key: cord-0066477-k4tgnbd1
authors: Araj, Salma Jaouni; Hassan, Samar
title: State of Quality in the COVID-19 Era “Initiatives and Priorities for Improving Quality in the Future” Reflections from the EMR Region
date: 2021-07-12
journal: nan
DOI: 10.1093/ijcoms/lyab010
sha: 3b5f280bcf25b8dacd72d38769999267a168b34f
doc_id: 66477
cord_uid: k4tgnbd1

nan

Compromising 9% of the worlds population (6) , nearly two thirds of the Eastern Mediterranean Region (EMR)'s countries are directly or indirectly affected by conflict, natural disasters, and political instabilities. (1) Others are wealthy countries classified under upper income by the World Bank and definitely we have no regional leadership, cooperation or clarity in data collection or reporting. All have been affected by COVID-19 and have worked to improve quality of care.

Looking at information that is available from governments and the WHO EMR office, we offer some insights on how well prepared our healthcare systems have been to navigate through this turbulent environment, what are the lessons learned so far, and how are we moving forward.

As of 11 March 2021, the 22 countries of the EMR have reported a total of 6,741,645 cases and 148,733 deaths (2) . These numbers of course, are missing the real numbers of death in countries where registration and follow up is weak. The Region deals with these cases, while grappling with existing challenges prior to the pandemic including serious shortages of health workforce, shortages of essential medicines, in most low-middle income countries, inadequate service delivery for assistive technology in many countries, and extremely limited access to medical devices in low-and middle-income countries and even some highincome countries. (1) Despite that, most countries in the EMR region established high-level national multisectoral coordination mechanisms and developed national plans covering the nine pillars of the WHO COVID-19 Strategic Preparedness and Response Plan. (3) While the pandemic has presented an array of challenges from managing the supply chain for personal protective equipment (PPE), to adjusting workforce capacity, to coping with financial loss(4), it has also driven many health systems across the region to embark on new models of health service delivery, highlighted the need for taking unorthodox approaches, and triggered a sustained demand for innovation (11) . Unprecedented strides have been taken in the EMR region, in the areas of [1] digital & telehealth expansion, [2] emergency care system strengthening, and [3] research and knowledge sharing -possibly a silver lining! In the area of Telehealth, a rapid expansion has been seen for payment systems and regulation, while allowing for the provision of remote access to quality healthcare services without increasing the risk of transmitting infection (5) , and with an attempt to address the health care needs of patients with chronic Box 1. Humanitarian Overview of the EMR Region: (31) . Ramifications of the pandemic were exacerbated by existing humanitarian crisis in many countries with armed conflict (32)  Eight EMR countries affected by conflict and humanitarian emergencies-Afghanistan, Iraq, Libya, the occupied Palestinian territory, Somalia, Sudan, Syria, and Yemen.  Over 12 million people are internally displaced across the region. 

Escalating hostilities in parts of Syria, Yemen and Libya continue to force people to flee their homes and exacerbate civilian suffering, deaths, and injuries.

Strategic Preparedness and Response Plan: (10) • Country-level coordination, planning, and monitoring • Risk communication and community engagement • Surveillance, rapid response teams, and case investigation • Points of entry, international travel, and transport • National laboratories • Infection prevention and control • Case management • Operational support and logistics Maintaining essential health services and systems diseases, and mental health conditions. This has been especially beneficial for the EMR region, where there is a double burden of communicable and noncommunicable diseases;the region has some of the highest NCD prevalence rates globally and future projections indicate an alarming increase. The COVID-19 pandemic lockdowns affected people's access to medications for management of their noncommunicable diseases (NCDs) and EMR countries but adaptations were made as illustrated in the below table: Another area with an expansion of initiatives was in Emergency Care Systems Strengthening, where many countries aimed to have more agile and resilient response systems. Several models were implemented in the EMR to ensure effective response including system activation and field facility communication strategies. In 2018, only 13 of 22 EMR countries reported having a national emergency care access number required for system activation (8) . However, in response to the WHO's key recommendation to strengthen the health system response to COVID-19, as 20 of 22 EMR member-states and Palestine have established ad-hoc national or regional COVID-19 hotlines for the public to access information, report suspected cases, and be screened for symptoms of COVID-19. (9) Another key functional component of emergency care system is field-to-facility communication. Such pre-arrival notification and coordination between ambulance services is rare in the EMR region (10) . As part of COVID-19 response, many countries established pre-arrival notification protocols, in order to ensure coordination to allow for an adequate clinical response to patients with COVID-19 respiratory problems. Additionally, the pre-arrival protocols ensure that emergency care units are prepared for critical and time-sensitive cases (e.g. Acute myocardial infarction, stroke, trauma etc.). (11) Among the weaker areas in healthcare decision and planning is the lack of data and research to guide interventions. However, the COVID-19 pandemic has stimulated an enormous amount of research by scientists across various disciplines and in the EMR who have contributed to the research initiatives and the collaborative knowledge sharing, within the following domains:

 (17)(18)(19)(20)(21)(22)(23)(24)(25)(24)(26)(27)(28)  COVID-19 Vaccine Clinical Trials: The EMR region has played an active role in the approval process of one of the earlier vaccines to be developed and approved (Sinopharm vaccine). The vaccine trial was a partnership between Sinopharm's China National Biotec Group (CNBG) and Abu Dhabi-based artificial intelligence and cloud computing company Group 42 (G42). It was widely tested in the UAE, Egypt, Bahrain, and Jordan. The vaccine was then approved and rolled out in many EMR countries beginning January 2021 (29)

While still facing the burdens of the pandemic, countries in EMR are forced to reassess and think creatively about healthcare quality in the post-COVID-19 world. In order to become resilient, countries in the EMR must continue efforts to build strong systems for health security, ensure sustained investments, and insist on strong governance of preparedness for future emergencies.(30). Though many interventions were catalyzed by panic and reactive modes, it is imperative to sustain the learning and build on the investments to date, such as the use of telehealth, community outreach, supporting research for decision making, strengthening emergency response, and developing more people-centered services though call centers, primary healthcare teams, community involvement and designing interventions that speak to citizen perceptions and culture. In this way, we can maximize resources and support each other.

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