The Impact of COVID-19 on NCD Services in the EMR (PDF)

Research article EMHJ – Vol. 28 No. 7 – 2022 The impact of the COVID-19 pandemic on service delivery for noncommunicable diseases in the Eastern Mediterranean Region Asmus Hammerich,1 Heba Fouad,1 Eglal...

Research article EMHJ – Vol. 28 No. 7 – 2022 The impact of the COVID-19 pandemic on service delivery for noncommunicable diseases in the Eastern Mediterranean Region Asmus Hammerich,1 Heba Fouad,1 Eglal E. Elrayah,1 Slim Slama,1 Fatimah El-Awa,1 Hicham El-Berri1 and Nisreen Abdel Latif1 World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Heba Fouad: [email protected]). 1 Abstract Background: The COVID-19 pandemic has adversely affected the delivery of noncommunicable diseases (NCDs) services globally as health systems are overwhelmed by the response to the pandemic. Aims: The World Health Organization (WHO) Regional Office for the Eastern Mediterranean conducted an assessment to evaluate the impact of COVID-19 on NCD-related services, programmes, funding and consideration of NCDs in COVID-19 response. Methods: Data were collected from countries of the WHO Eastern Mediterranean Region (EMR) in mid-2020 through a web-based questionnaire on NCD services-related infrastructure, policies and plans, staffing, funding, NCD services disruptions and their causes, disruption mitigation strategies, data collection on comorbidity, surveillance, and sugges- tions for WHO technical guidance. The data were exported into Microsoft Excel and summarized. Countries were grouped according to socioeconomic level. Results: Nineteen of the 22 countries in the EMR responded: 95% had NCD staff reallocated to support their COVID-19 response. Lower-income countries were less likely to include NCDs in their pandemic response plans and more likely to report disruption of services. The most commonly disrupted services were hypertension management (10 countries 53%), dental care (10 countries 53%), rehabilitation (9 countries 47%), palliative care (9 countries 47%) and asthma management (9 countries 47%). Conclusion: The COVID-19 pandemic has disrupted the continuity of NCD-related services in EMR countries. The abil- ity to mitigate service disruptions varied noticeably between countries. The mitigation measures implemented included triaging of patients, novel NCD medicines supply chains and dispensing interventions, and the use of digital health and telemedicine. Guidance and support for systems resilience, preparedness and response to crises are recommended. Keywords: NCDs services, COVID-19 response, WHO Eastern Mediterranean Region Citation: Hammerich A; Fouad H; Elrayah E E; Slama S; El-Awa F; El-Berri H; Abdel Latif N. The impact of the COVID-19 pandemic on service delivery for noncommunicable diseases in the Eastern Mediterranean Region. East Mediterr Health J. 2022;28(7):469–477. https://doi.org/10.26719/emhj.22.053 Received: 31/10/21; accepted: 09/05/22 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Introduction Globally, health systems have been struggling with, and in some cases have been overwhelmed by, the The ongoing COVID-19 pandemic is having a heavy toll dramatically increasing numbers of COVID-19 cases on people living with noncommunicable diseases (NCDs) (6). In response, countries had to reorient services and (1). From the early stages of the pandemic, it became to reallocate resources to defend against the pandemic, evident that people living with NCDs are at higher including reassignment of health care providers. In some risk of experiencing a severe impact from the disease countries, nonemergency health services were put on caused by the novel coronavirus and that they are more hold, with a complete shut-down of the health facilities likely to die from it (1,2). The burden of NCDs has been providing these services (1). All these factors combined considered an indicator for country-level vulnerability have disproportionately affected how the pandemic has to COVID-19 in addition to other vulnerability factors (3). jeopardized the sustainability of NCD services during the pandemic (7,8). Owing to these increased risks, people living with NCDs have been strongly advised to practise higher levels of Therefore, amid mounting concerns that many people vigilant preventive behaviours, including staying at living with NCDs in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) might not home and maintaining physical distancing (4). Further, be receiving appropriate treatment or access to medicines access to health care services for people living with NCDs during the pandemic, the Regional Office conducted a in particular has been adversely affected by restrictions rapid assessment survey to get a snapshot of the situation. applied on population movements and lockdowns which The survey was conducted to fully understand the impact were imposed in most countries to mitigate the effects of COVID-19 on NCD-related services and programmes of the pandemic on health systems and to “flatten the as well as to evaluate the scale of consideration of NCDs epidemic curve” (5). in COVID-19 response plans in countries of the Region. 469 Research article EMHJ – Vol. 28 No. 7 – 2022 Methods know if NCD funds had been reallocated to support the pandemic efforts. The EMR has an estimated population of about 679 million people (9) in 22 countries and territories which Policies and plans are classified into 3 groups by WHO to better account On the inclusion of NCD services in countries’ national for the socioeconomic disparities in the Region. Group 1 countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, COVID-19 preparedness and response plans, 12 of the and the United Arab Emirates) have the highest level of EMR countries (63%) reported that they had included socioeconomic development. Group 2 countries (Egypt, NCD services in their plans. Nevertheless, there were the Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libya, notable differences between country groups, with 6 of Morocco, the West Bank and Gaza Strip, the Syrian Arab the 9 countries in Group 2 (67%) and 1 of the 4 countries Republic and Tunisia) are the next most developed and in Group 3 (25%) being less likely to include NCDs in Group 3 countries (Afghanistan, Djibouti, Pakistan, their COVID-19 response plans compared with 5 of Somalia, Sudan and Yemen) are at the lowest level of the 6 countries in Group 1 (83%). The inclusion of NCD development (10). services in the list of essential health services during The data collection for the assessment of service the pandemic was lowest in Group 3 countries; only a delivery for NCDs during the COVID-19 pandemic was quarter of these countries reported implementing some conducted through a web-based questionnaire that was services. Furthermore, at the regional level, countries developed by WHO in the early phases of the pandemic reported diverse levels of consideration of specific to conduct a global rapid assessment of the disruption NCD-related services in their plans. Services to address of NCD services (11). The questionnaire was shared with cardiovascular diseases, cancer, diabetes (13 countries, NCD focal points in ministries of health in all EMR 68%) and chronic respiratory diseases (11 countries, 58%) countries in May 2020. The questionnaire was divided were those most frequently included in the COVID-19 into 5 main sections to cover: infrastructure, policies response plans in the EMR countries. However, dental and plans, NCD-related health services, surveillance, and services (8 countries, 42%), rehabilitation (6 countries, suggestions. It was designed to assess the effects of the 32%) and tobacco cessation activities (8 countries, 42%) pandemic from different angles including: NCD staffing, were not as widely included in the response plans as the services provision, funding of national COVID-19 4 main NCDs (Figure 1). Furthermore, 2 countries (11%) in response plans, levels and causes of service disruption, the Region reported the inclusion of additional services mitigation strategies implemented, data collection on such as mental health and counselling services in their comorbidity at the country level, and suggestions for COVID-19 response plans. When restricting the analysis WHO technical guidance. to countries that considered NCD services in their The collected data were exported to Microsoft Excel national COVID-19 response plans (n = 12), all of them workbooks and were checked for completeness and included cardiovascular disease, cancer and diabetes validity. Data were summarized as percentages of either services. the total number of countries which responded to the On the other hand, only 2 countries (11%) in the Region survey or a of their corresponding country group as reported allocating additional funding for NCDs in the described above. government budget for the COVID-19 response. Group 3 countries reported the highest proportion, with 1 out Results of 4 countries (25%) in the group allocating additional funding, followed by Group 1 with 1 out of 6 countries Survey response (17%). However, none of the countries in Group 2 reported Nineteen of the 22 (86%) countries in the EMR responded allocation of additional funds for NCDs. to the survey: all 6 Group 1 countries, 9 countries (90%) in Postponement of NCD activities during the pandemic Group 2 (missing response from Egypt), and 4 countries was reported by 80% of EMR countries (15 out of 19 (67%) in Group 3 (missing responses from Pakistan and Somalia). countries). Over 60% of the countries (12 countries) reported postponing public screening programmes. Infrastructure Implementation of NCD surveys was postponed by 7 Regarding the shifting of NCD-allocated staff and countries (37%) and mass communication campaigns by funding to the COVID-19 response, 95% of countries in the 8 countries (42%). Postponement of the WHO Package Region had some or all NCD staff supporting COVID-19 of Essential Noncommunicable Disease Interventions response efforts, either full- or part-time. Regarding (WHO PEN) was reported by 3 of the Group 3 countries the reallocation of NCD funds by governments to non- (75%), 4 of the Group 2 countries (42%) and none of the NCD services, only the United Arab Emirates reported Group 1 countries. Five of the 19 countries reported that some NCD funds had been reallocated to support disruption to additional services such as finalizing their COVID-19 response efforts. However, at the time of data multisectoral cancer strategies and holding conferences, collection, 8 countries (42%) reported that they did not workshops, campaigns and summits relevant to NCDs. 470 Research article EMHJ – Vol. 28 No. 7 – 2022 Figure 1 Distribution of Eastern Mediterranean Region country groups reporting inclusion of noncommunicable disease services on the list of essential health services in their COVID-19 response plans, 2020 (Group 1: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates; Group 2: Iraq, Islamic Republic of Iran, Jordan, Lebanon, Libya, Morocco, Syrian Arab Republic, Tunisia, West Bank and Gaza Strip; Group 3: Afghanistan, Djibouti, Sudan, Yemen) **Egypt, Pakistan and Somalia not included 90% 83% 80% 78% 78% 70% 67% 67% 68% 60% 58% 56% 50% 50% 44% 44% % 42% 42% 40% 33% 32% 30% 25% 20% 10% 0% 0% Group 1 Group 2 Group 3 EMR** Country group Cardiovascular disease services Cancer services Diabetes services Chronic respiratory disease services Chronic kidney disease and dialysis services Dental services Rehabilitation services Tobacco cessation services Noncommunicable disease-related health services in Group 3 were cancer services and asthma services services (3 of the 4 countries), while diabetes services were the most commonly disrupted services (5 of the 9 Regarding government policies on access to essential countries) in Group 2 (Figure 3). inpatient and outpatient NCD services during the pandemic, at the primary, secondary and tertiary care The reported disruption of NCD-related services levels, 13 (68%) of the countries reported that NCD in countries of EMR had many underlying causes. outpatient services had either been closed or were open The most common causes were the closure of disease- but with limited access and/or staff, or in alternative specific outpatient consultation clinics and the decrease locations with different modes. Three of the 4 Group 3 in inpatient volume due to the cancellation of elective countries reported that outpatient services were open care (both 47%, 9 countries). Staffing problems were with limited access, and the same proportion reported also a common issue, with 5 countries listing the fact that inpatient NCD management services were open for that staffing was not sufficient to provide services and 6 emergencies only. Additionally, 10 (53%) of the countries deploying NCD-related clinical staff to provide COVID-19 in the Region reported that inpatient NCD management services. Insufficient supplies of personal protective services were open for emergencies only. At the time of equipment for health care providers was one of the main data collection during the early stages of the pandemic, reasons for discontinuation of services, affecting Group 3 out of 5 countries in the EMR with community 3 (2 of the 4 countries) and Group 2 (2 of the 9 countries) transmission of the virus (60%) reported that outpatient but none in Group 1. services were either closed or restricted to some degree, In response to the pandemic control measures and and 10 of the 19 countries (53%) reported that inpatient disruption of services, countries have been putting in NCD management services were open for emergencies place a range of strategies to maintain health service only. delivery. The survey revealed that alternative strategies In addition to policies on access to inpatient and have been established in most countries to allow groups outpatient services, many countries reported more at higher risk, including people living with NCDs, to specifically on disruptions to a number of NCD-related continue receiving treatment. Nine countries in the services which had been partially or completely disrupted. Region (47%) reported the implementation of triaging Services were partially or completely disrupted in10 of and prioritization of patients, 42% used novel supply the 19 countries surveyed for hypertension treatment chains and/or dispensing approaches for NCD medicines, and urgent dental care, in 9 countries for rehabilitation and 6 countries (32%) redirected and referred patients services, palliative care services and asthma services, with NCDs to alternative health care facilities (Figure and in 8 countries for treatment for diabetes and cancer 4). Furthermore, 5 countries were using telemedicine management (Figure 2). The most commonly disrupted to replace in-person consultation. The most commonly 471 Research article EMHJ – Vol. 28 No. 7 – 2022 Figure 2 Distribution of disruption to the noncommunicable disease services reported in the countries of the Eastern Mediterranean Region, 2020 (Egypt, Pakistan and Somalia not included) 60.0% 50.0% 40.0% 36.8% 26.3% 42.0% 31.6% % 30.0% 47.4% 20.0% 42.1% 42.1% 26.3% 10.0% 21.1% 15.8% 15.8% 11.1% 0.0% Hypertension Urgent dental Rehabilitation Palliative care Asthma services Cancer treatment Diabetes and Cardiovascular management care services services diabetic emergencies complications (including MI, management stroke and cardiac arrhythmias) NCD service Service Completely disrupted Partially disrupted used alternative Figure strategies among 2. Distribution Group 2 countries of disruption Discussion disease services reported in to the noncommunicable were triaging and redirecting patients to alternative Region, 2020 (Egypt, Pakistan and Somalia not the countries of the Eastern Mediterranean This assessment was conducted during the early stages facilities; the use of novel supply chains was reported by included) of the COVID-19 pandemic, hence, the responses and all countries in Group 3 (Figure 4). measures implemented by countries might have changed Noncommunicable disease surveillance over the course of the pandemic and the rollout of vaccines (12,13). The findings on the different indicators Data on NCD comorbidity among COVID-19 patients from the EMR are comparable to those reported by WHO were collected in 15 (79%) of the EMR countries surveyed, at the global level and from the other WHO regions (11); including all countries in Group 1, 6 (67%) in Group 2 and the service disruption experienced in the EMR was part 3 (75%) in Group 3. of a global phenomenon. The most commonly disrupted services globally were for hypertension, diabetes and Suggestions for technical support asthma, with values ranging from 48% to 53%. Disruption Countries were invited to provide suggestions for NCD- levels in the EMR were comparable to those occurring in related technical guidance which WHO might provide the other regions. during the COVID-19 outbreak. This was an open-ended On the reallocation of resources, NCD staff being query, and responses were numerous and diverse, but a reassigned/deployed to help with COVID-19 response few themes for proposals emerged from the data: was reported in most of EMR countries consistent with prevention and management of COVID-19 in people the rate reported at the global level. However, globally, living with NCDs and provision of ambulatory 21% of countries reported that some NCD funds had been essential NCD services during a lockdown without reallocated; compared with only one high-income country jeopardizing the safety of patients or health care in the EMR (5%) has reallocated funds, which was the lowest compared with the other WHO regions (11). This is providers (cited 4 times); reflective of the limited and diverse availability of funds technical guidance on the provision of services and prioritization of NCD prevention and management for people living with NCDs through mHealth, across the globe (14). telemedicine and virtual consultations (cited 3 times); Implementation of the EMR policies and plans was promotion of mental health and provision of services fairly similar to those at global level, with 66% of countries for both the public and health care workers (cited 1 reporting that they had included NCD services in their time); national COVID-19 preparedness and response plans (11); the European Region (74%) reported the highest level and modification of the HEARTS technical packages and the African Region the lowest (59%) (Table 1). However, the WHO PEN protocol for NCDs (cited 1 time); the EMR reported a slightly lower level than the global 15 integrating NCDs into public health emergencies, average regarding the allocation of additional funding for with a particular focus on mental illness (cited 1 time). NCDs (Table 1). With regard to the government policies 472  Research article EMHJ – Vol. 28 No. 7 – 2022 Figure 3 Distribution of disruption of services for the main noncommunicable diseases reported in the country groups of the Eastern Mediterranean Region, 2020 (Group 1: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates; Group 2: Iraq, Islamic Republic of Iran, Jordan, Lebanon, Libya, Morocco, Syrian Arab Republic, Tunisia, West Bank and Gaza Strip; Group 3: Afghanistan, Djibouti, Sudan, Yemen) **Egypt, Pakistan and Somalia not included 75% 75% 56% 50% 50% 50% 47% 44% 44% 44% 42% 42% 42% % 33% 33% 25% 26% 22% 17% 17% 17% 11% 11% 0% Group 1 Group 2 Group 3 EMR** Disruption and country group Hypertension management completely disrupted Hypertension management partially disrupted Cardiovascular emergencies (including MI, stroke and cardiac arrhythmias) partially disrupted Cancer treatment partially disrupted Diabetes and diabetic complications management partially disrupted Asthma services partially disrupted on access to essential NCD services, the regional estimate level, 24% of the countries have reported that one of the Figure 3. adversely on policies Distribution ofNCD affecting disruption of services services, was slightly formain the reasons main four noncommunicable for discontinuing services was insufficient higher than the global average (11). Besides, while just diseases reported in the country groups of the Eastern Mediterranean Region, supplies of personal protective 2020 (Group equipment available above a third of countries at the global level reported 1:that Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, for inpatient NCD management services were open United healthArab Emirates; care providers Group to deliver 2: Iraq, services which was Islamic Republic slightly higher than the regional estimate of 21% (11). for emergencies only,ofthis Iran, was Jordan, Lebanon, reported for more thanLibya, Morocco, Syrian Arab Republic, Tunisia, West Bank half the countries and Gaza of the EMR. StaffingStrip; problems Group were a3: Afghanistan, In responseDjibouti, Sudan, Yemen; to these disruptions, triaging of patients **Egypt, consistent Pakistan issue at bothand Somalia global not included) and regional levels with was the most common strategy used by almost half around a quarter of countries at both levels reporting of countries to overcome service disruption at both insufficient staff to provide services (11). At the global global and regional levels followed by telemedicine Figure 4 Approaches used to overcome noncommunicable disease service disruptions in the country groups of the Eastern Famille réalisée en 2002 dans le Mediterranean Region, 2020 (Group 1: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates; Group cadre 2: duIraq, Projet panarabe sur la Islamic Republic of Iran, Jordan, Lebanon, Libya, Morocco, Syrian Arab Republic, Tunisia, West Bank and Gaza Strip; Santé Group de la 3: Cette Famille. Afghanistan, Djibouti, Sudan, Yemen) **Egypt, Pakistan and Somalia not included enquête a été menée par l’Office 100% National des Statistiques, en 100 étroite collaboration avec les 90 services en charge des questions 80 75% de population au ministère de la 70 Santé, de la Population et de la % 60 Réforme Hospitalière, dans la 50 47% 44% 44% 42% continuité du projet sur la santé 40 33% 33% 33% de la32% mère et de l’enfant « 30 22% 22% 22% 25% 25% 25% 25% 26% 17% 17% 21% PAPCHILD » initié par la Ligue 20 11% des États11% Arabes vers la fin des 10 0% années quatre-vingt. 0 Group 1 Group 2 Group 3 EMR** Telemedicine deployment to replace in-person consults Task shifting / role delegation Novel supply chain and/or dispensing approaches for NCD medicines Triaging to identify priorities Redirection of patients with NCDs to alternate health care facilities Others 16 473 Research article EMHJ – Vol. 28 No. 7 – 2022 Table 1 Comparison of noncommunicable disease service disruption and response at global and WHO regional levels (14) Indicator Worlda Eastern Africa Americas Europe South- Western- % Mediterraneanb % % % east Asia Pacific % % % NCD services partially or completely disrupted Hypertension management 53 53 61 45 66 60 27 Cardiovascular emergencies 31 26 51 17 26 20 27 Cancer treatment 42 42 59 28 32 70 38 Diabetes management 49 42 59 52 58 50 23 Asthma 48 47 66 28 61 50 23 Ministry of Health (or equivalent) staff with responsibility for NCDs/NCD risk factors reassigned/deployed to help with COVID-19 response 94 95 88 97 97 100 96 Countries reporting reallocation of NCD funds to nonNCD services due to COVID-19 response efforts Some funds 21 5 22 7 23 60 26 Don’t know 30 42 22 34 44 10 19 None/not yet 50 53 56 59 33 30 56 Countries reporting that ensuring continuity of NCD services was included on list of essential health services in their COVID-19 response plan No/don’t know 34 37 41 28 26 40 41 Yes 66 63 59 69 74 60 62 Countries reporting that additional funding has been allocated for NCDs in the government budget for the COVID-19 response Don’t know 23 32 22 24 28 0 19 No 59 58 63 62 54 80 48 Yes 17 11 15 10 15 20 33 Approaches used to overcome the service disruptions to NCD management and prevention in public sector health facilities Telemedicine deployment to replace in- person consultations 45 26 27 52 67 50 48 Task-shifting/role delegation 30 21 22 28 36 50 37 Novel supply chain and/or dispensing approaches for NCD medicines 35 42 24 48 26 30 44 Triaging to identify priorities 48 47 49 59 59 10 33 Redirection of patients with NCDs to alternate health care facilities 35 32 32 41 31 50 37 Countries where ministries of health collect or collate data on NCD-related comorbidities in COVID-19 patients 75 79 71 86 87 40 63 a Occupied Palestinian territory not included. b Egypt, Pakistan and Syrian Arab Republic not included. Data on global level and other WHO regions derived from the report on “The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment” (14). and the use of novel supply chains and/or dispensing and NCD risk factors to build on, including interventions approaches for NCD medicines through other channels, for tobacco cessation and other behavioural change at global and regional levels respectively (Table1) (11). It interventions (15). The Region was no exception from is worth mentioning that countries of the EMR already the global thrive in remote health service provision to had previous experiences in the use of technology and bridge disruptions during the COVID-19 pandemic (16,17). Digital Health Interventions (DHIs) for tackling NCDs Additionally, on NCD surveillance activities, 79% of 474 Research article EMHJ – Vol. 28 No. 7 – 2022 countries reported collection of data on COVID-19 NCD- Recommendations related comorbidity, which is just above the global level Countries of the EMR need to strengthen NCD prevention of 75%, with the highest level in the European Region and and control measures and to reinforce health systems the Americas and lowest in South East Asia (Table1) (11). resilience for NCDs during crises beyond the COVID-19 As previously described (7), this COVID-19 crisis is pandemic. The following policies, strategies and plans in fact a “syndemic” rather than a pandemic, where the are recommended for the EMR countries: effect of the pandemic is far beyond the transmission of Strengthening national governance to include the virus but is rather determined by interactions with NCDs in national emergency response plans for deeply rooted inequalities, especially when it comes to the ongoing COVID-19 and other challenging and people living with NCDs (4,7,18). This is also linked to disruptive crises, through the development and the disparities observed in this assessment in the ways adoption of practical guidance on and monitoring that countries have responded to COVID-19. COVID-19 of the continuity of essential services for NCDs and NCDs have synergistic effects on one another and especially during crises. This includes the use and disproportionately impact the poorest and the most mainstreaming of DHI innovations for remote NCD vulnerable groups, exacerbating inequalities (19). At the prevention, management, and self-care interventions. regional level, it has been observed that Group 3 countries are less NCDs-responsive compared to Group 1 countries, Strengthening health system resilience especially in with more disruption of services and less consideration to low-income countries, to help in coping with crises, NCD services in COVID-19 response plans. Paradoxically, through reinforcement of governance and leadership, the response from most of the countries of EMR was that sufficient flexible funding, human and physical they did not know or have not reallocated funds from resources, in addition to responsive service delivery NCDs to other services at the time of the data collection, using innovative approaches and DHIs. and this can be due to the limited resources for NCDs Prioritization of NCDs care and access to NCDs to begin with, especially in Group 3 countries, were service as a fundamental pillar to achieving Universal major disruptions of NCD services have taken place. Health Coverage and to combat inequities. In addition This also can explain efforts of Group 3, compared to to addressing underlying inequalities through the Group 2 and 1 countries, to allocate the already limited adoption of the “build back better” strategy and plans resources to NCDs during the pandemic to mitigate for Disaster Risk Reduction. the extensive disruptions and the parallel crisis in NCD Build bridges between national humanitarian services provision. The United Arab Emirates, the only emergency plans and national programmes, to country that reported reallocation of funds while it is develop comprehensive strategies on NCD responses one of the Group 1 countries which also have reported no including safeguarding continuity and resumption of postponement of the WHO PEN and limited reallocation NCD services. of staff. This may indicate that this re-allocation of funds had limited effect on the WHO PEN and NCD services in the country. Conclusion Emergency preparedness depends primarily on COVID-19 pandemic has adversely affected the continuity strong and resilient health systems and a qualified, of NCD services in countries of the EMR. Disruption of NCD services has occurred at all levels of care, primary well-resourced health workforce. Resilience is defined secondary, and tertiary as part of a global occurrence. The as “the ability to prepare for, manage (absorb, adapt ability of countries to respond to the disruption of services and transform) and learn from shocks” (19), and it is due to the implemented mitigation measures to contain significantly linked to the strength and the capacities of the outbreak has varied notably between countries. Many health systems and hence to income levels. The stronger implementations were put in place by countries of the the health systems in terms of all the building blocks: EMR mainly triaging to identify priorities as an adopted leadership/governance, financing, health workforce, strategy followed by the use of novel supply chains and/ service delivery, access to essential medicines, and the or dispensing approaches for NCD medicines. However, health information systems, the more able the country the use of DHIs stands out as the way to go to support to absorb shocks and to maintain and secure essential the continuity of NCD services and other essential services including NCD services during crises like the services during both crises and stability. More guidance COVID-19 pandemic (6). This pandemic has also been and support for systems resilience, preparedness, and described as a wake-up call for strengthening health response to crises are certainly needed. systems as it has evidently exposed the fragility of health systems especially in low- and middle-income Funding: None countries (8). Competing interests: None declared. 475 Research article EMHJ – Vol. 28 No. 7 – 2022 L'impact de la pandémie de COVID-19 sur la prestation de service pour les maladies non transmissibles dans la Région de la Méditerranée orientale Résumé Contexte : La pandémie de COVID-19 a eu des répercussions négatives sur la prestation de service pour les maladies non transmissibles dans le monde entier, car les systèmes de santé ont été débordés par la riposte à la pandémie. Objectifs : Le Bureau régional de l'OMS pour la Méditerranée orientale a évalué l'impact de la COVID-19 sur les services, les programmes et le financement liés aux maladies non transmissibles, ainsi que la prise en compte de ces maladies dans la riposte à la COVID-19. Méthodes : Des données ont été recueillies dans les pays de la Région de la Méditerranée orientale à la mi-2020 à l'aide d'un questionnaire en ligne sur les infrastructures, les politiques, les plans, la dotation en personnel, le financement, les perturbations des services et leurs causes, les stratégies d'atténuation des perturbations, la collecte de données sur les comorbidités et la surveillance, ainsi que les suggestions pour l'orientation technique de l'OMS. Les données ont été exportées dans Microsoft Excel et synthétisées. Les pays ont été regroupés en fonction de leur niveau socio-économique. Résultats : Dix-neuf des 22 pays de la Région de la Méditerranée orientale ont répondu : 95 % des membres du personnel en charge des maladies non transmissibles ont été réaffectés pour soutenir la riposte à la COVID-19. Les pays à faible revenu étaient moins susceptibles d'inclure les maladies non transmissibles dans leurs plans de riposte à la pandémie et plus enclins à signaler une interruption des services. Les services les plus fréquemment interrompus correspondaient à la prise en charge de l'hypertension (10 pays, soit 53 %), aux soins dentaires (10 pays, soit 53 %), à la réadaptation (9 pays, soit 47 %), aux soins palliatifs (9 pays, soit 47 %) et à la prise en charge de l'asthme (9 pays, soit 47 %). Conclusion : La pandémie de COVID-19 a perturbé la fourniture de services liés aux maladies non transmissibles dans les pays de la Région de la Méditerranée orientale et la capacité à atténuer les perturbations des services était variable d'un pays à l'autre. Les mesures d'atténuation comprenaient le triage des patients, les chaînes d'approvisionnement en médicaments nouveaux pour les maladies non transmissibles, les interventions de distribution et le recours à la santé numérique et à la télémédecine. Il est recommandé de fournir des orientations et un appui pour assurer la résilience des systèmes, la préparation et la réponse aux crises. ‫ عىل تقديم خدمات األمراض غري السارية يف إقليم رشق املتوسط‬19-‫أثر جائحة كوفيد‬ ‫ نرسين عبد اللطيف‬، ‫ربي‬ ّ ‫ هشام ال‬،‫العوا‬ ّ ‫ فاطمة‬،‫ سليم سالمة‬،‫ إجالل األمني الر ّيح‬،‫ هبة فؤاد‬،‫أزمس هامريش‬ ‫اخلالصة‬ ‫ حيث أصبحت ال ُّن ُظم الصحية ُمثقلة‬،‫سلبيا عىل تقديم خدمات األمراض غري السارية عىل مستوى العامل‬ ً ‫ تأث‬19-‫ لقد أثرت جائحة كوفيد‬:‫اخللفية‬ ًّ ‫ريا‬.‫باالستجابة للجائحة‬ ً ‫ أجرى املكتب اإلقليمي ملنظمة الصحة العاملية لرشق املتوسط‬:‫األهداف‬ ‫ فيام يتعلق باألمراض غري السارية من‬19-‫تقيياًم لتأثري جائحة كوفيد‬.19-‫ والعتبارات األمراض غري السارية يف االستجابة جلائحة كوفيد‬،‫خدمات وبرامج ومتويل‬ ‫ باستخدام استبيان عىل شبكة اإلنرتنت‬2020 ‫ ُمُجعت البيانات من بلدان إقليم منظمة الصحة العاملية لرشق املتوسط يف منتصف عام‬:‫طرق البحث‬ ،‫ وانقطاعات اخلدمات وأسباهبا‬،‫ والتمويل‬،‫ والتوظيف‬،‫ واخلطط‬،‫ والسياسات‬،‫بشأن ما يتعلق بخدمات األمراض غري السارية من البنية التحتية‬ ً ،‫والرتصد‬ ‫فضاًل عن مقرتحات اإلرشادات التقنية املقدمة‬ ُّ ِ ،‫املصاحب‬ ‫ ومجع البيانات بشأن االعتالل‬،‫واسرتاتيجيات التخفيف من تلك االنقطاعات‬ ‫تبعا ملستواها االجتامعي‬ ً ‫ كام ُصنِّفت البلدان‬.‫ وتلخيصها‬Microsoft Excel ‫ وجرى تصدير البيانات إىل برنامج‬.‫من منظمة الصحة العاملية‬.‫واالقتصادي‬ ‫ منها أعادت انتداب العاملني يف جمال‬%95 :‫ بلدً ا عىل االستبيان‬22 ‫ أجاب تسعة عرش بلدً ا من بلدان إقليم رشق املتوسط البالغ عددها‬:‫النتائج‬ ‫ وكانت البلدان املنخفضة الدخل أقل َم ًياًل إىل إدراج األمراض غري السارية يف خططها‬.19-‫األمراض غري السارية لدعم االستجابة جلائحة كوفيد‬ ،)‫ من البلدان‬%53( ‫ وكانت أكثر اخلدمات التي تعطلت هي عالج ارتفاع ضغط الدم‬.‫ وأكثر َم ًياًل إىل اإلبالغ عن انقطاع اخلدمات‬،‫ملواجهة اجلائحة‬.)%47(‫ وعالج الربو‬،)%47( ‫ والرعاية امللطفة‬،)%47( ‫ وإعادة التأهيل‬،)%53( ‫ورعاية األسنان‬ ‫ وتباينت القدرة عىل ختفيف‬،‫ تقديم اخلدمات املرتبطة باألمراض غري السارية يف بلدان إقليم رشق املتوسط‬19-‫ أعاقت جائحة كوفيد‬:‫االستنتاجات‬ ‫ وتدخالت‬،‫ وسالسل توريد أدوية جديدة لألمراض غري السارية‬،‫ وتضمنت تدابري التخفيف فرز املرىض‬.‫حدة انقطاعات اخلدمات من بلد آلخر‬.‫ و ُيوىص بتوجيه ودعم قدرة النظم عىل الصمود والتأهب واالستجابة لألزمات‬.‫ واستخدام الصحة الرقمية والتطبيب عن ُبعد‬،‫رصف األدوية‬ 476 Research article EMHJ – Vol. 28 No. 7 – 2022 References 1. Chang AY, Cullen MR, Harrington RA, Barry M. The impact of novel coronavirus COVID-19 on noncommunicable disease pa- tients and health systems: a review. J Intern Med. 2021 Apr;289(4):450–62. doi: 10.1111/joim.13184 2. Information note on COVID-19 and NCDs. Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/ item/covid-19-and-ncds, accessed 14 June 2022). 3. NCD COVID-19 Vulnerability Dashboard. New York: United Nations Development Programme; 2020 (https://public.domo.com/ embed/pages/aOV4p, accessed 14 June 2022). 4. Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, et al. Prevention and control of non-communi- cable diseases in the COVID-19 response. Lancet. 2020;395(10238):1678–80. doi: 10.1016/S0140-6736(20)31067-9 5. Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, Baguelin , et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID- 19 mortality and healthcare demand. London: Imperial College London, Imperial College COVID-19 Response Team; 2020. doi:10.25561/77482 6. Maintaining essential health services: operational guidance for the COVID-19 context. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services-2020.2, accessed 14 June 2022). 7. Horton R. Offline: COVID-19 is not a pandemic. Lancet. 2020 Sep;396(10255):874. doi:https://doi.org/10.1016/S0140-6736(20)32000- 6 8. Kraef C, Juma P, Kallestrup P, Mucumbitsi J, Ramaiya K, Yonga G. The COVID-19 pandemic and non-communicable diseases–a wake-up call for primary health care system strengthening in sub-Saharan Africa. J Prim Care Community Health. 2020;11. doi: 10.1177/2150132720946948 9. About us. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2021 (http://www.emro.who.int/ entity/about-us/index.html, accessed 13 March 2021). 10. Health systems strengthening in countries of the Eastern Mediterranean Region: challenges, priorities and options for future action. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2013 (EM/RC59/R.3: https://apps.who. int/iris/handle/10665/123147, accessed 14 June 2022). 11. The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. Ge- neva: World Health Organization; 2020 (https://www.who.int/publications/i/item/9789240010291, accessed 30 June 2022). 12. COVID-19 vaccines. Geneva: World Health Organization; 2021 (https://www.who.int/emergencies/diseases/novel-coronavi- rus-2019/covid-19-vaccines, accessed 14 June 2022). 13. COVID-19 vaccine tracker and landscape. Geneva: World Health Organization; 2021 (https://www.who.int/publications/m/item/ draft-landscape-of-covid-19-candidate-vaccines, accessed 14 June 2022). 14. Jailobaeva K, Falconer J, Loffreda G, Arakelyan S, Witter S, Ager A. An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low- and middle-income countries. Global Health. 2021;17(1):68. https://doi.org/10.1186/ s12992-021-00713-4 15. Advancing be he@lthy, be mobile in the Eastern Mediterranean Region: combating noncommunicable diseases through mobile technology. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2021 (https://apps.who.int/iris/ handle/10665/348134, accessed 14 June 2022). 16. Digital innovation stories during COVID-19. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2020 (http://www.emro.who.int/noncommunicable-diseases/publications/success-stories.html?format=html, accessed 14 June 2022). 17. Singer M, Bulled N, Ostrach B, Mendenhall E. Syndemics and the biosocial conception of health. Lancet. 2017 Mar;389(10072):941–50. doi: 10.1016/S0140-6736(17)30003-X 18. Mitgang EA, Blaya JA, Chopra M. Digital Health in Response to COVID-19 in Low- and Middle-income Countries: Opportunities and Challenges. Glob policy. 2021 Mar 17:10.1111/1758-5899.12880. doi: 10.1111/1758-5899.12880 19. NCDs & COVID-19: learning lessons building back better for the future. Geneva: NCD Alliance; 2020 (https://ncdalliance.org/ news-events/news/ncds-covid-19-learning-lessons-building-back-better-for-the-future, accessed 14 June 2022). 20. Thomas S, Sagan A, Larkin J, Cylus J, Figueras J, Karanikolos M. Strengthening health systems resilience, Key concepts and strat- egies. Copenhagen: European Observatory on Health Systems and Policies; 2020. PMID: 32716618 477