From The Field WHO MAGAZINE ON UHC ISSUE 2 2019
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STories From
The Field
WHO MAGAZINE ON UHC
ISSUE 2 – 2019
About the
Universal
Health Coverage
Partnership
The Universal Health Coverage The UHC Partnership is in its ninth
Partnership (UHC-P) promotes year of operation. Since it started in
universal health coverage (UHC) 2011, it has evolved into a significant
by fostering policy dialogue on and influential global partnership
strategic planning and health working in 115 countries in all 6
systems governance, developing WHO regions, with the support
health financing strategies and of 7 significant donors. There are
supporting their implementation, 34 health policy advisors operating
and enabling effective development on the ground with support from
cooperation in countries. WHO advisors in Head Quarters and
Regional Offices and over 900 million
The UHC Partnership’s aim is to people benefiting from interventions
build country capacity and reinforce that increasingly relate to community-
the leadership of the Ministry of level, people-centred, integrated
Health to build resilient, effective primary health care.
and sustainable health systems in
order to make progress towards UHC. The UHC Partnership is supported
We aim to bridge the gap between by the European Union, the Grand
global commitments and country Duchy of Luxembourg, Japan, Ireland,
implementation and serve as a France and United Kingdom.
country-level resource for UHC2030,
the global movement to build
stronger health systems for UHC.
Welcome
The WHO magazine about how countries
to ‘Stories
From The Field’
all around the world are working to achieve
universal health coverage (UHC). Contents
Nigeria Producing well-trained, skilled and qualified health workers to achieve UHC.................. 6
Egypt Laying the foundations: making UHC a reality .............................................................................................. 12
Dominica Strengthening primary care with a new cadre of community health workers.........10
Syrian Arab Republic Tackling NCDs in emergencies through primary health care....................20
© 2016 Samy Rakotoniaina / MSH, Courtesy of Photoshare
Tajikistan Strengthening rehabilitation in UHC to leave no one behind................................................. 24
Liberia Task-sharing for UHC: training nurses and midwives in obstetrics,
neonatal care and anesthetics....................................................................................................................................................30
Kyrgyzstan Improving access to essential quality medicines........................................................................... 34
Lebanon New Policy Support Observatory and National Health Forum:................................................ 38
a milestone for UHC
Estonia Making medicines affordable and accessible for all............................................................................. 42
The Joint Working Team for All this contributes greatly to make
UHC at WHO has collaborated progress towards UHC; the goal that
with colleagues in Regional and we are all striving for to ensure that
Country Offices to bring you these everyone around the world has access
If you don't have time to read every
inspiring stories of change. to the health care they need, without
word, you might like our 60-second
being driven into poverty because
summary at the end of each article!
The stories demonstrate how health of the cost.
systems are getting stronger and
providing better quality services, how Of course, the impact that we
care at the primary level is expanding are seeing is not achieved by WHO
and becoming more effective and alone. We work in close association
accessible, and how communities with governments and other national
and citizens are engaging with health stakeholders in their endeavours
governments in meaningful ways to to achieve better health outcomes for
influence health policy and practice. the population. We hope these articles
give a flavour of how we work and
what we can all achieve when we
work strategically together.
6 Joint Working Team for UHC: Stories from the field. 7
The project has achieved
Students of School of Midwifery, Moniaya, Ogoja learning at a practicum site. Photo: WHO
numerous successes at
federal levels and in Bauchi
and Cross River states.
Dr. Wondimagegnehu Alemu,
WHO representative in Nigeria (2016 – 2018
Nigeria Producing well-trained,
skilled and qualified health
workers to achieve UHC Health training institutions
One of the project’s key activities is tutor- pupil ratios, their equipment WHO conducted a needs
training and producing skilled health was obsolete and not well maintained, assessment in these 11 institutions
A project in Nigeria is transforming the health workforce in Cross workers which has has achieved many or they did not have a conducive and clearly identified what they
positive outcomes so far. Health training teaching, learning and housing needed to improve in order to regain
River and Bauchi States. Many health training schools have regained institutions in both States are much environment to train health workers. accreditation. With the government’s
accreditation and are now training and producing highly qualified stronger and better able to produce lead, WHO improved the teaching
sufficient number of qualified frontline The truth of the matter is that and learning conditions, providing
and skilled health workers. health workers with appropriate if you don’t have trainings going technical assistance in reviewing
skill-sets. Combined with increased on, as the years go by and more and mentoring, while the government
government investment in the health people retire from service, they worked on improving the institutions’
In 2014, a project began called The project is being implemented
workforce from the government, phase out and everywhere physical infrastructure and
‘Enhancing the Ability of Frontline by WHO, the Global Health Workforce
health services are heading in the becomes empty and shutdown refurbishment.
Health Workers to Improve Health in Alliance (GHWA) and the Population
right direction to achieve universal and of course we can’t offer
Nigeria’, funded by the Government Council (PC) through partnerships
health coverage. services,” said Dr Betta Edu, Now there is much cause for
of Canada through the Global Affairs formed with the Federal Ministry
Director General. Cross River celebration. The health institutions
Canada (GAC). The project has the of Health, the Bauchi State Ministry
When the ‘Enhancing the Ability of State Primary Healthcare regained their accreditation status
overall aim of improving the health of Health and its Departments,
Frontline Health Workers to Improve Development Agency. and all 11 institutions are now training
of infants, children, women, and men Agencies and Parastatals and the
Health in Nigeria’ project started in health workers with conducive
in Bauchi and Cross River States by Cross River State Ministry of Health
2014, only 3 out of 11 health training teaching environments and state
strengthening the capacities of frontline and its Departments, Agencies
institutions in Bauchi and Cross River of the art equipment.
health workers to deliver maternal, and Parastatals.
States had official accreditation from
neonatal and child health care services
the regulatory bodies to train and
at the primary health care level.
confer degrees to health workers. The
other institutions had their accredited
status withdrawn for a range of
reasons: they did not have adequate
8 Joint Working Team for UHC: Stories from the field. 9
Without the support of Global
Affairs Canada and WHO, the
dream of establishing the College
of Nursing and Midwifery would
not have materialised.
Hajiya Rakiya Saleh, Provost, College of
Nursing and Midwifery, Bauchi State
Cross River State Bauchi State
Health workforce training institutions As of 2019, there are now over 400 The Bauchi State College of Nursing
in Cross River State have received a nurses, midwives, community health and Midwifery has developed with
revitalizing boost since the ‘Enhancing extension workers (CHEWS) and junior support from the ‘Enhancing the
the Ability of Frontline Health Workers community health extension workers Ability of Frontline Health Workers
to Improve Health in Nigeria’ project (JCHEWS) in various health training to Improve Health in Nigeria’ project.
started in 2014. To date, all five of its institutions in Cross River State. They Established in 2011, but unable to
nursing and midwifery schools are are now receiving training with modern obtain accreditation due to a lack
accredited and able to admit and demonstration equipment in an of resources, the College is now a
train health workers. This means improved learning environment thriving hub for training health
that the State can now recruit highly that is equipped with standard workers from all over the State. It now
trained and professional front line ICT facilities, updated curricula, and has teaching and learning equipment
health workers and place them relevant books. This next generation for demonstration rooms, libraries,
where they are most needed. of the health workforce also benefits dormitories and science laboratories
from well-trained, qualified and and an additional 20 tutors.
The project supported the professional motivated teaching staff. School of Midwifery, Ogoja, Cross River State
training for nursing school educators, The College of Health Technology Photo: WHO
provided contemporary teaching and Exposing these trainees to Ningi has also grown its capacity to
learning equipment in demonstration modern practical and demonstration deliver world-class health training.
rooms and laboratories, and provided equipment, and contemporary The library is restocked with new
technology support in the form of techniques and methods results books, and is now benefitting from
computers, printers and Internet in well-trained and high-quality new technology and equipment,
connection. Libraries were replenished professional frontline health workers. instructional materials and student
with contemporary text-books and Now Cross River State has a rich handbooks and curriculum. These
learning tools, and technical support reservoir of incoming health workers interventions resulted in the
was provided to develop training - some of whom started graduating Community Health Practitioners
curricula, manuals and methods. in September 2018 - and quality Board of Nigeria granting the
Offices, classrooms and dormitories schools. The health care delivery school accreditation.
were revamped with new furniture system will be stronger as a result,
and most schools also received a 32- and the population will have access
seater bus so that students could to better quality services.
easily travel between learning sites.
Bauchi State College of Nursing and Midwifery. Photo: WHO The College of Health Technology Ningi library. Photo: WHO
10 Joint Working Team for UHC: Stories from the field. 11
Student nurses in a practical session at the Bauchi State College of Nursing and Midwifery. Photo: WHO
This project is consistent with
Nigeria’s drive towards achieving
universal health coverage through
Primary Health Care revitalization SUMMARY
as outlined in the National Strategic
Health Development Plan II.
This requires adequate numbers of NIGERIA
competent, highly skilled, motivated FACT
and productive frontline health A project in Nigeria is
transforming the health
workers that are equitably distributed. workforce in Cross River State
Dr Peter Clement Lasuba, Officer-in-Charge, WHO Nigeria. and Bauchi State. Many health
training schools are much
stronger and are now training
and producing highly qualified
and skilled health workers.
WHY IT MATTERS
Having the right numbers of
qualified and skilled health
workers to deliver frontline
Gender matters Task-shifting training Summary maternal, neonatal and child
As part of the project, WHO WHO also supported the Nursing WHO was also part of a consortium of In combination, these interventions health care services at the
supported Bauchi and Cross-River and Midwifery Council of Nigeria partners supporting the government in Cross River and Bauchi States have primary health care level is
States in establishling gender desks (NMCN) to review the curriculum to develop a national task-shifting boosted the quality and professionalism crucial for UHC.
and appointing gender desk officers. training for midwives to include and task-sharing policy. WHO then of the health workforce. There is now
WHO worked with the University of gender-based violence education supported the Cross River and Bauchi a pool of well-trained EXPECTED IMPACT
Calabar’s Department of Public and other gender-specific maternal States to adapt the national policy to A rich reservoir of incoming
Health of the University of Calabar and child health topics and themes. their own particular contexts and the and skilled frontline health workers health workers, quality training
to develop a gender training manual. The curriculum has become far more Population Council supported the to enter into service upon graduation. schools and a strategy for
During a five-day training, the newly- gender transformative than before, States in the policy’s implementation The project has also enabled more placing health workers where
appointed gender desk officers and graduates are now able to apply with guidance from WHO. strategic approaches for ensuring they are most needed are
learned how to conduct gender a gender lens in whatever they better distribution of the right good steps towards UHC. The
analysis and mainstream gender into are doing. First there was a need to train the number of workers with the right health care delivery system
health planning to make activities cadre of health workers whose tasks skills across all health centres. In will be stronger as a result and
and policies more gender sensitive. would be shifted or shared. As a part the future, this will have a powerful the population will have access
In Bauchi State in the north, where of the project, the Population Council impact on the health services to better quality services.
gender issues are keenly felt, there provided training around core maternal delivered and the wellbeing of the
have been some advances. For and child health interventions and population, allowing for clear progress IN PRACTICE
example, a State gender policy emergency obstetric care at the on the road towards UHC. The project is being
has been developed and is being primary care level. The Population implemented by WHO, Global
implemented. Generally, midwifery Council also provided supportive Health Workforce Alliance
is seen as a female cadre. As a result, supervision visits conducted by a joint and the Population Council, in
most of the training schools team led by the Bauchi anc Cross partnership with the Federal
previously only admitted females, River States’ State Primary Health Ministry of Health, the Bauchi
but now male students are also in Care Development Agency (SPHCDA) State Ministry of Health and
midwifery schools. As simple as it of Bauchi and Cross River States the Cross River State Ministry
sounds, this is progress. of Health.
12 Joint Working Team for UHC: Stories from the field. 13
Egypt Laying the foundations:
making UHC a reality
On Easter Monday in 1859, the foundation was laid for the new city of Port
Said, on Egypt’s northern coast. It was the beginning one of Egypt’s most
© Omar Mohsen, Photoshare.
ambitious projects of modern times – the construction of the Suez Canal.
One hundred sixty years later, Port Said is laying the foundation for another
ambitious project: universal health coverage for all Egyptians.
The right to health is explicitly Office in Egypt, to operationalize
enshrined in Egypt’s new constitution, this principle and make UHC a
which also defined the principle of reality. Port Said will be the first
social health insurance. Since the to implement Egypt’s new universal Building a foundation
law was passed in 2014, the Egyptian health insurance programme as part There are three aspects to UHC:
government has been working hard, of making coverage available to all. accessibility, availability, and affordability.
It also establishes three new As part of the process,
health structures: a Universal
with the support of the WHO Country While Egypt’s health sector reforms
Health Insurance Organization to
WHO carried out an
address all three aspects of the health
care system, for many people the
manage the insurance programme; extensive assessment
the Health Care Organization,which
biggest barrier to accessing health
oversees the provision of services;
of the country’s strategic
care is affordability.
and the Accreditation and Oversight purchasing system and its
Organization, which is responsible for
So one of the top priorities of the
setting quality standards, monitoring
governance structure,and
reforms is to ensure that everyone
can afford care by creating and
quality, and granting accreditation. provided recommendations
implementing a new universal
Using as a basis the six building blocks
for implementation of
health insurance programme.
of health systems as developed by WHO, reforms to the system.
the work included carrying out costing
Putting a new national health
and actuarial studies to inform UHI
insurance programme in place
financing as well as technical discussions The result of all this work is a
required overhauling Egypt’s health
and professional dialogues. law which makes universal health
sector, which included changing
© Center for Communication Programs, Photoshare
insurance compulsory for all, while
governance structures and revamping
WHO also provided capacity-building also securing credible funding,
health organizations. WHO worked
workshops for government officials to introducing new, diversified funding
closely with the Egyptian government
enable them to regularly update the mechanisms, reforming pooling and
on the development of the new law
national health accounts and financial purchasing arrangements, and
and is collaborating closely with various
risk protection indicators. redefining cost-sharing structures.
ministerial and UHI committees on
the transformation process.
As part of the process, WHO carried The process of developing the
out an extensive assessment of the law engaged a number of different
The new law, which was voted
country’s strategic purchasing system stakeholders, including civil society.
in December 2017, mandates the
and its governance structure, and
separation of financing from the
provided a number of recommendations
provision of health services.
for implementation of reforms to
the system.
14 Joint Working Team for UHC: Stories from the field. 15
From law to reality
Work on improving access
WHO is also contributing at the
to health services, meanwhile,
local level by conducting capacity-
is moving ahead steadily in Port
building workshops for general
Said. With the assistance of the
practitioners, dentists and nurses
government, health facilities are
in Port Said. It has also introduced
being renovated, equipment is
Patient Safety Friendly Hospital
being secured for hospitals and
initiatives in a number of hospitals
other facilities, and registration of
and primary health care facilities
programme participants has begun.
in the governorate. Community
engagement is also a key element
To assist with this last workstream,
in the implementation of the new
WHO is supporting the development
insurance law.
of the health information system,
which includes indicator lists, civil
WHO is working with the
registration and vital statistics, and
governorate to design a public
electronic medical records.
awareness campaign along with
avenues for community participation.
In particular, the government is
seeking to address the needs of
the most vulnerable segments of © Catherine Harbour, Photoshare
Port Said’s population.
SUMMARY
Primary health care model
Egypt is addressing the other two The new universal health insurance
aspects of UHC, accessibility and law reinforces the primary health care
availability, by building their health model. It stipulates that primary health
system around a primary care model, care facilities are to serve as the first
with a goal of addressing the majority level of contact, and that primary care EGYPT
of people’s health needs through physicians should receive specialized
community-based care. training in family medicine. FACT
The right to health is explicitly
Much of the work to build a Conclusion enshrined in Egypt’s new
primary care-based model has By making health insurance constitution. Port Said will be
already taken place over the last available to everyone, and reinforcing the first to implement Egypt’s
two decades. Historically, Egypt had a community-based approach, Egypt new universal health insurance
placed a disproportionate emphasis will be poised to meet the changing programme to make health
on specialized care, but beginning needs of its growing population. Port services available to all.
in 1997, a series of reforms led to Said was once known around the
the creation of the family health world for having a vibrant and diverse WHY IT MATTERS
model, with the family classified population; perhaps now it will be The previous health system
as the basic unit of care. known for having a population that only provided insurance for
is as healthy as it is vibrant. about 58% of the population,
This was characterized by a and many people could not
responsive and comprehensive afford to access health services.
package of services that included
maternal and child health services, EXPECTED IMPACT
family planning, immunization and Health insurance for everyone
management of childhood illnesses. means that the whole
population can access the
This improved the quality of health services they need, with
PHC service delivery, and resulted an emphasis on primary care.
in sharp declines in both maternal
and under-5 mortality rates. However, IN PRACTICE
even with these reforms, a substantial The Egyptian government
proportion of the population worked closely with WHO
remained unable to afford health on the development of the
©xxxxxx Photoshare
care. The previous health care new law on health insurance.
system provided insurance for only Now WHO is collaborating
approximately 58% of the population; with ministries and universal
hence, the need for a new law which health insurance committees
provides insurance for everyone. on the transformation process.
16 Joint Working Team for UHC: Stories from the field. 17
Dominica Strengthening primary
Community health workers graduating. Photo: WHO.
care with a new cadre of
community health workers
In Dominica, an island in the West Indies with a population of just over
70,000, change is underway to transform the health system into one that
focuses increasingly on primary health care, is people- and community-
centred and is better placed to achieve universal health coverage and
access (or Universal Health, as it is known in the Region of the Americas). Building a stronger health system
In 1978, at the time of the Alma Ata It culminated in a comprehensive It was a pleasure working with
declaration, the Dominica health report which argued strongly that UHC the PAHO/WHO team of experts,
system was a model for primary in Dominica will only be achieved the management team in the
health care, but over the past several through strengthening primary health Ministry of Health and Social
years the primary health care system care and simultaneously addressing Services and members of the
grew weaker faced with resource weaknesses within the health system Dominica National Health
constraints and a greater national relating to governance, health financing, Commission to conduct the
focus on hospital care. Unfortunately, resource allocation and management, comprehensive assessment and
the population’s health situation in and ensuring an integrated approach facilitate the training of the
Cadre of new community health workers. Photo: WHO
Dominica worsened following to health services delivery with inter- CHWs. Even though there were
Hurricane Maria, which devastated sectoral and community participation. many challenges, as would be
the island in September 2017. This The report made several high-level expected following a major
has had a significant impact on recommendations to implement hurricane, the teams worked
human resources for health and action during 2019-2020. collaboratively to overcome
the operation of community health them and bring to fruition the
centres, several of which were The training of the CHWs was just one project deliverables. We are
destroyed or made non-functional. of the more urgent recommendations looking forward to
for health system strengthening. The implementing the major
A systematic approach to skills-based training of CHW in Dominica recommendations of the
strengthening the health system intends to address the shortage of assessment report during the
and primary health care services health personnel and increase the course of the next two years, to
was required. Japanese grant funding capacity to deliver people-centered enable the transformation of the
through the UHC-Partnership supported care within community settings and Dominica Health System to one
a comprehensive assessment of the multidisciplinary teams. All this greatly that is PHC-based, resilient,
Dominica health system after Hurricane strengthens primary health care. sustainable and capable of
The Pan American Health Organization, implemented. One example Maria. The PAHO/WHO technical attaining universal health
the regional office of the World Health of this is the cadre of 27 new team was comprised of seven persons coverage and access and the UN
Organization (PAHO/WHO) has been community health workers (CHW) focusing on various strategic aspects SDGs,” Dr. Rufus Ewing, Advisor
working with the Dominica Ministry who graduated from a training of universal health coverage and access. for Health Systems and Services
of Health and Social Services to programme in September 2018, The team conducted the assessment for Barbados and the Eastern
undertake a thorough assessment and are now starting work in in association with the Dominica Caribbean Countries and the
of the health system, and specific communities to support health Ministry of Healthand Social Services Project Manager.
recommendations are now being services at the primary level. and the National Health Commission
during 2018 and early 2019.
18 Joint Working Team for UHC: Stories from the field. 19
Reflections from the graduates Summary
I was introduced to the health The training of CHWs in Dominica
industry by my mother who is just one of many initiatives geared
is a Community Health Nurse. towards transforming Dominica’s
Just to see her whole effort health system to become a strong
toward caring for people and and sustainable people- and
The course was a great opportunity to taking care of the elderly, community-centred health system,
achieve clarity on health, the community and children, young or old, I felt based on primary health care in order
that I wanted to play a part.” to achieve universal health coverage
what makes a community, how it functions and Mr Vigilant, graduate CHW and access and the Sustainable
what can affect its functionality. Health is broad Development Goals. There is much
One of the things that more work to be done over the next
and has many areas which taught us that we have motivated me was caring for SUMMARY
to adapt to different personalities and to different persons who are unable to care two to three years to implement
for themselves, because we all the major recommendations actions
environments. The course has produced 27 know that living a healthy needed for the transformation of the
qualified foot soldiers for their respective lifestyle is key to any society.” health system. But already, communities
communities and by extension the primary Ms Winston, graduate CHW are beginning to enjoy the impact of DOMINICA
being able to access primary health
health care service in Dominica. The six months was intensive. services where skilled, qualified and FACT
Coming into the programme motivated CHWs are hard at work. Dominica’s health system is
Ms Bertisha Bertrand, graduate CHW. I honestly had no idea what transforming into one that
I was getting myself into but focuses increasingly on PHC
I must say it has really given and is better placed to achieve
me a deeper appreciation for UHC and access (or Universal
the health services and the Health, as it is known in the
ability to be able to reach out Region of the Americas).
to the community and to assist
everyone especially the elderly.” WHY IT MATTERS
Ms Peter, graduate CHW Dominica’s PHC system was
Training community health workers growing weaker due to
The Ministry of Health and Social resource constraints and a
The Minister of Health and Social Ms Wilson spoke to the
Services in collaboration with PAHO greater national focus on
Services, Hon Dr Kenneth Darroux graduates, saying,
and with the support of Japanese hospital care. Hurricane Maria
congratulated the graduates on
funding through the UHC Partnership, devastated the island in 2017,
the successful completion of the Always remember when you
has trained a cadre of 27 CHWs. The which had a significant
programme. He said that the training chose to become a Community
CHW training was conducted by impact on human resources
was conceptualized in-order to Health Aid [Worker], you made
skilled and experienced Dominica- for health and the operation
respond to the need for increased one of the most important
based nurses in collaboration with the of community health centres.
human resource capacity in the decisions of your life, you have
Ministry of Health and Social Services
health sector. chosen to dedicate yourselves
and WHO PAHO. The curriculum was EXPECTED IMPACT
to the care of others.”
developed by the course instructors Training a cadre of new
Taking into consideration the
and vetted and approved by PAHO. community health workers to
constantly increasing demand Ms Jean Jacob, Program
support PHC means that
on our health services both Coordinator for the Community
The six-month programme took communities can enjoy access
quantum and quality and Health Aide programme, provided
place at the University of the West to primary health services
juxtaposing this against available a comprehensive report on the course
Indies Open Campus in Dominica, where skilled, qualified and
resources human and otherwise, including theoretical and practical
and comprised 13 subject areas and motivated health workers are
you can appreciate that today’s components of the programme
Basic Clinical Skills. All participants hard at work. In the long term,
ceremony is a step in the right as well as the collaboration with
passed the Basic Life Support exam the whole health system will
direction towards narrowing a number of organizations within
and received certificates at an official be stronger, making progress
this ever-widening gap.” the communities.
graduation ceremony on 15th April towards UHC.
2019. Family and friends of the
Minister Darroux thanked PAHO Ms Bertisha Bertrand spoke on behalf
graduating class, the Permanent IN PRACTICE
for the technical support provided of the graduating class. She said that
Secretary in the Ministry of Health PAHO/WHO has been
to the program, and commended on starting the course she had very
and Social Services, Mrs Letitia working with the Dominica
the PAHO Country Program Specialist, little knowledge about the role of a
Lestrade-Wyke, Master of Ceremony, Ministry of Health and Social
Ms Anneke Wilson on the great work Community Health Aide. She is
Mrs Terrillia Ravailiere the Chief Services to undertake a
done since being assigned to Dominica. pleased to also now have a more
Nursing officer, and other staff from thorough assessment of the
in-depth awareness of the meaning
the Ministry of Health and University health system and specific
of health.
of the West Indies open campus recommendations are now
Community health workers receiving certificates. Photo: WHO.
attended the ceremony. being implemented.20 Joint Working Team for UHC: Stories from the field. 21
Syrian Arab Republic
NCD patients waiting to receive care at PHC centre of
Maerdabsa Idlib northwestern Syria. Photo: WHO.
Leave no one behind
Universal health coverage means no
Tackling NCDs in emergencies one must be left behind, including
people living in emergency settings.
In the difficult context of a complex
through primary health care
humanitarian emergency, it is all the
more important for WHO and
partners to work together to ensure
that the people of the Syrian Arab
Republic receive the health care
Patients in north-western Syrian Arabic Republic are receiving treatment and care services they need.
for noncommunicable diseases (NCDs) in primary health care settings, despite living
through a conflict.
I visited the primary healthcare In the country, an estimated 45% of with these diseases and implement
center because I started to feel all deaths are related to NCDs, which low-cost solutions for treatment.
my heart flutter, my chest began include cardiovascular disease,
to tighten, I felt pain and a diabetes, cancer and chronic Nine health facilities in northwestern
shortness of breath. I could respiratory disease among others. Syrian Arab Republic piloted the
hardly walk. At the center, I got Cardiovascular disease alone accounts integrated approach to treating NCDs,
an appointment with the for 25% of all deaths. NCDs are also which encompassed improving
internal medicine doctor, and increasing in younger people and diagnosis and treatment at the
they did laboratory tests and an tend to be chronic. Risk factors primary care level. WHO and its
electrocardiogram for me, then, include tobacco use, physical partners had to find innovative
they gave me the needed inactivity, harmful use of alcohol, and solutions to fit the care setting, which,
medications and diet unhealthy diets. due to the emergency situation, can
instructions. I’ve followed the frequently change.
instructions and, thank God, I In north-western Syria priorities
got better and feel well now. I such as trauma care remain but Oftentimes, patients don’t
NCD patient receives care at Zerdana PHC in Idlib northwestern Syria. Photo: WHO.
pay regular visits to the doctor this does not mean that the realize the severity of their
and have less symptoms than impact of chronic illnesses symptoms and don’t seek care.
before,” These are the words of related to NCDs should be But also, with a diagnosis, there
Hana Haj Omar, a woman from underestimated. The problem is is often no continuity of care for
Mardebseh in Idlib governorate not visible enough due to the various reasons including
in the Syrian Arab Republic. She ongoing conflict,” says Annette displacement, shortages in
was fortunate enough to be able Heinzelmann, World Health medicines and of medical staff.
to visit a centre like this, which Organization (WHO) Emergency However, despite immense
could give her the health Lead for the response in north- challenges and limited
services she needed. western Syrian Arab Republic. resources, WHO is investing in
NCD care,” said Heinzelmann.
Providing primary health care services To lessen the impact of NCDs on
in a country like the Syrian Arab individuals and society, WHO
Republic, which is facing one of the integrated NCD care into primary
world’s most complex humanitarian health care (PHC) for the first time in
emergencies, presents many 2018, with financial support of USAID.
challenges for addressing non- Delivering NCD interventions through
communicable diseases (NCDs). With primary health care strengthens early
a severely weakened health system, detection and timely treatment,
challenges include short supplies of especially in a setting with limited
medicines and ensuring access and resources. It is an important way to
continuity in health services. reduce the risk factors associated22 Joint Working Team for UHC: Stories from the field. 23
Improving health worker capacity
Controlling NCDs involves more WHO and its partner Primary Care
than medicines or medical supplies. International (PCI) provided remote
It requires skilled health workers who mentoring and support to the health This patient today (Hana), was not aware that
work according to standard protocols facilities and implementing partners
and put patients at the heart of care. through the duration of the programme
she has hypertension which led to which led to
to ensure adherence to protocols for an oedema in her leg and accelerated heart rate.
In order to ensure that local health diagnosis and treatment of major NCDs
workers were able to diagnose and for several months. The trainings
These are complications as a result of her heart
treat patients with NCDs, WHO sought to develop ‘NCD champions’: failure, caused by the hypertension. When we
trained over 240 people from the nine health workers with clinical NCD skills,
pilot facilities in the PEN (Package of and understanding of the systems
saw those symptoms; an electrocardiogram
Essential Non-Communicable and leadership required to deliver and laboratory tests were done, she was given
disease) protocols for diagnosis and good NCD care.
treatment of NCDs in resource-limited
the needed medications - diuretic pills and
SUMMARY
settings. Due to security limitations, I am confident that the remote antihypertensive drugs - and has made
trainings for participants from north- mentoring has resulted in direct
west Syrian Arab Republic were held positive outcomes for NCD
noticeable progress. This is one of the
in Gaziantep, Republic of Turkey. patients in north-western Syrian success stories of this centre.
Arab Republic, in terms of
Returning as master trainers, diagnosis, treatment, and more
Dr Jamal Alwan, Internal Medicine doctor at
Mardebseh primary healthcare center. SYRIA
they cascaded trainings for all evidence-based use of limited
staff working in the selected health resources. The doctors and FACT
facilities. This created standardized nurses I worked with here have Patients in north-western Syrian
treatment through a structured drug been extraordinarily enthusiastic, Arab Republic are receiving
protocol, improved patient-centric and keen to cascade the training treatment and care for NCDs in
services, consistent monitoring and to their colleagues.” Dr Adam primary health care settings,
follow-up, and increased screening. Sandell, PCI clinical team. despite living through an
These are all vital components in the ongoing conflict.
road to recovery for NCD patients.
WHY IT MATTERS
The country is facing a complex
Increasing treatment capacity humanitarian emergency. Its
Part of the remote mentoring included During the course of the health system is severely
WHO providing NCD emergency kits programme, Syria Relief and weakened, with short supplies
comprising medical equipment and Development, an NGO partner, of medicines and medical staff
22 essential medicines for chronic reported marked increases in and difficulties to ensure
diseases such as hypertension, cardiac the number of patients being access and continuity in health
diseases, diabetes, chronic respiratory diagnosed with and treated services. NCDs are responsible
disease, and selected mental health for NCDs. for 45% of all deaths.
and neurological conditions. They
also included ‘field guides’ illustrating Interlinking access to medicines EXPECTED IMPACT
Doctor checks patient test results in PHC in Idleb Northwestern Syria. Photo: WHO.
NCD treatment protocols based on and medical supplies with capacity People are able to access health
WHO standards. building activities ensures continuity PHC services for NCD care,
of care for patients. despite the huge challenges
These kits were reviewed and facing the health system. There
updated in 2016, and again in 2018, is a marked increased in the
to fit the context in the Syrian Arab number of patients being
Republic. Used for the first time in diagnosed with and treated for
north-western Syrian Arab Republic, NCDs.
by the end of the programme,
27 NCD emergency kits had been IN PRACTICE
distributed, which provided a WHO has collaborated with
three-month supply of medicine partners such as USAID and
for 90000 people. Primary Care International to
integrate NCD care into PHC in
health facilities in the north
west of the country. The project
trained over 240 local health
workers to diagnose and treat
patients with NCDs, delivered
remote mentoring and
provided NCD emergency kits.24 Joint Working Team for UHC: Stories from the field. 25
The National Programme is a big step
forward and we are confident that it
will improve the health of people with
Tajikistan Strengthening
disabilities, as well as support their
education,employment and self-
esteem for full inclusion in society,
rehabilitation in UHC to leave
Mr Asadullo Zikrihudoev, Chairman of the National National Association
of Persons with Disabilities in Tajikistan.
no one behind
Tajikistan’s focus on ‘health for all’ is taking on significant meaning for Robia was only six months old when
she fell ill in 2009 and was unable to
thousands of adults and children suffering from a range of health conditions, move her legs. After a month, doctors
impairments and disabilities. Rehabilitation services are an important part of diagnosed her with polio and she was
sent to a rehabilitation centre but for
primary health care and achieving universal health coverage. By taking a several years there was no progress. In
primary health care approach, the government is transforming access to 2013, however, things changed. Robia What is rehabilitation and
started to have physiotherapy and who is it for?
services and reaching parts of the population often left behind. received training in everyday life skills Rehabilitation involves a set of In Tajikistan, NCDs have increased by
that could make her independent. interventions that helps people to 18% in the last decade and are the
She received a support brace from function in society better. It may be leading cause of death and disability,
the National Orthopaedic Centre, needed by anyone who experiences accounting for 59% of all deaths in
which is adjusted as she grows. difficulties in mobility, vision, hearing, 2014. Currently, there are over 180,000
A confident Robia. When asked what she wants to be when she grows up, without hesitation she replies,
“A therapist… the kind that helps children.” She does not see any reason why this would not be possible.
She is now thriving at school, getting speech, swallowing or cognition, for registered children and adults with
good grades, and continues to visit example. While rehabilitation is often disabilities in Tajikistan. People with
the rehabilitation centre twice a week. associated with disability, it is also disabilities, older people and people
Her mother knows how important important for people who are ageing, with NCDs make up the largest groups
the services have been. “As a result those who have experienced injuries, in need of rehabilitation services.
my child began to feel better, more who have mental health conditions
active, more cheerful. Now she walks or who live with non-communicable As countries strive to meet Sustainable
independently using a brace and diseases (NCDs) such as a stroke or Development Goal 3 (Ensure healthy
stick. She has friends and helps me diabetes. Rehabilitation can improve lives and promote well-being for all at
around the house.” people’s ability to participate more all ages), rehabilitation must inevitably
fully in everyday life and can improve be part of the fundamental approach
Robia is just one of many children their ability to return to work or to strengthening the health system.
and adults who have benefited from school. It can also reduce the costs But in the midst of other priorities it
the government of Tajikistan’s work of ongoing health care and support. can sometimes get overlooked. Often
to establish a national rehabilitation it takes a particular ‘event’ for a
programme, which started in 2013. Awareness of the need for government to realise the significant
It has transformed the lives of many rehabilitation dates back to the positive impact that rehabilitation can
people, and crucially, services are Alma Ata Declaration of 1978 which have on a population’s health and
free of charge to those who need states that to address the main health productivity. This is what happened
Photo: WHO / Satish Mishra.
them. This is a key step towards needs of people in the community, in Tajikistan.
universal health coverage (UHC). health care must include promotive,
WHO has provided support to the preventive, curative, rehabilitative and
government, promoting rehabilitation palliative services. Today, rehabilitation
as a key element of a strong health is even more significant than in
system and by providing policy previous decades because of ageing
and implementation advice for populations and the huge increase
the programme. in NCDs.26 Joint Working Team for UHC: Stories from the field. 27
Strong government leadership Developing a National Programme
In 2010, a large polio outbreak Between 2013 and 2016 the MOHSP international non-governmental
affected several hundred adults developed a national policy, systems and organisations, and donors. Following
and children who had irreversible services for rehabilitation. Beginning in the launch of the programme,
impairments and urgently needed 2016, the MOHSP further strengthened rehabilitation and assistive products
rehabilitation services. However, and expanded rehabilitation services were included in the state-
Tajikistan’s traditional approach from tertiary to primary levels, and this guaranteed health service (the basic
to rehabilitation, based on an work is ongoing. benefit package). The package
outdated model, was not working. ensures guaranteed and free services
The government approached WHO WHO supported this thorough for certain segments of the
in 2012 for support in improving policy development process with population, especially the poor. To
these crucial services. It was a perfect advocacy and technical advice and date, over 180 000 men, women and
opportunity for WHO to promote collaborating with development children have benefitted.
rehabilitation as a key aspect of a partners like United States Agency for Representatives of organization for people with speech and hearing impairment providing their inputs in
strong health system. International Development (USAID) This National Programme focuses drafting of the National Programme on Rehabilitation – Leaving no one behind. Photo: WHO/ Satish Mishra
and United Nations Partnership to on all people with long-term physical,
The Government’s strong leadership Promote the Rights of Persons with sensorial and intellectual impairments,
and political support for rehabilitation Disabilities (UNPRPD) to mobilize those with mental health conditions
drove significant reforms across the funds for Tajikistan. and those with functional difficulties
health system. This was trigged partially caused by NCDs, surgery, infectious
by the polio outbreak but it had an The Government developed a diseases, neurological disorders,
impact which reached far beyond multi-sectoral National Programme injuries or ageing. The Programme
polio. At the government’s request, on Rehabilitation of Persons with aims to provide all these people with
WHO worked with the Ministry of Disabilities (2017-2020) through a high-quality services to ensure their
Health and Social Protection (MOHSP) consultative process involving full and equal enjoyment of human
in 2013 to undertake a situational ministry representatives, disabled rights and to respect their dignity.
analysis of existing rehabilitation people’s organisations, national and
policy and governance and the
impact of service provision on
people with health conditions,
impairments and disabilities.
The analysis found a scarcity of
trained rehabilitation professionals
(physiotherapists, occupational
therapists, speech and language
therapists, orthotic and prosthetic
The National Programme on
technicians, psychologists and Rehabilitation (2017-2020) aims to
physical and rehabilitation medicine
doctors). Also, most rehabilitation
create an enabling environment with
services were located in urban areas, equal opportunities for all. WHO’s
rather than rural areas where the
majority of the population lives.
support in involving diverse disability
Coordination for referrals was weak, and development stakeholders has
and there was little funding for
rehabilitation services. This situation,
made a significant contribution to
however, quickly changed. shaping the National Programme to
better meet the needs of its users
Dr Saida Umarzoda, First Minister of Health and Social Protection.
Wheelchairs are on the national
priority assistive product list.
Photo: WHO/ Satish Mishra28 Joint Working Team for UHC: Stories from the field. 29
Data matters Summary
Collecting accurate and up-to-date With high-level political engagement
information about health and and leadership, the government of
Nine-year-old Robia Rahimova (right) plays with her friend Mariam Narzuloeva.
rehabilitation is one of the most Tajikistan has established a modern
Thanks to the rehabilitation interventions, Robia has learned to walk using
a support brace and forearm crutch, regaining functionality as well as her
important elements for the rehabilitation system within a
Government of Tajikistan in order relatively short period of time and has
to make evidence-informed decisions strengthened vital services to parts of
and progress towards UHC. WHO the population often left behind.
confidence and cheerfulness. Photo: WHO/ Satish Mishra.
provided technical support to the
Agency for Statistics on how to gather Rehabilitation is an essential part of
reliable data on areas such as health the continuum of care, along with
service use, unmet needs and the prevention, promotion, treatment and
financial burden on households of palliative care, and should therefore
paying for health. Now the Household be considered an essential
Budget Survey contains a health and component of integrated health
SUMMARY
disability module, and those who services. Rehabilitation is relevant to
conducted the interviews for the people with many different health
survey received in-depth training on conditions and those experiencing
using interview technology and disability across the lifespan and
processing the data. The impact of across all levels of healthcare. Through
this goes further, as now information including rehabilitation as an essential TAJIKISTAN
on health and disability will also be element of the health system,
included in the national census (due Tajikistan is making strong progress FACT
to take place in 2020). towards UHC and health for all. As part of primary health care
and making progress towards
Services in the community Assistive products Health workforce for rehabilitation The revised health module allow Prevention of impairments and UHC, Tajikistan has established
Before 2013, most rehabilitation Assistive products are a key aspect A strong multidisciplinary rehabilitation us to collect data on household access to quality services for different a National Rehabilitation
services were centralized and in major of rehabilitation. A national priority workforce, and rehabilitation concepts expenditure on health for health conditions also requires a Programme for adults and
urban centres; but this was a barrier assistive products list was developed promoted in all health workforce informed policy-making and strong health system which is still an children suffering from a
to the 73.6% of the population living to guide future activities such as education, is crucial in order to provide better targeting of public funds ongoing work in Tajikistan, especially range of health conditions,
in remote rural areas who needed product development and production, comprehensive rehabilitation services. as a key strategy to mitigate the for conditions amenable to primary impairments and disabilities.
to access health and rehabilitation service delivery, market shaping, impact of out-of-pocket payments health care such as vaccination, good
services in their own communities. procurement and reimbursement. The MOHSP have trained and improved on household welfare,” said hypertension and diabetes detection WHY IT MATTERS
The Tajikistan government promoted For example, Tajikistan imports about the capacity of rehabilitation centre the First Deputy Director of the and management. Awareness of the need for
Community-delivered Rehabilitation 800 wheelchairs a year; however, the staff (including physiotherapists and Agency of Statistics, Tajikistan. rehabilitation dates back to
as way to bring services to the annual need is greater than 11 700. occupational therapists), who attended the Alma Ata Declaration of
community and ensure better access. national capacity-building workshops. 1978. Today, rehabilitation is
From 2016, community rehabilitation MOHSP, with the support of WHO, This led to the establishment of more important than ever
programmes have been established produced a report in 2019 showing rehabilitation units within the because of ageing populations
in 35 of Tajikistan’s 66 districts, that Tajikistan’s current levels of hospitals and strengthening of existing and the huge increase in non-
benefitting nearly 10 000 people quality wheelchairs are insufficient, rehabilitation centers. The MOHSP is communicable diseases.
in rural areas. and maintenance repair centres are supporting six local health workers –
not provided for or are underfunded. physiotherapists, occupational EXPECTED IMPACT
To reach universal coverage of therapist and therapy assistants - to Rehabilitative and assistive
wheelchairs, the government needs attend formal long-term training products have been included
10 000 wheelchairs annually over the programmes outside Tajikistan, with
Health and disability in Tajikistan’s state-guaranteed
next 3-5 years. This is important as the obligation to return to the country questionnaires are new to us, health service. The package
the strength of the assistive product to support the MPHSP in providing ensures free services for certain
provision system influences the way rehabilitation services nationwide.
we never collected such data. segments of the population,
a person accesses health services It is good that WHO organized especially the poorest, and
and integrates into society, including WHO is collaborating with the World over 180,000 people have
education and employment. People Confederation for Physical Therapy and
the training for us, we have benefited.
need to access assistive products that the World Federation of Occupational learned a lot.
are appropriate for them and of good Therapists (WFOT) to further strengthen IN PRACTICE
said Zarrina Mazutova, and interviewer
quality, without suffering financial rehabilitation in Tajikistan. In 2018, WHO from Kushonion District, Khatlon Region. Tajikistan’s Ministry of Health
hardship as a result. welcomed representatives of the WCPT and Social Protection has led
and WFOT to Dushanbe to facilitate the way to establish the
collaboration with the MOHSP to National Rehabilitation
improve capacity building and Programme; WHO has
education for rehabilitation promoted rehabilitation as a
professionals. This has led to initiation key element of a strong health
of programme to strengthen system and provided policy
rehabilitation education in Tajikistan. and implementation advice.30 Joint Working Team for UHC: Stories from the field. 31
Liberia Task-sharing for UHC:
A new born baby in Monrovia, Liberia © 2015 K.Ochel/MI, Courtesy of Photoshare.
training nurses and midwives
in obstetrics, neonatal care
and anesthetics
In Liberia, a transformative project is training nurses and midwives to
become qualified obstetric and neonatal clinicians. It reduces the delays
commonly experienced in recognizing and treating emergencies, saves lives
and ensures that mothers and babies receive the health care they need.
A trainee midwife clinician in In Liberia, a transformative project The nurses and midwives are being Reducing deaths in
Liberia is very clear that her newly is training nurses and midwives to trained to far higher levels than usual women and children
acquired skills are saving lives. become qualified obstetric and in obstetric and neonatal care in what For some years the Government Liberia is aiming for a 50%
neonatal clinicians. It reduces the is known as ‘task-sharing’ with other of Liberia has prioritized reproductive, reduction in national maternal
A mother with obstructed delays commonly experienced in medical professionals. Why is this so maternal, newborn, child and and newborn deaths and stillbirths
labor referred to our rural recognizing and treating emergencies, important? Maternal and newborn adolescent health to save lives by 2023, to be on track to meet
hospital when my senior doctor saves lives and ensures that mothers deaths in Liberia are tragically all too and accelerate progress towards SDG3 by 2030. For this to be
had just left to find food to eat. and babies receive the health care frequent. Every day, an event claims Sustainable Development Goal 3 achieved, increased numbers of
I had to do a cesarean section they need. Through improving the the lives of four to five mothers and (SDG3) targets for reducing maternal pregnant women and newborns
along with the intern doctor. first level referral hospital-based eight to ten newborns and most and neonatal mortality and achieving must have equitable access to
During the surgery, the patient maternal and neonatal care and deaths occur around the perinatal UHC. According to the latest Liberian high-quality services in hospitals
had a deep posterior tear in the coordinating with community-based period, immediately before and after Demographic and Health survey, and selected health centers.
uterus, which was repaired care throughout Liberia, the country birth. Many deaths are due to delays the general coverage of the majority Importantly, efforts need to focus
without the senior doctor’s help. is taking firm steps towards universal in recognizing a life-threatening of interventions for reproductive, on hard-to-reach communities
It was difficult, but it was done. health coverage (UHC). emergency at the community level. maternal, newborn, and child health and vulnerable women and
I monitored the patient and her Other causes are delays reaching a increased substantially during adolescent girls and babies in
baby, the whole night worrying hospital with the right facilities and 2007-2013. But there are variations 11 rural counties.
about bleeding, but she did not staff to treat the patient, and delays in coverage across the regions with
bleed. We had to keep the at hospitals to identify and respond the North-Western and South-Eastern
urinary catheter in for seven days to the emergency. Added to this is B region experiencing a 25% higher
A mother waits with her baby at a private clinic
to prevent a fistula forming due the problem of the lack of doctors in in Kolahun, Liberia. © 2005 Kevin McNulty, maternal and newborn mortality
to the first obstructed labor, and Liberia, with only 298 doctors and 16 Courtesy of Photoshare. than the national average.
she was discharged eight days obstetricians available in a population
later along with her baby.” of about 4.8 million. Nurses, midwives
and community birth attendants
have the potential to carry out
critical medical tasks.You can also read
