]11]. The
COVID-19 response in the EMR was influenced by multiple factors affecting viral
transmission, such as state fragility and conflict; demographics, as this region
has a younger population than most; early applications of travel and social
restrictions, which limited spread at the beginning of the pandemic; large
numbers of migrant workers; mass gatherings; and pilgrimage. Saudi Arabia made
an unprecedented decision to downsize Hajj and suspend Umrah, and other EMR
countries implemented public health and social measures. However, as “COVID-19
fatigue” set in, many countries loosened their restrictive measures, which often
affected the disease trend [Al-Mandhari AS, Brennan RJ, Abubakar A, Hajjeh R.
Tackling COVID-19 in the Eastern Mediterranean Region. Lancet.
2020;396(10265):1786-1788. [https://europepmc.org/abstract/MED/33220856]
[CrossRef] [Medline]10]. Although some countries used and built on past health
emergency experiences and systems, such as Saudi Arabia applying lessons learned
from the Middle East respiratory syndrome experience [Obied DA, Alhamlan FS,
Al-Qahtani AA, Al-Ahdal MN. Containment of COVID-19: the unprecedented response
of Saudi Arabia. J Infect Dev Ctries. 2020;14(7):699-706.
[http://www.jidc.org/index.php/journal/article/view/32794457] [CrossRef]
[Medline]12,Tackling infectious disease outbreaks in the Eastern Mediterranean
Region. World Health Organization Regional Office for the Eastern Mediterranean.
2020. URL: https://applications.emro.who.int/docs/9789290224198-eng.pdf?ua=1
[accessed 2024-01-24] 13], other countries were poorly prepared. For example, 6
EMR countries still lack national infection prevention and control guidelines,
and 5 (Afghanistan, Iraq, Libya, Palestine, and Tunisia) developed their
infection prevention and control guidelines in the past year only, with the
support of the WHO [COVID-19 pandemic response in the Eastern Mediterranean
Region: progress report of the incident management support team, 2021. World
Health Organization Regional Office for the Eastern Mediterranean. 2022. URL:
https://iris.who.int/handle/10665/365838 [accessed 2024-01-24] 14]. The COVID-19
pandemic has exposed gaps in the health systems at multiple levels globally,
even in high-income countries with strong health systems. The Islamic Republic
of Iran, for example, which had a strong existing health care system, witnessed
the largest rate of infections and deaths [El-Jardali F. Impact of COVID-19 on
health systems in the Mediterranean. IEMed Mediterranean Yearbook 2021. 2021.
URL:
https://www.iemed.org/publication/impact-of-covid-19-on-health-systems-in-the-mediterranean/
[accessed 2024-01-24] 15].

The pandemic also highlighted the weak epidemiological capacity of the region
[Tackling infectious disease outbreaks in the Eastern Mediterranean Region.
World Health Organization Regional Office for the Eastern Mediterranean. 2020.
URL: https://applications.emro.who.int/docs/9789290224198-eng.pdf?ua=1 [accessed
2024-01-24] 13]. Data were generated but were not always analyzed, interpreted,
and used as evidence for action. Additionally, surveillance systems are
fragmented, with many being old and paper based [The work of WHO in the Eastern
Mediterranean Region: annual report of the regional director 2020. World Health
Organization Regional Office for the Eastern Mediterranean. 2021. URL:
https://www.emro.who.int/about-who/regional-dire ctor/rd-reports.html [accessed
2024-01-24] 16]. There is also an issue of trusting the shared information in
the region because of the underreporting of some countries or their hesitancy to
share data [Whittaker C, Walker PGT, Alhaffar M, Hamlet A, Djaafara BA, Ghani A,
et al. Under-reporting of deaths limits our understanding of true burden of
COVID-19. BMJ. 2021;375:n2239. [CrossRef] [Medline]17,COVID-19 pandemic response
in the Eastern Mediterranean Region: 2020 progress report of the incident
management support team. World Health Organization Regional Office for the
Eastern Mediterranean. 2021. URL:
https://applications.emro.who.int/docs/9789290226765-eng.pdf?ua=1 [accessed
2024-01-24] 18].

Several countries within the EMR encountered obstacles in addressing the
COVID-19 pandemic. For instance, Pakistan struggled due to its fragile health
care infrastructure, characterized by shortages of health care professionals,
hospital beds, and essential medical equipment necessary for treating patients
with COVID-19 [Khalid A, Ali S. COVID-19 and its challenges for the healthcare
system in Pakistan. Asian Bioeth Rev. 2020;12(4):551-564.
[https://europepmc.org/abstract/MED/32837562] [CrossRef] [Medline]19].
Similarly, Iran encountered difficulties in delivering crucial medical and
humanitarian supplies due to economic sanctions [Karimi A, Turkamani HS.
U.S.-imposed economic sanctions on Iran in the COVID-19 crisis from the human
rights perspective. Int J Health Serv. 2021;51(4):570-572.
[https://journals.sagepub.com/doi/abs/10.1177/00207314211024912?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub
0pubmed] [CrossRef] [Medline]20]. Additionally, Yemen and Syria faced
difficulties managing the pandemic within the context of ongoing conflict,
displacement, and the challenges of maintaining health care infrastructure and
resources [Alsabri M, Alhadheri A, Alsakkaf LM, Cole J. Conflict and COVID-19 in
Yemen: beyond the humanitarian crisis. Global Health. 2021;17(1):83.
[https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-021-00732-1]
[CrossRef] [Medline]21].

ACHIEVEMENTS AND LESSONS LEARNED

Despite the abovementioned challenges, there are many successes and lessons
learned. First, the EMR countries that succeeded in facing COVID-19 had
high-level political commitment and high-level multisectoral coordination.
Often, the heads of state or prime ministers led the multisectoral committees or
crisis committees, and this is an example of leadership. Also, regional
laboratories were quick to mobilize and build on previous infrastructure and
systems, such as those dedicated to influenza, polio, and other communicable
diseases [Al-Mandhari AS, Brennan RJ, Abubakar A, Hajjeh R. Tackling COVID-19 in
the Eastern Mediterranean Region. Lancet. 2020;396(10265):1786-1788.
[https://europepmc.org/abstract/MED/33220856] [CrossRef]
[Medline]10,Contributions of the polio network to the COVID-19 response: turning
the challenge into an opportunity for polio transition. World Health
Organization. 2020. URL: https://www.who.int/publications/i/item/9789240011533
[accessed 2024-01-24] 22]. Polio response teams were used in the field and
played major roles in COVID-19 vaccination and community mobilization
[Contributions of the polio network to the COVID-19 response: turning the
challenge into an opportunity for polio transition. World Health Organization.
2020. URL: https://www.who.int/publications/i/item/9789240011533 [accessed
2024-01-24] 22]. Before the COVID-19 pandemic, the region had expanded its
influenza network due to the influenza pandemic potential. The WHO supported the
strengthening of influenza surveillance and testing for respiratory infections.
As a result, most countries had the capacity to test for respiratory viruses in
a timely manner, allowing the successful use of reverse transcription polymerase
chain reaction (RT-PCR) tests for SARS-CoV-2 testing in influenza labs and
national influenza centers [Health emergency preparedness after COVID-19:
building for the future. World Health Organization. 2021. URL: https:/ /www.
who.int/ about/ accountability/ results/ who-results-report-2020-mtr/
featured-story-preparedness. %5BAccessed [accessed 2024-01-24] 23]. RT-PCR
capacity for SARS-CoV-2 was expanded quickly to subnational levels across all 22
EMR countries. The WHO ensured the quality of SARS-CoV-2 testing by encouraging
all countries to participate in the external quality assessment program for
national and subnational laboratories. The WHO’s logistics hub in Dubai, UAE,
which is the WHO’s largest repository of medical equipment and supplies
globally, was also an asset to the region as it moved thousands of tons of
supplies to the world and the region, including millions of RT-PCR tests
[Alsuwaidi AR, Al Hosani FI, ElGhazali G, Al-Ramadi BK. The COVID-19 response in
the United Arab Emirates: challenges and opportunities. Nat Immunol.
2021;22(9):1066-1067. [https://www.nature.com/articles/s41590-021-01000-5]
[CrossRef] [Medline]24].

Due to a lack of high-quality data, epidemiologists had to consider a variety of
indicators [Backhaus A. Common pitfalls in the interpretation of COVID-19 data
and statistics. Inter Econ. 2020;55(3):162-166.
[https://europepmc.org/abstract/MED/32536714] [CrossRef] [Medline]25], including
testing rates and measuring the burden on health systems-related indicators,
such as hospital occupancy, intensive care unit occupancy, bed occupancy rates,
and case fatality ratios. These indicators allowed the WHO to estimate the
extent of the pandemic and the COVID-19 response. A very high case fatality
ratio could mean that the country is not reporting all cases, has a weak testing
capacity or strategy, is poorly managing cases, or may have different case
fatality definitions. Therefore, it is important to not only report data but to
also interpret it for evidence-based policy making [Backhaus A. Common pitfalls
in the interpretation of COVID-19 data and statistics. Inter Econ.
2020;55(3):162-166. [https://europepmc.org/abstract/MED/32536714] [CrossRef]
[Medline]25].

Limited testing capacity, supplies, and infrastructure were other reasons
countries did not provide accurate data [COVID-19 crisis response in MENA
countries. Organisation for Economic Co-operation and Development. 2020. URL:
https:/ /www. oecd.org/ coronavirus/ policy-responses/
covid-19-crisis-response-in-mena-countries-4b366396/ [accessed 2024-01-24] 26].
For example, Somalia and Djibouti did not have RT-PCR capacity at the beginning
of the pandemic; however, they managed to procure the needed equipment
[Responding to COVID-19 in Somalia: progress report: 6 months of resilience and
strength. WHO Regional Office for the Eastern Mediterranean. 2020. URL:
https://applications.emro.who.int/docs/9789290223559-eng.pdf?ua=1 [accessed
2024-01-24] 27,Elhakim M, Tourab SB, Zouiten A. COVID-19 pandemic in Djibouti:
epidemiology and the response strategy followed to contain the virus during the
first two months, 17 March to 16 May 2020. PLoS One. 2020;15(12):e0243698.
[https://dx.plos.org/10.1371/journal.pone.0243698] [CrossRef] [Medline]28].
Enhanced data reporting was significantly increased due to improved laboratory
capacity in the region, both for testing and sequencing. The pandemic was an
opportunity to build capacity in genome sequencing, enabling the monitoring of
the circulation of SARS-CoV-2 variants. Almost 15 countries in the region have
genome sequencing capacity and are able to support other countries without such
capacity [The work of WHO in the Eastern Mediterranean Region: annual report of
the regional director 2020. World Health Organization Regional Office for the
Eastern Mediterranean. 2021. URL:
https://www.emro.who.int/about-who/regional-dire ctor/rd-reports.html [accessed
2024-01-24] 16,COVID-19: WHO EMRO biweekly situation report #11. World Health
Organization. 2021. URL:
https://www.emro.who.int/images/stories/coronavirus/documents/covid_19_bi_weekly_sitrep_11.pdf?ua=1
[accessed 2024-01-24] 29].

The pandemic resulted in several innovations, including apps, telemedicine,
hotlines, and e-clinics. More countries in the region used innovative solutions
to improve data collection, analysis, and dissemination to build strong
surveillance capacities and bridge information gaps. For example, using phone
companies’ mobility data to measure whether social interventions are
successfully implemented allowed for a better understanding of people’s mobility
patterns [Grantz KH, Meredith HR, Cummings DAT, Metcalf CJE, Grenfell BT, Giles
JR, et al. The use of mobile phone data to inform analysis of COVID-19 pandemic
epidemiology. Nat Commun. 2020;11(1):4961.
[https://doi.org/10.1038/s41467-020-18190-5] [CrossRef] [Medline]30]. Another
innovation included oxygen production and supply, as some countries, such as
Somalia, had no oxygen plants and no capacity to produce oxygen [Oxygen saves
lives in Somalia on the path to UHC: country case study from the 2021 progress
report on the implementation of the Global Action Plan for healthy lives and
well-being for all (GAP). World Health Organization. 2021. URL:
https://www.who.int/news-room/feature-stories/detail/somalia2021.%5BAccessed
[accessed 2024-01-24] 31]. Since Somalia did not have electric power, especially
at the subnational level, they built small solar plants and used solar power to
generate oxygen [Oxygen saves lives in Somalia on the path to UHC: country case
study from the 2021 progress report on the implementation of the Global Action
Plan for healthy lives and well-being for all (GAP). World Health Organization.
2021. URL:
https://www.who.int/news-room/feature-stories/detail/somalia2021.%5BAccessed
[accessed 2024-01-24] 31]. Similarly, there was a lot of stigma around mental
health in the region [Eaton J, Rahman A, Gater R, Saxena S, Hammerich A, Saeed
K. From adversity to resilience in the COVID-19 era: strengthening mental health
systems in the Eastern Mediterranean Region. East Mediterr Health J.
2020;26(10):1148-1150.
[https://applications.emro.who.int/emhj/v26/10/1020-3397-2020-2610-1148-1150-eng.pdf]
[CrossRef] [Medline]32]. However, during the pandemic, 17 countries
(Afghanistan, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya,
Morocco, Pakistan, Palestine, Qatar, Saudi Arabia, Tunisia, UAE, and Yemen)
incorporated mental health and psychosocial support within their emergency
response plans by establishing hotlines, e-clinic consultations, and platforms
to serve the remote areas [Mental health and psychosocial support. World Health
Organization. 2023. URL: https://www.emro.who.int/mhps/mental_
health_professionals.html.%5BAccessed [accessed 2023-09-21] 33-Progress report
on scaling up mental health care: a framework for action. World Health
Organization Regional Office for the Eastern Mediterranean. 2021. URL:
https://applications.emro.who.int/docs/EMRC68INFDOC3-eng.pdf [accessed
2024-01-24] 35].

A total of 17 EMR countries (Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait,
Lebanon, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Sudan, Syria Arab
Republic, Tunisia, UAE, and Yemen) banned waterpipe smoking outdoors; however,
this was temporary [WHO report on the global tobacco epidemic 2021: addressing
new and emerging products. World Health Organization. 2021. URL:
https://www.who.int/publications/i/item/9789240032095 [accessed 2024-01-24] 36].
In terms of the next steps and moving forward, the region needs to take
advantage of these innovations and opportunities to enhance preparedness because
they are feasible if there is the right commitment and policies.

There was a need for epidemiological modeling to predict the potential impact of
public health and social measures, so the WHO established a modeling support
team and used data from countries that requested this assistance to help model
the progression of the pandemic [Adib K, Hancock PA, Rahimli A, Mugisa B,
Abdulrazeq F, Aguas R, et al. A participatory modelling approach for
investigating the spread of COVID-19 in countries of the Eastern Mediterranean
Region to support public health decision-making. BMJ Glob Health.
2021;6(3):e005207.
[https://gh.bmj.com/lookup/pmidlookup?view=long&pmid=33762253] [CrossRef]
[Medline]37]. COVID-19 also increased interest in epidemiological studies on the
ground, including seroprevalence studies to understand population immunity
levels or risk factors. The WHO provides standard protocols for seroprevalence
studies [Coronavirus disease (COVID-19) technical guidance: the unity studies:
early investigation protocols. World Health Organization. 2019. URL: https:/
/www. who.int/ emergencies/ diseases/ novel-coronavirus-2019/
technical-guidance/ early-inves tigations. %5BAccessed [accessed 2024-01-24]
38]. The WHO also worked with countries on vaccine effectiveness studies, and
many countries took part in clinical trials on vaccines and therapeutics.
Through this, countries built their capacities, which is helpful for
preparedness [The work of WHO in the Eastern Mediterranean Region: annual report
of the regional director 2020. World Health Organization Regional Office for the
Eastern Mediterranean. 2021. URL:
https://www.emro.who.int/about-who/regional-dire ctor/rd-reports.html [accessed
2024-01-24] 16].

The positive side of the COVID-19 pandemic was that it revealed many of the gaps
and weaknesses in the public health system and how to bridge these gaps [Rose
SM, Paterra M, Isaac C, Bell J, Stucke A, Hagens A, et al. Analysing COVID-19
outcomes in the context of the 2019 Global Health Security (GHS) index. BMJ Glob
Health. 2021;6(12):e007581.
[https://gh.bmj.com/lookup/pmidlookup?view=long&pmid=34893478] [CrossRef]
[Medline]7]. The gaps include the nonflexibility of the health systems,
workforce shortages, health service fragmentation (primary care, secondary care,
and public health), and designs of health facilities. Additionally,
misinformation was a significant challenge during the pandemic, and the outdated
“disease model” adopted by most health systems does not meet the current needs
of the population [Primary health care: closing the gap between public health
and primary care through integration. World Health Organization. 2018. URL:
https://iris.who.int/handle/10665/326458 [accessed 2024-01-24] 39]. Indeed,
access and use of essential health services such as maternal and neonatal care
and routine immunization were highly affected [Maintaining essential health
services: operational guidance for the COVID-19 context: interim guidance, 1
June 2020. World Health Organization. 2020. URL:
https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services
-2020.2 [accessed 2024-01-24] 40]. The WHO conducted 3 surveys [The impact of
the COVID-19 pandemic on noncommunicable disease resources and services: results
of a rapid assessment. World Health Organization. 2020. URL:
https://www.who.int/publications/i/item/9789240010291 [accessed 2024-01-24]
41,Presentation of preliminary results of 2021 assessment on NCD service
disruption during COVID-19 pandemic. World Health Organization. 2021. URL:
https:/ /www. who.int/ publications/ m/ item/
presentation-of-preliminary-results-of-2021-assess
ment-on-ncd-service-disruption-during-covid-19-pandemic. %5BAccessed [accessed
2024-01-24] 42] to measure the global disruption of essential health services.
The first, conducted between May 2020 and July 2020, showed that the EMR was the
WHO region with the highest disruption in health services due to health center
closures, stigma, and fear of transmission [The impact of the COVID-19 pandemic
on noncommunicable disease resources and services: results of a rapid
assessment. World Health Organization. 2020. URL:
https://www.who.int/publications/i/item/9789240010291 [accessed 2024-01-24] 41].
The WHO worked closely with countries and published guidelines to address the
impact of the pandemic on essential health services, including how primary
health care workers should be trained to screen for COVID-19 [Maintaining
essential health services: operational guidance for the COVID-19 context:
interim guidance, 1 June 2020. World Health Organization. 2020. URL:
https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services
-2020.2 [accessed 2024-01-24] 40]. The same survey conducted a year later, in
April 2021, demonstrated a significant improvement in the continuity of
essential health services, although they were still disrupted [Presentation of
preliminary results of 2021 assessment on NCD service disruption during COVID-19
pandemic. World Health Organization. 2021. URL: https:/ /www. who.int/
publications/ m/ item/ presentation-of-preliminary-results-of-2021-assess
ment-on-ncd-service-disruption-during-covid-19-pandemic. %5BAccessed [accessed
2024-01-24] 42].

COVID-19 VACCINATION

With regard to vaccination, increasing vaccine coverage is a WHO priority for
some EMR countries. In less than a year, effective vaccines were developed,
tested, produced, and administered, which is an unprecedented success in the
history of infectious diseases [Abubakar A, Al-Mandhari A, Brennan R, Chaudhri
I, Elfakki E, Fahmy K, et al. Efforts to deploy COVID-19 vaccine in the WHO
Eastern Mediterranean Region within the first 100 days of 2021. East Mediterr
Health J. 2021;27(5):433-437.
[https://applications.emro.who.int/EMHJ/V27/05/1020-3397-2021-2705-433-437-eng.pdf]
[CrossRef] [Medline]43]. The goal of the WHO for the EMR is to reach 40%
coverage by the end of 2021 and 70% by mid-2022. A total of 9 countries
(Bahrain, Iran, Jordan, Kuwait, Morocco, Oman, Qatar, Saudi Arabia, Tunisia, and
the UAE) have so far achieved the end-year goal; however, 6 conflict-affected
countries (Afghanistan, Djibouti, Somalia, Sudan, Syria, and Yemen) are at less
than 10% coverage as of December 2021 [Statement by WHO’s regional director for
the Eastern Mediterranean on COVID-19. World Health Organizaton. 2021. URL:
https:/ /www. emro.who.int/ media/ news/
who-regional-directors-statement-on-covid-19-22-december-2021. html [accessed
2024-01-24] 44,Hasan Q, Elfakki E, Fahmy K, Mere O, Ghoniem A, Langar H, et al.
Inequities in the deployment of COVID-19 vaccine in the WHO Eastern
Mediterranean Region, 2020-2021. BMJ Glob Health. 2022;7(Suppl 4):e008139.
[https://gh.bmj.com/lookup/pmidlookup?view=long&pmid=35764354] [CrossRef]
[Medline]45]. As of October 21, 2023, a total of 13,533,465,652 vaccine
doses had been administered worldwide. Globally, the persons vaccinated with a
complete primary series per 100 population and the persons vaccinated with at
least 1 booster or additional dose per 100 population were 66.18 and 31.9,
respectively. In the EMR, the respective figures were 51.61 and 19.0,
respectively. Within the EMR, the figures were lower, with 51.61 individuals per
100 population having completed a primary series and 19.0 individuals per 100
population having received at least one booster or an additional dose [WHO
coronavirus (COVID-19) dashboard. World Health Organization. 2023. URL:
https://covid19.who.int/table [accessed 2023-11-02] 46].

RECOMMENDATIONS FROM THE WORLD HEALTH ASSEMBLY THAT BENEFIT THE EMR

Many committees presented their recommendations during the last World Health
Assembly, including the Independent Panel for Pandemic Preparedness (established
by the WHO and Global Preparedness Monitoring Board) and the Independent
Oversight Committee. The committees came up with over 200 recommendations
[WHA74. World Health Organization. 2021. URL:
https://apps.who.int/gb/e/e_wha74.html [accessed 2024-01-24] 47], but some of
the key recommendations and lessons learned that will benefit the EMR include
the following:

1. The importance of political leadership is what made a big difference in the
countries that did better than others.
2. Community engagement and community trust are important to prevent the
pandemic’s spread and major economic collapse.
3. “No one is safe until everyone is safe” is not just a slogan, because if any
country does not implement prevention measures, the virus can travel to
other areas of the world.
4. The return on investment in health security is immense. How long does it
take to receive a return on your investment? How much do we need to invest
in pandemics? There were estimates done, and an early estimate of the cost
of the pandemic was about US $11 trillion up to the middle of 2021; another
US $10 trillion has been added since then. However, if you invest in
preparedness, it will cost US $5 per person per year, so for a global
population of 8 billion, it will only cost US $40 billion. To prompt action
from policy makers, it is essential to present them with these monetary
figures.

RESHAPING PUBLIC HEALTH

During the COVID-19 pandemic, different reasons have called on the EMR countries
to reshape their public health. Many countries in the EMR are experiencing new
dynamic population growth due to birth, migration, and aging populations.
Additionally, the region is facing what is termed a “brain drain.” For example,
Egypt has a shortage of doctors because 65% of Egyptian doctors leave the
country to seek opportunities abroad. Additionally, the world is witnessing
continuous technological advances in the biological, physical, and digital
spheres [Kabbash I, El-Sallamy R, Zayed H, Alkhyate I, Omar A, Abdo S. The brain
drain: why medical students and young physicians want to leave Egypt. East
Mediterr Health J. 2021;27(11):1102-1108. [https://doi.org/10.26719/emhj.21.050]
[CrossRef] [Medline]48].

The burden of the disease in the region should also be considered. The Institute
of Health Metrics studied the number of deaths per 100,000 in 2019, per disease
per country, and showed that besides the known causes of death such as
communicable disease, noncommunicable disease, etc, the region has witnessed
other causes of mortality due to violence, mainly in Iraq, Syria, and Yemen.
Accordingly, in the region, the leading cause of death from 2000-2019 was
related to collective violence and interventions [GBD 2015 Eastern Mediterranean
Region Collaborators. Danger ahead: the burden of diseases, injuries, and risk
factors in the Eastern Mediterranean Region, 1990-2015. Int J Public Health.
2018;63(Suppl 1):11-23. [https://europepmc.org/abstract/MED/28776238] [CrossRef]
[Medline]49].

Furthermore, there is no specific data on public health personnel in the region.
Data are mainly available on medical health workers, and Saudi Arabia and Sudan
are the only 2 countries with registered public health professionals in the Arab
world. On the other hand, only a small proportion of the public health workforce
(public health consultants) are fully trained with 4-5 years of competency-based
training, and around one-quarter (public health practitioners) are qualified in
public health but without structured training. Therefore, the public workforce
in the region needs to be tackled in terms of skills, experience, and
foundational knowledge [Al-Mohaithef M, Javed NB, Elkhalifa AM, Tahash M,
Chandramohan S, Hazazi A, et al. Evaluation of public health education and
workforce needs in the kingdom of Saudi Arabia. J Epidemiol Glob Health.
2020;10(1):96-106. [https://europepmc.org/abstract/MED/32175716] [CrossRef]
[Medline]50].

Investments in primary health care to mitigate the risks of future pandemics and
to maintain accessibility and delivery of essential health services during
emergencies [Maintaining essential health services: operational guidance for the
COVID-19 context: interim guidance, 1 June 2020. World Health Organization.
2020. URL:
https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services
-2020.2 [accessed 2024-01-24] 40]; investment in the health workforce, including
training, mobilization, and redistribution to sustain high-quality essential
health services delivery; and data management and surveillance are key elements
of a successful response [The work of WHO in the Eastern Mediterranean Region:
annual report of the regional director 2020. World Health Organization Regional
Office for the Eastern Mediterranean. 2021. URL:
https://www.emro.who.int/about-who/regional-dire ctor/rd-reports.html [accessed
2024-01-24] 16]. These actions and initiatives can also expand and reinforce
health system capacities, providing an opportunity within the COVID-19 response
for countries to reshape their health workforce and services and improve health
security for future health emergencies [Rose SM, Paterra M, Isaac C, Bell J,
Stucke A, Hagens A, et al. Analysing COVID-19 outcomes in the context of the
2019 Global Health Security (GHS) index. BMJ Glob Health. 2021;6(12):e007581.
[https://gh.bmj.com/lookup/pmidlookup?view=long&pmid=34893478] [CrossRef]
[Medline]7,Maintaining essential health services: operational guidance for the
COVID-19 context: interim guidance, 1 June 2020. World Health Organization.
2020. URL:
https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services
-2020.2 [accessed 2024-01-24] 40,Petrey A, Baisden T. COVID-19: make it the last
pandemic: the independent panel for pandemic preparedness and response. NZ Sci
Rev. 2021;77(1-2):19. [https://ojs.victoria.ac.nz/nzsr/article/view/7752]
[CrossRef]51].

Integrating public health into primary health care is an essential approach to
reshaping public health and achieving preparedness. Primary care is the first
point of contact for the community with the health system; it must be available
24 hours a day and should provide services in a continuous, personalized, and
holistic way. Unfortunately, in many settings, primary health care focuses on
treating the illness rather than preventing it. Therefore, integrating public
health functions into the primary health care system is highly significant to
ensure disease prevention, health promotion and protection, and a proper
response to threats [Primary health care: closing the gap between public health
and primary care through integration. World Health Organization. 2018. URL:
https://iris.who.int/handle/10665/326458 [accessed 2024-01-24] 39].

Accordingly, 6 models were identified by the WHO technical series on primary
care called “Closing the gaps between public health and primary care through
integration” to attain the integration of public health into primary health care
and provide a tool to help countries be prepared during threats and emergencies.
This, in turn, focuses the services on the population’s needs, achieving a
person-centered approach. These models can be applied either individually or in
combination, depending on the flexibility of the health systems, and they are
titled as follows [Primary health care: closing the gap between public health
and primary care through integration. World Health Organization. 2018. URL:
https://iris.who.int/handle/10665/326458 [accessed 2024-01-24] 39]:

1. Public health services are integrated into primary care
2. Public health professionals and primary care providers are working together
3. Comprehensive and proactive benefit packages that include public health
4. Primary care services within public health settings
5. Building public health incentives in primary care
6. Multidisciplinary training of primary care staff in public health

With a focus on the first model, integrating public health professionals into
primary care, where they are involved in many public health functions, can be
easily achieved progressively. It is essential to understand that the primary
health team is complex and should not only include family medicine and freshly
graduated doctors; rather, it should include the public health workforce, such
as Field Epidemiology Training Program professionals. Additionally, building the
competencies of the public health workforce is crucial because, even though the
region has 2 public health academies—the International Academy of Public Health
and Weqaya Public Health Academy—most of the workforce is untrained [Primary
health care: closing the gap between public health and primary care through
integration. World Health Organization. 2018. URL:
https://iris.who.int/handle/10665/326458 [accessed 2024-01-24] 39,Al-Mohaithef
M, Javed NB, Elkhalifa AM, Tahash M, Chandramohan S, Hazazi A, et al. Evaluation
of public health education and workforce needs in the kingdom of Saudi Arabia. J
Epidemiol Glob Health. 2020;10(1):96-106.
[https://europepmc.org/abstract/MED/32175716] [CrossRef] [Medline]50].

Many aspects need to be considered when reshaping public health: (1) financial
allocation and establishing an independent national body for public health; (2)
investing in public health laboratories, whole genome sequencing, public health
analysis such as artificial intelligence, real-world data, real-world evidence,
research, and people; and (3) teaching for precision public health where people
are the center of health.

A hard lesson learned from this pandemic is that countries should not be
dependent on other countries to provide them with essential medicines and
vaccines. It is of great importance to strengthen health systems and work toward
universal health coverage and health security, as Dr Tedros Adhanom Ghebreyesus,
the Director General of the WHO, says that “Health security and global health
coverage are two sides of the same coin” [COVID-19 virtual press conference
transcript - 21 October 2021. World Health Organization. 2021. URL: https:/
/www. who.int/ publications/ m/ item/
covid-19-virtual-press-conference-transcript---21-october-2021 [accessed
2024-01-24] 52]. Capacity building is the way forward, including capacity
building in integrated disease surveillance and in ensuring the continuity of
health services. Additionally, engaging all relevant stakeholders, accelerating
vaccine rollout, prioritizing COVID-19 response, and investing in emergency
preparedness and the health systems are essential.

CONCLUSION

The political instability and fragile health systems in some of the EMR
countries have hampered the effectiveness and efficiency of the strategies
adopted to combat the COVID-19 pandemic. The EMR IMST for COVID-19 pillars was
critical to the WHO’s role in coordinating the response during the pandemic.
Although multiple challenges affect the transmission of the virus in this
diverse region, there were many successes, and it is of great importance to
build on these successes and focus on building the human and regional capacities
as a way forward. Furthermore, focusing on public health is a key factor in
responding to pandemics and biological threats, with COVID-19 being a clear
example. The current health system faces many gaps and challenges, which can be
overcome by adopting different approaches—specifically, integrating public
health into primary care as an essential approach to reshape public health in
the region and be prepared against threats and emergencies.

RECOMMENDATIONS AND AREAS OF IMPROVEMENT

Several areas of improvement need to be taken into consideration at both the
national and regional levels to improve the response to future threats and
pandemics. Countries should develop and update a multisectoral emergency
preparedness plan and enhance government and political leadership capacity
toward biological threats. They must strengthen their health systems and work
toward universal health coverage and security. This can be achieved by
integrating public health into primary care as an essential approach to
reshaping public health through adopting 1 or more of the 6 models of
integration identified by the WHO. Moreover, there is a need to invest in
building human capacities, including epidemiologists; emergency responders;
community health workers; health economists; communication specialists; and most
crucially, health leaders. Countries should also work toward community
engagement and community trust by assessing people’s needs and engaging them in
the decision-making process because public health is about people, for people,
and by people. Finally, analyzing and interpreting collected data and using it
by policy makers is essential for action and decision-making.

On the other hand, different actions need to be taken at the regional level to
effectively control the spread of the pandemic. As the COVID-19 pandemic
demonstrated, certain countries have greater capacities than others in the
region and must facilitate cooperation, solidarity, and support. High-income
countries, for example, should ensure vaccine sharing, equity, and distribution
with low-income countries. Moreover, countries in the region can implement twin
programs where human resources can be shared across countries.

CONFLICTS OF INTEREST

None declared.

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--------------------------------------------------------------------------------

‎

ABBREVIATIONS

EMR: Eastern Mediterranean RegionIMST: Incident Management Support TeamRT-PCR:
reverse transcription polymerase chain reactionUAE: United Arab EmiratesWHO:
World Health Organization

--------------------------------------------------------------------------------

Edited by A Mavragani, T Sanchez; submitted 23.06.22; peer-reviewed by DK Yon, S
El Khamlichi; comments to author 13.09.23; revised version received 24.09.23;
accepted 21.11.23; published 15.02.24

©Lara Kufoof, Rana Hajjeh, Mohannad Al Nsour, Randa Saad, Victoria Bélorgeot,
Abdinasir Abubakar, Yousef Khader, Salman Rawaf. Originally published in JMIR
Public Health and Surveillance (https://publichealth.jmir.org), 15.02.2024.

This is an open-access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),
which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in JMIR Public Health and
Surveillance, is properly cited. The complete bibliographic information, a link
to the original publication on https://publichealth.jmir.org, as well as this
copyright and license information must be included.

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Please cite as:

Kufoof L, Hajjeh R, Al Nsour M, Saad R, Bélorgeot V, Abubakar A, Khader Y, Rawaf
S
Learning From COVID-19: What Would It Take to Be Better Prepared in the Eastern
Mediterranean Region?
JMIR Public Health Surveill 2024;10:e40491
doi: 10.2196/40491 PMID: 38359418 PMCID: 10871069

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