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COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...
COVID-19 STRATEGIC       Reinforcing the collective
PREPAREDNESS AND         readiness and response
                         in the WHO Eastern
    RESPONSE PLAN        Mediterranean Region
          2021 EDITION
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...
COVID-19 STRATEGIC       Reinforcing the collective
PREPAREDNESS AND         readiness and response
                         in the WHO Eastern
    RESPONSE PLAN        Mediterranean Region
          2021 EDITION
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...
WHO Library Cataloguing in Publication Data

Names: World Health Organization. Regional Office for the Eastern Mediterranean
Title: COVID-19 strategic preparedness and response plan: reinforcing the collective readiness and response in the WHO Eastern
Mediterranean Region, 2021 edition / World Health Organization. Regional Office for the Eastern Mediterranean
Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2021
Identifier: WHO-EM/CSR/383/E
Subjects: COVID-19 - epidemiology | Betacoronavirus | Disease Outbreaks | Disaster Planning | Civil Defense | Health Information
Management | Eastern Mediterranean Region
Classification: NLM WC 506.4

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Document WHO-EM/CSR/383/E

COVID-19 strategic preparedness and response plan – 2021 edition                                                                 iv
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...

Foreword from the Regional Director                                                     vi
1. Purpose of the document                                                              1
2. Global situation                                                                     2
3. Situation in the Eastern Mediterranean Region                                         4
   3.1 Epidemiological situation                                                         4
        3.1.1 Evolution of the COVID-19 epidemic in the Region                           4
        3.1.2 Current situation in the Region (as at 28 February)                        6
   3.2 Risk assessment of COVID-19 in the Region                                         9
   3.3 Operational context                                                              10
        3.3.1 Humanitarian settings and vulnerable groups                               10
        3.3.2 Effects on health systems and essential services                          11
        3.3.3 Social and economic effects                                               12
        3.3.4 Public health and social measures                                         12
        3.3.5 Vaccines                                                                  13
        3.3.6 Regional contribution to global research, development and innovation      14
   3.4 Regional collaboration and coordination                                          14
4. Key lessons learned for leveraging the COVID-19 response in the Region in 2021       16
   4.1 Partnership and coordination                                                     16
   4.2 Communications (external and internal)                                           16
   4.3 Operations support and logistics                                                 16
   4.4 Health operations and technical expertise                                        17
   4.5 Health information management and surveillance                                   17
   4.6 International Health Regulations and social measures                             18
   4.7 Research and knowledge management                                                18
   4.8 Essential health services and systems                                            18
   4.9 COVID-19 vaccine                                                                 19
5. Beyond COVID-19                                                                      20
6. Strategic preparedness and response plan for COVID-19 in the Eastern Mediterranean   21
   Region in 2021
   6.1 Goal                                                                             21
   6.2 Regional strategic objectives                                                    21
Areas of work and priority activities for COVID-19 preparedness and response in 2021    23
7. Budget summary by pillar (2021)                                                      32
8. Monitoring and evaluation                                                            33
Annex 1.                                                                                34
COVID-19 SPRP M&E framework for 2021: Proposed indicators

WHO EASTERN MEDITERRANEAN REGION                                                        v
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...

Over the past year, all three levels of the World Health           Based on the experience of the past year, we will also
Organization (WHO) have worked with countries to provide           aggressively scale up fragmented data systems, improve
guidance and oversight to ensure a streamlined and                 data sharing by countries, and strengthen infection
coordinated response to COVID-19 by national authorities,          prevention and control policies. This will be key in light
partners, communities and the private sector. The                  of the growing number of variants appearing around the
Organization has built experience and gained insights into         world, which need to be identified and detected. The longer
what worked best and what did not work so well in the              the pandemic goes on, the more such variants are expected
COVID-19 strategic preparedness and response plan for              to emerge, perhaps undermining the effectiveness of the
2020.                                                              vaccines we have just started to celebrate rolling out.

Looking ahead, and building on this wealth of experience,          The coming period in our Region will be challenging for
the regional COVID-19 strategic preparedness and response          us all, and making sure that we reduce fear, stigma and
plan for 2021 lays out the coordinated action required             hesitancy will be critical to our efforts. One year into
at national and regional levels to overcome challenges,            the pandemic, we understand that COVID-19 fatigue has
address inequities and work towards ending the COVID-19            set in, and that we now face a new threat – not just of
pandemic.                                                          misinformation and disinformation, but of communities
                                                                   desperate to go back to pre-COVID-19 times.
The revised plan brings together the collective actions
needed to suppress transmission, reduce exposure, address          In addition to the public health risks that the virus presents,
misinformation and disinformation, protect the vulnerable          we are understandably concerned about the economic,
through vaccination, reduce mortality and morbidity, and           social and political costs of the pandemic. We also should
accelerate equitable access to new COVID-19 vaccines and           not forget other emergencies in our Region – crises that are
tools. The Incident Management Support Team (IMST) will            characterized by years of conflict, and the consequent social
continue to ensure coordination, planning, financing and           and political disruptions that have further devasted the lives
monitoring for the response across all countries and at a          of millions.
regional level, providing operational support, including for
logistics and supply chains, as well advocating for countries      We cannot defeat COVID-19 as a divided region, or by
to conduct research and innovation.                                politicizing the pandemic. Using “Health as a Bridge to
                                                                   Peace” we hope that our shared goal of saving lives and
COVID-19 vaccines are finally within reach. To work towards        ending the pandemic will allow for countries to come
defeating COVID-19, we need open, fair and equitable               together to work for the common good. COVID-19 has
sharing of vaccines. But even after we overcome the initial        shown us that the virus can only be beaten through
challenges of limited supplies, uneven access and staggered        solidarity, coordination and collaboration, allowing us to
roll-out, a range of well-designed programme strategies will       achieve our regional vision of Health for All, by All.
be needed to drive up acceptance and uptake of vaccines in
the countries of the Region.
                                                                   Dr Ahmed Al-Mandhari
                                                                   WHO Regional Director for the Eastern Mediterranean

COVID-19 strategic preparedness and response plan – 2021 edition                                                                vi
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...

On 30 January 2020, the coronavirus disease 2019                   the Region’s Vision 2023, and WHO’s Thirteenth General
(COVID-19) outbreak was declared a public health                   Programme of Work 2019–2023.
emergency of international concern. Four days later, the
World Health Organization (WHO) global COVID-19 strategic          Building on successful strategies in 2020 and lessons
preparedness and response plan (SPRP) was published,               learned, this document was developed by the WHO Regional
followed by the first edition of the SPRP for the Eastern          Office for the Eastern Mediterranean to help to guide the
Mediterranean Region to accelerate regional readiness.             public health response to COVID-19 in the Region in 2021. It
The present document is the third edition of the regional          sets the regional strategic priorities that WHO will support in
SPRP, serving as an update to the July 2020 edition and            2021 to reinforce collective readiness and response to the
aligned with the most recent version of the global SPRP,           COVID-19 pandemic.

The WHO Eastern Mediterranean Region

COVID-19 strategic preparedness and response plan – 2021 edition                                                                1
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...

  On 31 December 2019, WHO was alerted to several                                                                                                                                                                                                                                                                                         Africa and 1.4% from the Western Pacific. The country
  cases of pneumonia of unknown origin in Wuhan, Hubei                                                                                                                                                                                                                                                                                    most affected is the United States of America with 28
  province, China. One week later, on 7 January 2020,                                                                                                                                                                                                                                                                                     174 978 cumulative cases and 506 760 associated deaths
  Chinese authorities confirmed that they had identified a                                                                                                                                                                                                                                                                                (CFR 1.8%), followed by India which reported a total of 11
  new type of coronavirus as the cause of the pneumonia                                                                                                                                                                                                                                                                                   096 731 cases and 157 051 associated deaths (CFR 1.4%)
  cluster. The novel coronavirus belongs to the same family of                                                                                                                                                                                                                                                                            and Brazil with 10 455 630 cases and 252 835 associated
  coronaviruses that cause illnesses ranging from the common                                                                                                                                                                                                                                                                              deaths (CFR 2.4%). The highest incidence rates are reported
  cold to more severe diseases such as Middle East respiratory                                                                                                                                                                                                                                                                            from Andorra (14 confirmed cases per 100 population),
  syndrome (MERS) and severe acute respiratory syndrome                                                                                                                                                                                                                                                                                   followed by Montenegro and the Czech Republic (both
  (SARS). The illness caused by this novel coronavirus is                                                                                                                                                                                                                                                                                 with 13 confirmed cases per 100 population) and Gibraltar
  referred to as coronavirus disease 2019 (COVID-19).                                                                                                                                                                                                                                                                                     (12 confirmed cases per 100 population). The highest
                                                                                                                                                                                                                                                                                                                                          CFRs are reported in Yemen (27.7%) followed by Mexico
  Since January 2020, COVID-19 has spread across the world,                                                                                                                                                                                                                                                                               (8.9%), while the lowest CFRs are reported from Singapore
  disrupting even the most resilient health systems and                                                                                                                                                                                                                                                                                   (0.05%) and Mongolia (0.08%). Globally, 144 countries
  services. Global incidence rates slowed down after the                                                                                                                                                                                                                                                                                  have self-reported community transmission while 43
  implementation of public health and social measures,                                                                                                                                                                                                                                                                                    countries have self-reported sporadic or no cases.1 The
  but with premature lifting of some social measures and                                                                                                                                                                                                                                                                                  overall epidemiological data vary among WHO regions,
  the probable impact of the emergence of variants of                                                                                                                                                                                                                                                                                     countries and territories, and within countries. The observed
  concern, incidence increased at the end of 2020 and into                                                                                                                                                                                                                                                                                trends may not always represent the evolving and real
  2021. As at 28 February 2021, over 113 million COVID-19                                                                                                                                                                                                                                                                                 epidemiological situations due to incomplete reporting.
  cases have been reported globally, with over 2.5 million                                                                                                                                                                                                                                                                                Countries have different capacities in detection, confirmation
  reported deaths (case fatality ratio (CFR) 2.2%) (Fig. 1).                                                                                                                                                                                                                                                                              and reporting of COVID-19 cases. The response capacities in
  Of these cases, 44.5% were reported from the Region of                                                                                                                                                                                                                                                                                  terms of case investigation, contact tracing, quarantine, case
  the Americas, 34.1% from Europe, 11.9% from South-East                                                                                                                                                                                                                                                                                  management and isolation, among other factors, contribute
  Asia, 5.6% from the Eastern Mediterranean, 2.5% from                                                                                                                                                                                                                                                                                    to the varying incidence and mortality rates.

     Fig. 1. Global and regional trends in COVID-19 cases, 28 February 2021

                                                                                                    Eastern Mediterranean Region
                                                                                                    African Region
                                                                                                    The Americas
                                                                                                    European Region
Number of cases (in thousands)

                                                                                                    South-East Asia Region
                                                                                                    Western Pacific Region




                   WHO coronavirus disease (COVID-19) dashboard (, accessed 1 March 2021).

   WHO EASTERN MEDITERRANEAN REGION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             2
COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN - 2021 EDITION Reinforcing the collective readiness and response in the WHO Eastern ...
For reasons that are not completely understood, males are                    data, in the first three months of the pandemic health
slightly more affected than females especially in terms of                   care worker infections slightly exceeded 10% of reported
disease severity and case fatality (51% of cases and 57%                     cases, declining to less than 5% by early June 2020 and to
of deaths). However, females are often disproportionately                    approximately 2.5% by September 2020. In addition, the
affected by the social and economic consequences of                          heavy burden placed on health workers involved in the
response measures. Women also suffer from loss or limited                    response and within the wider health system has had a
accessibility to reproductive and sexual health services,                    negative impact on their health and well-being.3
antenatal care and other maternal health services. There
are reports from several countries of increased incidence of                 Vaccinations against COVID-19 have started and are ongoing
gender-based violence.2                                                      in many countries worldwide. As at 9 February 2021, Our
                                                                             World in Data reported that 134.65 million vaccine doses
Regarding age groups, adults aged 25–55 years are the                        had been administered globally and at least 65 countries
most affected, but disease severity and risk of death are                    had initiated vaccination campaigns.6 The majority of these
associated with increased age. Elderly populations are more                  countries were in Europe and North America, although
at risk of severe symptoms and death, with over 80% of                       vaccination efforts are starting in Africa, South America,
deaths occurring in individuals aged above 65 years. The                     South and South-East Asia, and the Eastern Mediterranean
COVID-19 pandemic has taken a toll on the mental, social                     (13 countries in the Eastern Mediterranean Region had
and economic well-being of individuals and communities.                      begun vaccination by 28 February 2021).

It has been estimated that most COVID-19 infections                          As SARS-CoV-2 variants have become a significant concern
originate from relatively few individuals in high-transmission               globally, WHO established the SARS-CoV-2 Virus Evolution
events or settings.3,4 Transmission mainly occurs among                      Working Group to assess the levels of risk and impacts of
close contacts of infected persons in indoor spaces and can                  mutations on public health. Implementing or improving
be amplified by poor ventilation. Secondary attack rates are                 sequencing capacity at the national level has become a
higher in household settings (recent estimates from two                      priority in this regard.
meta-analyses5 suggest household secondary attack rate is
approximately 17–21%), and outbreaks have been reported                      Health systems and delivery of regular health services
from a number of settings, including long-term living                        have been severely affected by the COVID-19 pandemic
facilities, prisons, religious or social events, as well as food             and financial hardship has increased due to demand for
processing plants.                                                           COVID-19-related services. To ensure equitable access
                                                                             to diagnostics, therapeutics and vaccines, health system
Data show that about 7.7% of cases worldwide are among                       capacities such as financing, workforce planning, clinical
health care workers, although there are wide variations                      care, logistics and supply chain management must be
among countries, with changes over time. Based on WHO                        strengthened.

  Gender and COVID-19: advocacy brief, 14 May 2020. Geneva: World Health Organization; 2020 (
WHO-2019-nCoV-Advocacy_brief-Gender-2020.1 eng.pdf?sequence=1&isAllowed=y, accessed 21 February 2021.
  Endo A, Abbott S, Kucharski AJ, Funk S. Estimating the overdispersion in COVID-19 transmission using outbreak sizes outside China. Wellcome Open Res.
2020;5:67. doi:10.12688/wellcomeopenres.15842.3.
  Koh WC, Naing L, Chaw L, Rosledzana MA, Alikhan MF, Jamaludin SA, et al. What do we know about SARS-CoV-2 transmission? A systematic review and
meta-analysis of the secondary attack rate and associated risk factors. PLoS ONE. 2020;15(10):e0240205. doi:10.1371/journal.pone.0240205.
  COVID-19 strategic preparedness and response plan, 1 February 2021 to 31 January 2022. Geneva: World Health Organization; 2021 (
publications/i/item/WHO-WHE-2021.02, accessed 21 February 2021).
  COVID-19 data explorer: COVID-19 vaccine doses administered per 100 people [online database]. Oxford: Our World in Data; 2021 (https://ourworldindata.
g=0&pickerMetric=total_cases&pickerSort=desc, accessed 10 February 2021).

COVID-19 strategic preparedness and response plan – 2021 edition                                                                                     3

    3.1 Epidemiological situation

    3.1.1 Evolution of the COVID-19 epidemic in the Region
The first cases of COVID-19 in the Eastern Mediterranean                    restrictions and other mobility measures were imposed by
Region were reported by the United Arab Emirates on 29                      countries in the Region, the proportion of locally acquired
January 2020 among travellers coming from Wuhan, China.                     infections increased. Most of the Region showed a slow start
By the end of February 2020, 11 countries in the Region had                 to the outbreak in the first three months of the pandemic;
reported confirmed cases of COVID-19. In the subsequent                     however, in May 2020 disease transmission accelerated
weeks, the Region witnessed an increasing number of                         and rapid local and community spread were subsequently
countries with confirmed cases, and all 22 countries and                    observed in many countries.7 This could be attributed
territories had recorded COVID-19 cases by 10 April 2020.                   to easing of public health and social measures such as
                                                                            travel restrictions and partial or full lockdowns, which
Most of the new cases recorded in the first three weeks                     were relaxed during the holy month of Ramadan in many
of the pandemic were imported and linked to countries/                      countries, and to social gatherings during this month.
cities highly affected by COVID-19 outbreaks. When travel

The Region’s cumulative cases surpassed 6.4 million on 28 February 2021.
From the first reported COVID-19 case, it took 150 days to reach 1 million cases.
From there:

                1 to 2 million cases                                    72 days
                2 to 3 million cases                                    52 days
                3 to 4 million cases                                    30 days
                4 to 5 million cases                                    38 days
                5 to 6 million cases                                    42 days

On 28 February 2021, COVID-19 deaths reached 144 947.
From the first reported death, it took 90 days to reach 10 000 deaths.
From there:

                10 000 to 50 000 deaths                                               102 days
                50 000 to 100 000 deaths                                              90 days

 Al-Mandhari A, Brennan R, Abubakar A, Hajjeh R. Tackling COVID-19 in the Eastern Mediterranean Region. Lancet. 2020;396(10265):1786–8.

WHO EASTERN MEDITERRANEAN REGION                                                                                                          4
Two waves of the pandemic were observed in 2020 across                                                              Generally, countries in the Region have shown mixed
the Region: the first peak was reached in week 25 (starting                                                         patterns of resurgence, decrease or stabilization in the last
on 14 June) with 138 844 new confirmed cases and                                                                    six months. The curve has fluctuated in recent weeks, with
3435 deaths, followed by a gradual decrease in reported                                                             12 countries reporting an increase in numbers of cases until
cases and deaths. In week 35 (starting on 23 August) a                                                              February 2021 (Fig. 2). The trend in COVID-19 deaths has
significant increase in the number of confirmed cases and                                                           shown the same pattern, with a sharp increase since mid-
deaths was observed across the Region. COVID-19 cases                                                               October 2020, declining from mid-November and plateauing
increased sharply from mid-October 2020 and reached a                                                               since the beginning of 2021. The Islamic Republic of Iran,
peak in mid-November 2020. This increase was initially                                                              Lebanon, Tunisia, Pakistan and Egypt have been the main
due to a resurgence of cases in the Islamic Republic of                                                             contributors to the number of deaths since the beginning of
Iran, Jordan and Morocco, surpassing the number of cases                                                            2021 (Fig.3).
reported during the mid-June 2020 peak. The second wave
peaked in week 47 (starting on 16 November), where the
highest weekly number of cases since the beginning of the
pandemic was reported (251 094 cases, 6300 deaths). Then,
a gradual decrease in the number of confirmed cases was
observed until the end of 2020.

Fig. 2. Weekly distribution of COVID-19 cases and CFR in the Eastern Mediterranean Region,
        29 January 2020–28 February 2021
                    300 000                                                                                                                                                                    16

                                                                               Cases                                                                                                           14
                    250 000
                                                                               CFR (%)
                    200 000
  Number of cases


                                                                                                                                                                                                    CFR (%)
                    150 000                                                                                                                                                                    8

                    100 000
                     50 000

                           0                                                                                                                                                                   0
                               5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8
                                                                                                2020                                                                            2021

                                                                                                Epidemiological weeks

Fig. 3. Weekly distribution of COVID-19 deaths in the Eastern Mediterranean Region,
        29 January 2020–28 February 2021


Number of deaths





                           5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8
                                                                                                  2020                                                                                   2021
                                                                                              Epidemiological weeks

COVID-19 strategic preparedness and response plan – 2021 edition                                                                                                                                              5
3.1.2 Current situation in the Region (as at 28 February)

The Eastern Mediterranean Region (home to 9% of the                   attack rates have been reported from Bahrain (7.2 cases
world’s population) has the fourth highest number of cases            per 100 population), followed by Qatar (5.7 cases per 100
and deaths among the six WHO regions. As at 28 February               population) and Lebanon (5.5 cases per 100 population);
2021, a total of 6 421 085 cases of COVID-19 and 144                  these countries also have among the highest testing rates in
947 associated deaths (CFR 2.3%) have been reported,                  the Region.
representing 5.6% of the cases and 5.7% of the deaths
reported globally. Since the beginning of the outbreak, the           The regional CFR is 2.3%, ranging from 0.2% to 27.7%
Islamic Republic of Iran has reported the highest number              (median CFR = 1.8%). The highest CFRs are reported by
of cases in the Region (1 631 169 cases; 25.4% of the total           Yemen (27.7%) followed by the Syrian Arab Republic
for the Region) followed by Iraq (695 489; 10.8%) and                 (6.6%). The lowest CFRs are reported by Qatar (0.2%)
Pakistan (581 365; 9.1%). The Islamic Republic of Iran has            followed by the United Arab Emirates (0.3%) and Bahrain
also reported the highest number of cumulative associated             (0.4%), a result of better quality health care systems,
deaths (60 073; CFR 3.7%) followed by Iraq (13 406;                   increased testing capacity, adequate hospital and intensive
CFR 1.9%) and Pakistan (12 896; CFR 2.2%). The highest                care capacity and trained staff.

Fig. 4. COVID-19 cumulative incidence per 100 000 population and total deaths per country,
        Eastern Mediterranean Region, 28 February 2021

                                                   Lebanon      Syrian Arab

                                    Occupied Palestinian
                                                                                                    Islamic Republic
                                                             Jordan                      Iraq            of Iran

                  Morocco                                                                                               Afghanistan
                                                                                                    Kuwait                    Pakistan

                                                   Libya          Egypt
                                                                                                                       United Arab
                                                                                    Saudi Arabia                       Emirates

                                                                  Sudan                    Yemen
         Incidence per million     Deaths per million                                           Somalia
                < 100                      < 50
                100–1000                   50–100                                                                                    Qatar
                1001–10 000                101–500
                10 001–50 000
                                           > 500
                > 50 000

The trends in incidence and mortality vary across the Region          COVID-19 transmission patterns have evolved over time,
(Fig. 4), in part due to variations in detection, diagnostics,        with 16 countries currently self-reporting community
reporting and response capacities of Member States, as well           transmission, five countries (Afghanistan, Bahrain, Djibouti,
as demographic differences. Moreover, response capacities             Egypt, Morocco) self-reporting clusters of cases, and one
are most variable at the subnational level, contributing to           country self-reporting sporadic cases (Saudi Arabia).
some uncertainty on numbers of cases reported nationally.
The implementation of public health and social measures
coupled with their intensity, coverage and public adherence
also contribute to this variation.

WHO EASTERN MEDITERRANEAN REGION                                                                                                             6
In terms of testing, a total of 97 602 151 laboratory-                       transmissibility and/or reduced virus neutralization among
confirmed PCR tests have been conducted across the Region                    humans. These variants include the SARS-CoV-2 VOC
since the start of the pandemic, including 3 272 018 tests                   202012/01, the VOC linked to infections among farmed
in week 8 of 2021, which showed a 2% increase compared                       mink, the SARS-CoV-2 501Y.V2 and most recently SARS-
to the previous week (3 197 386). Countries in the Region                    CoV-2 B1.1.248. Out of 14 countries in the Region with
have adapted different testing strategies, despite WHO’s                     SARS-CoV-2 genome sequencing capacity, 13 have reported
recommendation to follow the COVID-19 case definitions8.                     VOCs (as at 28 February 2021) including Bahrain, Iran
As a result of different testing strategies and capacities,                  (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Libya,
Jordan, Lebanon and Gulf Cooperation Council (GCC)                           Morocco, occupied Palestinian territory, Oman, Pakistan,
countries have reported the highest numbers of tests per                     Saudi Arabia and the United Arab Emirates.
capita, while countries with complex emergencies such
as Afghanistan, Somalia, Sudan, Syrian Arab Republic and                     Data from the Region’s case database of 2 015 925 records
Yemen reported the lowest number of tests per capita in                      show that, as is the case globally, males are more affected
the Region. The number of tests per 100 000 population                       than females, with a male to female ratio of 1.8 to 1.0.
varies from 40 to 310 057, with a regional median of 13                      This ratio varies among countries, ranging from 1.1 in Egypt
467 tests. The cumulative test positivity ratio is also widely               to 4.0 in Qatar. COVID-19 is more prevalent among adults,
variable, ranging from 1% to 25% with a median of 10.4%.                     with about two thirds of COVID-19 cases in the Region
The lowest test-positivity ratio has been reported from                      being reported among those aged 25–55 years, and the
Bahrain, Saudi Arabia and the United Arab Emirates, while                    most affected age group being 25–35 years of age. The risk
Afghanistan, Syrian Arab Republic and Tunisia reported the                   of death increases with age, with the highest frequency
highest positivity ratio.                                                    of deaths reported among those over 55 years of age.
                                                                             Increased rates of severe and complicated disease, with
Over the past few months, several SARS-CoV-2 variants                        more adverse long-term outcomes, are also associated with
of concern (VOC) have been identified and preliminary                        older age.
evidence suggests that they may have increased

                                                                                                                                       © WHO/EMRO

 WHO COVID-19: case definitions: updated in Public health surveillance for COVID-19, published 16 December 2020. Geneva: World Health Organization; 2020

COVID-19 strategic preparedness and response plan – 2021 edition                                                                                     7
The risk of COVID-19 infection among frontline health care      To estimate the burden of COVID-19 in the Region, sero-
workers is higher than in the general population. Early         epidemiological investigations are being conducted in
reports suggested that health care workers accounted for        multiple countries to complement surveillance data
7–10% of all reported infections in the Region during the       and guide the public health response, often with WHO
first three months of the pandemic. However, data on health     support. In 2020, several countries reported their findings
care-associated infections are limited. In the Region, around   in peer-reviewed journals or shared data with WHO. Most
2% of case report forms reported through the regional           nationwide surveys conducted between June and December
platform, Eastern Mediterranean Flu (EMFLU), referred to        2020 in the Region estimated the prevalence of SARS-CoV-2
cases among health care workers. Underreporting and lack        antibodies at 10%, which is consistent with the observations
of appropriate surveillance mechanisms to report infections     from global nationwide studies. Notably, low-income
among the health workforce have likely contributed to           countries and countries with complex emergencies have
an underestimation of health worker infections. The 14          reported higher estimates of prevalence in their populations,
country support missions by WHO during 2020 consistently        up to 25% nationally and 30% subnationally (although
found deficiencies in infection prevention and control (IPC)    these countries have reported the lowest numbers of cases
governance and practice as one of the most consistent           in the Region). The highest rates of antibody prevalence
findings.                                                       were reported in health care workers and migrant workers
                                                                (specifically “craft and manual workers”).

                                                                                                               © WHO/EMRO

WHO EASTERN MEDITERRANEAN REGION                                                                                            8
3.2 Risk assessment of COVID-19 in the Region

WHO continues to assess the risks of COVID-19 at global,           major impact on vaccine efficacy, although there is some
regional, country and community levels. The collection             concern. WHO is working closely with countries in the
and analysis of epidemiological surveillance data from all         Region to enhance genomic surveillance in order to detect
countries in the Region has significantly improved over            and monitor mutations and their implications for disease
time, and the availability of these data has allowed WHO to        transmissibility, diagnostics, vaccines, therapeutics and
conduct risk assessments on a regular basis to inform the          overall public health responses.
public health response. While understanding of the SARS-
CoV-2 virus continues to grow regarding the epidemiology,          The COVID-19 vaccine roll-out has started in many
pathophysiology, diagnosis and management of the virus             countries and territories of the Region, and a decrease
and associated disease, much remains unknown, such                 in cases has been observed in the United Arab Emirates
as the source, the evolution of the virus over time, the           since its deployment. Despite these positive preliminary
duration of human immunity, the impact of the vaccines             observations, it is still too early for the vaccination
on new variants, and the long-term impacts of infection            programme to impact COVID-19 transmission considering
on health. However, the availability of genetic sequencing         the challenges it faces, including new variants. Delays in
data has provided valuable information on the biology              vaccine procurement, distribution and administration could
and evolution of SARS-CoV-2. Combining the sequencing              potentially alter the course of transmission at the population
and epidemiological data provides real-time knowledge              level in the months to come. Efforts to ensure rapid and
and understanding of the emergence of new variants and             fair vaccine deployment among priority groups are being
the impact on diagnostics and vaccines. WHO has been               pursued through the COVAX Facility. Maintaining public
working with a global network of public health experts             health and social measures alongside vaccination is still
to continuously assess the evolving situation and provide          essential to limit transmission and reduce the morbidity and
recommendations to Member States.                                  mortality associated with COVID-19. However, pandemic
                                                                   fatigue could adversely affect the continued acceptance
One major public health concern is the reported VOC in             of and compliance with public health and social measures
recent months. Several SARS-CoV-2 VOC have been identified         by the population. The regional and country-level risks for
and preliminary evidence suggests that they may have               COVID-19 remain very high given the evolving situation of
increased transmissibility or be associated with reduced           COVID-19 across the Region, preparedness and response
virus neutralization among humans. Nonetheless, there is           capacities of Member States and the numerous challenges
no strong evidence to date that these new variants have            faced.
                                                                                                                   © WHO/EMRO

COVID-19 strategic preparedness and response plan – 2021 edition                                                                9
3.3 Operational context

    3.3.1 Humanitarian settings and vulnerable groups
The Eastern Mediterranean Region is home to nearly                                 Additionally, as at 2019, there are 46 million professional
600 million people living across 22 socioeconomically                              and low-income labour migrants in the Region (of which
and geopolitically diverse countries and territories. Nine                         22 million are from the Region), with differential access
countries of the Region are directly impacted by complex                           to and coverage of health services.10 Migrants and forcibly
humanitarian emergencies, and 43% of people in need of                             displaced populations, refugees in particular, are often
humanitarian assistance globally are located in the Region                         excluded from national programmes for health promotion,
(101 million people in total). As of 2019, the Region hosted                       disease prevention, treatment and care, as well as from
275 032 asylum-seekers, 11.8 million refugees (half being                          financial protection schemes for health, social services
Palestinian), 18.7 million internally displaced persons and                        and social protection. This exclusion could affect early
370 478 stateless persons.9 These populations are often                            detection, testing, diagnosis, contact tracing and treatment
vulnerable to poor health due to the conditions they live                          for COVID-19. In addition, it increases the risk of COVID-19
in and their limited access to needed quality health care.                         spreading within these populations, where the outbreak can
In addition, those who can access health care services are                         remain undetected.
often faced with financial hardship.
                                                                                   Moreover, due to limitations imposed by the pandemic,
                                                                                   the role of public health and humanitarian partners has
                                                                                   been further challenged. In a global survey conducted in
                                                                                   November 2020, health cluster partners reported facing
                                                                                   increased operational constraints in terms of insufficient
                                                                                   funding, human resources capacity and supplies in
                                                                                   safely delivering both COVID-19 response activities and
                                                                                   essential health services. Existing fragile health systems
                                                                                   in the Region have led to suboptimal disease surveillance
                                                                                   and preparedness and response capacities, making
                                                                                   countries particularly vulnerable to the emergence and
                                                                                   rapid transmission of novel pathogens. The COVID-19
                                                                                   pandemic has further exacerbated public health risks and
                                                                                   vulnerabilities especially among women and children in
                                                                      © WHO/EMRO

                                                                                   emergency countries, requiring concerted efforts to address
                                                                                   the double burden of maintaining essential health services
                                                                                   in an emergency context and responding to COVID-19 as the
                                                                                   pandemic continues to evolve.

   Population statistics [online database]. New York, NY: United Nations High Commissioner for Refugees; 2020 (,
accessed 1 March 2021; last update in December 2020).
    World migration report 2020. Geneva: International Organization for Migration; 2019 (,
accessed 1 March 2021).

WHO EASTERN MEDITERRANEAN REGION                                                                                                                   10
3.3.2 Effects on health systems and essential services

The pandemic has had a major impact on essential                               To ensure continuity of services, WHO has established a
health services. Lockdown measures imposed early on                            dedicated pillar on essential health services as part of the
in the pandemic, mobility limitations, the fear of getting                     SPRP to provide regular and tailored support to countries.
COVID-19 infection and closure of some services has led                        Numerous guidance documents and protocols have been
to less utilization of and accessibility to essential health                   published to guide countries in ensuring the continuity
services. The supply chain of various essential medicines                      of essential care. In this regard, the operational guidance
and vaccines was disrupted, leading to major shortages                         on maintaining essential services serves as the main
and further impacting the management of chronic illnesses.                     guidance12,13 alongside capacity-building materials and
Many gaps were highlighted in health system design and                         community-based guidance and assessment tools.
implementation, including coordination mechanisms,
supportive institutional arrangements, capacities and                          Countries in the Region have adopted a range of
supportive legislations, funding and equitable financing                       approaches to ensure continuity of health services, including
arrangements, qualified health workforce mix, and access to                    telemedicine and eHealth, capacity-building, supply chain
quality medicines and medical products.                                        strengthening, modalities to reactivate and improve
                                                                               access to services at primary and secondary care levels,
WHO has conducted various global surveys to better assess                      streamlining health care, and improving IPC across the
the impact of the pandemic on essential health services. A                     continuum of health care delivery.
rapid assessment was conducted in mid-202011 to which 13
countries of the Region responded (59%). The assessment
reported frequent disruption of essential health services
in the Eastern Mediterranean Region, with an average
disruption of 75% – higher than all other WHO regions (PAHO
was not included in the survey). An assessment in May
2020 shed light on the impact of the COVID-19 pandemic
on services for noncommunicable diseases (NCDs). With
responses from 19 (86%) countries in the Region, the most
common reasons for discontinuing or reducing services
were the closure of outpatient clinics and cancellation of
elective care (47%), insufficient staffing (26%) and NCD
clinical staff being deployed to provide COVID-19 relief
(32%). About half of the countries surveyed had partially
or completely disrupted NCD services. Similarly, results

                                                                                                                                                       © WHO/EMRO
of a rapid assessment on mental health and psychosocial
services (MHPSS) showed widespread disruption of these
services in the Region, despite the mental toll that COVID-19
and associated public health and social measures have taken
on individuals.

   Pulse survey on continuity of essential health services during the COVID-19 pandemic: interim report, 27 August 2020. Geneva: World Health Organization;
2020 (, accessed 1 March 2021).
   Analysing and using routine data to monitor the effects of COVID-19 on essential health services: practical guide for national and subnational decision-
makers. Interim guidance, 14 January 2021. Geneva: World Health Organization; 2021 (
2019-nCoV-essential_health_services-monitoring-2021.1-eng.pdf?sequence=1&isAllowed=y, accessed 21 February 2021).
   Maintaining essential health services: operational guidance for the COVID-19 context. Interim guidance, 1 June 2020. Geneva: World Health Organization;
2020 (, accessed 21 February 2021).

COVID-19 strategic preparedness and response plan – 2021 edition                                                                                      11
3.3.3 Social and economic effects

The COVID-19 pandemic has uncovered and intensified                      effects on gender inequalities: violence against women
existing social and health inequities. Evidence shows clear              and girls has increased, girls have less access to online
socioeconomic inequities in rates of infection and mortality             education than boys, and women have taken on more
from COVID-19 that reflect existing social, economic and                 unpaid household and caring roles with lockdown measures
geographic inequities. Moreover, containment measures                    in place. Mental health disorders have increased for a
have had significant effects on health inequities by                     variety of reasons such as financial pressures, social isolation
deteriorating the social determinants of health.                         and anxiety about the pandemic. While the challenges
                                                                         are substantial and increasing, they also enable the
In countries of the Region, levels of food insecurity,                   identification of gaps to reduce inequities in the future. The
malnutrition and poverty substantially increased during                  Commission on Social Determinants of Health in the Eastern
2020. In some instances, this was associated with                        Mediterranean Region has recommended for Member States
containment measures and related decreases in income                     to position social justice at the heart of decision-making,
due to unemployment, reductions in working hours and                     and to foster a whole-of-society endeavour to improve
inadequate social protection mechanisms to provide                       health and reduce inequities.
sufficient support. The pandemic has also had significant

3.3.4 Public health and social measures
Since the beginning of the COVID-19 pandemic, countries                  and other education settings, and closure of public and
have been implementing public health measures to prevent                 social services. Levels of implementation, enforcement and
or slow the transmission of COVID-19, including individual,              adherence to these measures have varied across countries
environmental or community measures in the form of                       and territories in the Region.
surveillance, response and social interventions. Various
social measures have been implemented by countries such                  The implementation of such measures can have
as mandating physical distancing, mandating mask-wearing                 considerable social and economic costs. Daily monitoring,
in public places, movement and travel restrictions, banning              recording and analysis of these measures show that the
of gatherings and mass gathering events, closure of schools              implementation of social measures is mostly not based
                                                                         on an objective, evidence-based risk assessment, but
                                                                         rather focuses on the epidemiological and socioeconomic
                                                                         situations. In some countries of the Region, the
                                                                         decision-making process has been skewed towards the
                                                                         socioeconomic situation.

                                                                         The Regional Office for the Eastern Mediterranean will
                                                                         continue to raise awareness and disseminate WHO guidance
                                                                         on performing risk assessments to inform decisions related
                                                                         to public health and social measures. The Regional Office
                                                                         has developed a dashboard that includes three layers of
                                                                         data (public health and social measures, epidemiological
                                                                         data and movement data) extracted from the Google daily
                                                            © WHO/EMRO

                                                                         monitoring reports in the context of COVID-19. Monitoring,
                                                                         recording and analysing of data from the dashboard,
                                                                         including for modelling purposes, will continue to guide and
                                                                         inform regional and national decisions.

WHO EASTERN MEDITERRANEAN REGION                                                                                                     12
3.3.5 Vaccines

Alongside public health and social measures to slow the            included in the NDVPs. However, the inclusion of migrants
spread of the virus and reduce transmission, safe and              could be challenging due to limited accessibility to vaccines.
efficacious vaccines are a powerful tool to rapidly control        A monitoring mechanism to evaluate the implementation of
the pandemic if a large proportion of the global population        the NDVPs should be ensured. Eligibility, target groups and
is vaccinated against COVID-19. Through the global solidarity      review processes are yet to be developed in collaboration
initiatives, WHO has brought together public and private           with humanitarian organizations. Formal approval of
sector donors, pharmaceutical and research companies, and          Gavi is ongoing for allocation of the 5% buffer stock for
other experts to rapidly invest and support the development        humanitarian use.
of COVID-19 vaccines. Within a few months of the pandemic,
several vaccines had reached phase 3 clinical trials and were      The regional working group on COVAX has organized
showing promising results. By December 2020, the first             several orientation webinars and virtual trainings targeting
vaccine was approved by regulatory authorities in different        the Regional Immunization Technical Advisory Group,
countries and showed a high efficacy rate.                         the national immunization technical advisory groups,
                                                                   WHO country offices, programme managers, and the
Safe and effective vaccines for COVID-19 are now available         Expanded Programme on Immunization (EPI) focal persons.
and are already proving to be powerful tools in the global         Furthermore, the Regional Review Committee, consisting of
effort to control the pandemic. All 22 countries and               WHO and UNICEF regional staff members, headquarters staff
territories of the Eastern Mediterranean Region have joined        members and partner organizations, with four to five people
the COVAX Facility and committed to global coordination            per country panel, was established to review applications to
for the fair and equitable distribution of COVID-19 vaccines.      COVAX. Several challenges have been identified in terms of
Of these countries, 11 were considered self-financing              concerns regarding the delay of COVAX vaccines compared
countries (high-income countries) and 11 were eligible for         to other vaccines, public acceptance of vaccine, and logistics
the Advanced Market Commitment (AMC) funded through                support particularly in low-capacity and disrupted health
official development assistance ( low- and middle-income e         systems.
countries, according to the World Bank classifications).

By 28 February 2021, 15 countries in the Region had
completed their readiness assessment using the COVID-19
Vaccine Introduction Readiness Assessment Tool (VIRAT/
VRAF 2.0). Eleven AMC countries had submitted their vaccine
request form to the COVAX Facility and outlined their needs
with respect to technical assistance, but none had reported
readiness regarding the ultra-cold chain. Development of
a national deployment and vaccination plan (NDVP) had
started in 14 countries in the Region and WHO is providing
technical assistance in finalizing the plans. Twenty-one
countries had provided emergency use authorization for at
least one vaccine. Thirteen countries had started COVID-19
                                                                                                                              © WHO/EMRO

vaccination and more than 11 million doses had been
administered to target populations. As many countries in
the Region are facing humanitarian crises, populations in
fragile, conflict and vulnerable settings are prioritized and

COVID-19 strategic preparedness and response plan – 2021 edition                                                              13
3.3.6 Regional contribution to global research, development and innovation

In line with the COVID-19 Research and Development             formally enrolled in the global Unity Studies initiative to
Blueprint, countries in the Region have continued to           further the understanding of transmission patterns, severity,
accelerate innovative research to help contain the             clinical features and risk factors for infection.
pandemic, facilitate care for those affected and contribute
to global research platforms. Ten of the 22 countries and      Other countries also continue to conduct epidemiological
territories in the Region have joined the global quest         research and publish in peer-reviewed journals. The Region
for an effective treatment: the WHO Solidarity trial. For      has also been a hub of technological innovation, including
vaccine development, more than four countries have been        the development of mobile applications for contact tracing,
involved in independent vaccine trials in collaboration with   the creation of home-made cloth masks, the use of robots
manufacturers. For diagnostics, all countries in the Region    for IPC in hospitals, innovative biomedical equipment, and
have been using commercial PCR tests and providing regular     the use of digital health applications to maintain essential
feedback on their effectiveness. This role has been further    health services. Additionally, the development and use
amplified since the emergence of the new variants and          of mathematical models for decision-making on public
their detection. Three countries have also contributed to      health and social measures, as well as to assess their
the evaluation of rapid immunoassay tests through sero-        epidemiological impact, has been a highlight innovation
epidemiological studies. Moreover, eight countries have        throughout the COVID-19 response.

3.4 Regional collaboration and coordination

Supported by WHO, all 22 countries and territories of the      countries. The Regional Director has established mechanisms
Region have activated a national multisectoral coordination    for engaging experts from the Region and beyond, as
mechanism to facilitate efficient and comprehensive            well as other United Nations agencies, academia and the
response activities, with the active engagement of local       media. The Regional Director also engages with United
partners and donors. Many countries have established           Nations resident/humanitarian coordinators in the Region
a dedicated multidisciplinary committee to lead the            through regular meetings to ensure their support to the
coordinated response reflecting, in most instances, a whole-   COVID-19 response at the country level. In agreement with
of-government approach. Health clusters are utilized in nine   ministers of health, a Ministerial Group on COVID-19 was
countries and lead the response with humanitarian partners     established consisting of seven countries (Egypt, the Islamic
in the field to ensure adequate COVID-19-related service       Republic of Iran, Lebanon, Morocco, Oman, Saudi Arabia
delivery and to ensure the continuity of essential health      and Somalia). A dedicated technical working group held
services.                                                      a series of consultative meetings, during which countries
                                                               shared country-specific experiences highlighting successes,
In the WHO Eastern Mediterranean Region, the Regional          challenges and lessons learned on COVID-19 response. As
Director closely engages with ministers of health on a daily   a result, key recommendations were provided to guide
basis to update countries on new guidance and global and       strategic plans for 2021 to strengthen preparedness and
regional concerns, build consensus and foster evidence-        response in the Region.
based decisions, in addition to sharing experiences across

WHO EASTERN MEDITERRANEAN REGION                                                                                         14
A regional network of 35 technical and operational partners        IMST has provided and continues to provide a management
was established that convenes virtually on a biweekly              and coordination platform to escalate areas of concern
basis to coordinate support for country-level responses            across the Region, tailoring the required support needed
and exchange updates. WHO has also continued to act as             to overcome challenges and address needs. For 2021,
the health cluster lead in the response to the pandemic            the IMST has revisited its structure to improve internal
at global, regional and national levels. In addition, WHO          coordination across its different response pillars and
continues to leverage the capacities of the Global Outbreak        improve monitoring and reporting. A vaccine pillar has been
Alert and Response Network (GOARN) and emergency                   added to IMST as pillar 10. This has fostered the integration
medical team initiatives to support country operations across      and internal coordination between vaccine-preventable
the Region and globally.                                           diseases and immunization (VPI), research, vaccine safety
                                                                   and risk communication and community engagement
Within WHO’s Regional Office, the regional Incident                (RCCE) components of the pillar. Pillar 10 will promote
Management Support Team (IMST) was established                     a comprehensive and integrated approach to COVID-19
in January 2020 and rapidly expanded to involve all                response and facilitate the uptake of COVID-19 vaccines in
departments and expertise to tailor and address the regional       different countries.
needs to curb and prevent further spread of COVID-19. The

                                                                                                                   © WHO/EMRO

COVID-19 strategic preparedness and response plan – 2021 edition                                                                15

4.1 Partnership and coordination
•   Coordination mechanisms were in place in many                     to ensure accountability, responsiveness and equitable
    countries to support the response, including accountable          access to quality health care. Furthermore, building
    whole-of-government approaches to decision-making.                trust between governments and communities at both
    The most effective mechanisms were those in which                 national and subnational levels needs improvement,
    the highest levels of government were fully engaged               as demonstrated by non-compliance to public health
    and followed the evidence-based guidance provided by              measures. Collaborative governance and promoted
    public health experts. However, these mechanisms need             leadership skills and capacities in health decision-
    to be better structured, maintained and strengthened              making need to be strengthened for a whole-of-
    through adjustments to their structure and operations             government and whole-of-society approach.
    using the lessons learned, such as optimizing the use of
    emergency operations centres.                                 •   There is a need to better identify and acknowledge
                                                                      specificities of the response in fragile, conflict and
•   Governance arrangements and capacities demonstrated               vulnerable settings. This will allow guidelines, response
    gaps in delivering essential public health functions              mechanisms and funding to be better tailored to enable
    including gaps in coordination, oversight and                     adequate and timely response to COVID-19, and future
    regulations, as well as in preparedness and response              pandemics, in areas already affected by crises.

4.2 Communications (external and internal)
•   The production of clear credible information and              •   Maintaining regular, timely and proactive
    messaging, alongside ensuring its wide dissemination              communications to highlight WHO’s position to key
    via social media platforms and improving coordination             stakeholders on key platforms raised the Region’s
    with the media, is critical to fight misinformation/              profile, increased the number of followers, generated
    disinformation and empower individuals, communities               media coverage and established the Regional Office
    and populations to adapt appropriate risk-reducing                as a credible source of information, including by other
    behaviours and improve knowledge, perceptions and                 WHO regions who use our materials on their platforms.

4.3 Operations support and logistics
•   Maintaining a pre-positioned repository of essential              delivery dates, as well as technical details such as
    health commodities proved critical to the acute phase             quantities, weights, volumes and expiry dates, is critical
    of the response and enabled WHO to immediately and                to WHO’s response.
    rapidly distribute personal protective equipment (PPE)
    and other essential medicines.                                •   Expanding logistics capabilities across the Region,
                                                                      in coordination with Member States, is required to
•   The increased supply chain management requirements                maintain current service delivery levels and to improve
    associated with the COVID-19 response revealed the                national-level distribution of supplies.
    need to have qualified logistics/supply coordinators
    based in all WHO country offices to facilitate the delivery   •   The digitalization of the COVID-19 Supply Chain System,
    of medical supplies.                                              established to centralize procurement and distribution
                                                                      to help to overcome acute shortages of essential
•   Increasing the visibility of supply chain data including          supplies caused by the pandemic, should be explored to
    financial commitments, physical locations and expected            enhance WHO’s resilience to future health shocks.

WHO EASTERN MEDITERRANEAN REGION                                                                                             16
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