The Covid-19 pandemic has caused unprecedented disruption to global health systems, resulting in economic and social turbulence as well as loss of life. The pandemic has disproportionately impacted vulnerable populations and exposed the limitations of health systems worldwide. To effectively prepare for and respond to crises, health systems must possess resilience, which involves building the capacity of health actors, institutions, and populations to maintain core functions during a crisis, adapt to changing circumstances, and reorganize if needed.

As the Eastern Mediterranean Region (EMR) has varied levels of governmental and financial support, the resilience of public health in the region also varies. Achieving public health resilience requires breaking down barriers and creating effective strategies that work within the structure, governance, and financing of each health system across all its levels.

The Seventh Eastern Mediterranean Public Health Network (EMPHNET) Regional Conference, held on November 2021, focused on exploring ways to achieve public health resilience. Holding the theme "Towards Public Health Resilience in the EMR: Breaking Barriers,” this five-day event featured 101 oral and twelve poster presentations, six pre-conference workshops, ten roundtable discussions, and six keynote speeches. The conference aimed to engage public health experts and entities in discussions of challenges hindering public health resilience in the region and offer a space for displaying accomplishments of public health professionals in the EMR. The latest EMPHNET publication titled “Toward Public Health Resilience in the Eastern Mediterranean Region: Findings From the Seventh Eastern Mediterranean Public Health Network Regional Conference,” sheds a light on the activities, outcomes, and recommendations of this conference.

Findings from Preconference Workshops

The five preconference workshops held addressed border health approaches to mitigate cross-border communicable disease spread; the mobilization of Field Epidemiology Training Programs (FETPs) and rapid response teams in the EMR; continuous professional development for public health workforce; brucellosis surveillance, diagnosis, and control using the “One Health” approach; and identifying barriers and strategies to integrate and use Non-Communicable Diseases (NCDs) data sources.

The first workshop centered on border health approaches to mitigate cross-border communicable disease spread. The workshop highlighted the importance of cross-border public health surveillance, information sharing, and collaboration as part of a comprehensive border health system. Participants identified border health factors and activities that a public health authority would consider when a neighboring country is faced with a highly pathogenic outbreak, including identifying resource needs, reviewing current public health emergency or pandemic plans and standard operating procedures (SOPs), enhancing surveillance, considering nonpharmaceutical interventions, and risk communication messaging. Participants also discussed the need for public health corridors, a strategy developed by the Collaborative Arrangement for the Prevention and Management of Public Health Events in Civil Aviation, which describes how to manage essential flights in a manner that maintains safety and prevents the transmission of Covid-19, and other diseases. They recommended that countries adopt multiple border health mechanisms as different layers of protection against the spread of internationally transmissible diseases.

The second workshop focused on the mobilization, and the roles of public health RRTs, FETPs, and public health emergency operations centers (PHEOCs), with participants discussing the need to coordinate the responsibilities of these elements for effective and efficient emergency response plans. A framework that links FETPs, RRTs, and emergency operations centers (EOCs) was discussed and the importance of standardizing training and capacity building, maintaining good communication, and sharing information for an effective coordinated response was also emphasized by the participants.

The third workshop focused on improving the skills and knowledge of public health workers in the EMR through Continuous Professional Development (CPD). In particular, it addressed the need for FETP graduates to acquire additional competencies in response to emerging threats such as the Covid-19 pandemic. The workshop participants identified ongoing competency requirements and proposed a strategy for incorporating CPD activities to meet those requirements. The recommendation was to institutionalize CPD within the public health system and to include it in the FETP career path, which will help the public health workforce in the EMR be better equipped to respond to emerging health challenges through the highest standards of professional practice.

The fourth workshop concentrated on brucellosis, a widespread zoonotic disease that affects public and veterinary health, especially in the Middle Eastern and North African (MENA) regions. The objectives of the workshop were to discuss the latest laboratory diagnostic recommendations for brucellosis, explore the "One Health" approach to control the spread of the disease, and present a suitable methodology for conducting surveillance studies of zoonotic diseases.

The workshop emphasized the importance of the implementation of the One Health concept, involving multidisciplinary teams and advanced laboratory detection methods, while including the analysis of the socioeconomic impact and burden of the disease. These steps would be necessary for effectively controlling the spread of zoonotic diseases, establishing surveillance systems, and shaping national action plans in EMR countries.

The fifth workshop focused on identifying the barriers and strategies for integrating and utilizing NCDs data sources. It aimed to review the fundamentals of health information systems (HIS) and to use Jordan as a case study to identify the challenges in creating a comprehensive national HIS. The workshop highlighted the importance of generating high-quality health data to guide evidence-based decision-making and national planning. However, the discussions raised several barriers, including the complexities of integrating data between different health sectors in Jordan's multisectoral approach to healthcare, the lack of useful data, low workforce capacity, financial constraints, and lack of sustainable health system financing. Despite these challenges, the workshop attendees reached a consensus on the need for a national HIS that caters to NCDs in Jordan.

Findings from Roundtables

The roundtable sessions covered a diverse range of topics related to public health in the EMR. The first topic addressed the challenges faced by FETPs in responding to Covid-19, such as logistics, surveillance systems, and vaccine acceptance. The roundtable emphasized the need for continuously supporting FETPs, and new ones in other countries.

The second topic shed light on the institutionalization of rapid response to public health emergencies in the EMR. In this session, it was stated that it is important to link RRTs, FETPs, and EOCs across the health system, invest in the career development of RRTs and FETP graduates, and standardize the curriculum and competencies for RRT training.

The third topic focused on the integration of Early Warning and Response (EWAR) with event-based and indicator-based surveillance being crucial for effective disease surveillance and response, particularly in EMR countries experiencing humanitarian emergencies. Accordingly, the World Health Organization (WHO) aims to integrate surveillance systems into Ministries of Health systems in EMR countries by 2025 to enhance disease surveillance and response capabilities and strengthen the region’s health security. Currently, the EMR has eight active EWAR Network systems in seven countries facing protracted humanitarian emergencies, with efforts in applying a unified surveillance system with a single data collection point and IT infrastructure within each country to collect necessary information.

The fourth roundtable focused on the importance of building resilient health systems to effectively cope with health and economic crises such as the Covid-19 pandemic. The session highlighted a need for prioritizing resilient health systems for all member states, investing in health for socioeconomic development and emergency preparedness, adopting an integrated approach to health security and universal health coverage (UHC), building and strengthening the primary health care (PHC) foundation, and investing in essential public health functions (EPHFs).

The fifth roundtable session focused on the sustained implementation of the International Health Regulations (IHR) in Iraq and the need for enhanced multisectoral coordination amidst ongoing conflict. Panelists recommended strengthening communication between IHR focal points, unifying the IHR implementation processes, increasing funding for basic research on viral pathogens, improving coordination between public health and veterinary laboratories, and building biorisk capacity for future public health emergencies of concern. They also emphasized the importance of sustained efforts to build networks for IHR compliance between all stakeholders, ministries, focal points, and the WHO.

The sixth roundtable highlighted the impact of emerging infectious diseases on global health security and emphasized the need for institutionalization, governance, and political commitment to strengthen the role of One Health. Recommendations were made to promote multisectoral collaboration in sharing epidemiological data and laboratory information, community engagement, and cultural changes to improve understanding of the interconnectedness of human-animal-ecosystems, and to enhance the collaboration between nongovernmental organizations and the private sector is necessary to enhance One Health . The five principles of equity, parity, equilibrium, stewardship, and transdisciplinary were identified as important for capacity building. Improved surveillance systems and joint responses to health threats were also emphasized to be essential at all levels, from local to global.

The seventh roundtable centered around the anticipated future of public health post Covid-19. The pandemic highlighted the need for better governance, more robust health systems and capacities, and the need to shift the paradigm toward public health and preventive medicine. It sheds light on the importance of coordination and collaboration among countries and stakeholders in different multilateral and global initiatives. Many aspects need to be revised, including collaboration among countries, world trade regulations, budget allocation, partnership with the private sector, and health inequalities. Governments should build on their experiences and sustain the positive impacts of Covid-19 on public health by promoting and facilitating the adoption of actions to reduce environmental pollution, revising tobacco control policies to build on the success of smoking reduction, and facilitating patients with chronic diseases to adopt regular self-care and healthy lifestyles.

The eighth roundtable centered on the support for public health research capacity, quality, and productivity in the EMR. It was found that the region's productivity in public health research is lower than the global average due to various challenges such as lack of funding, data availability, language barriers, guidelines and regulations, and inadequate research skills. Research in conflict contexts also faces additional challenges, but successful research publication has positively influenced policy makers and decision makers in the region. To address these challenges, it was concluded that official guidelines for data sharing should be developed, universities should incorporate research skills in their curricula, and research institutions should focus on developing research capacity educational programs. Initiatives such as hiring professional copy editors to improve the publication of research and knowledge transfer frameworks should also be implemented to facilitate collaborative knowledge transfer between researchers, policy makers, and relevant stakeholders.

The ninth roundtable focused on the impact of the Covid-19 pandemic on routine immunization services and the challenges faced by the Expanded Program on Immunization (EPI) in introducing the Covid-19 vaccine while maintaining coverage of other essential vaccines. The disruption in immunization services was particularly pronounced in underserved communities affected by conflict or living in remote or slum settings. Preparedness was identified as a crucial factor in maintaining EPI functionality and delivering the Covid-19 vaccine, and lessons learned from the pandemic should be used to strengthen routine immunization services in the future. The Covid-19 vaccine also highlighted the shift in EPI service delivery from children under 18 years to all age groups, paving the way for the introduction of new vaccines in the future.

Findings from the Keynote Speaker Sessions

1. EPHFs and UHC in the EMR:

EPHFs are crucial for achieving UHC in the EMR. The EMR countries have prioritized UHC and developed a regional framework for action to advance it. To date, Qatar and Morocco are the only countries that have assessed their public health systems using the EMR assessment tool. The Covid-19 pandemic has emphasized the need for stronger health systems that are resilient against public health threats and are regularly assessed to reveal gaps and help achieve UHC cost-effectively and sustainably.

2. Lessons from US Covid-19 Response:

Effective Covid-19 outbreak control requires continuous epidemiological and genomic surveillance, especially in high-risk groups, increasing vaccine demand and booster uptake, and clarifying misinformation. Epidemiological surveillance is crucial for learning about the effectiveness of Covid-19 vaccines against new variants. Prompt investigations of outbreaks in highly vaccinated areas or populations are key priorities to learn about virus dynamics and mutations.

3. Learning from Covid-19:

The Covid-19 pandemic exposed weaknesses in the health systems of some EMR countries due to political instability and fragile health systems. Countries that responded well to Covid-19 had a high level of political commitment and multisectoral coordination. Innovations, such as telemedicine and hotlines, proved useful. There is a need to invest in building human capacities, strengthening health systems, and work toward community engagement and trust. At the regional level, there is a need for more cooperation, solidarity, and support to effectively control the spread of the pandemic.

4. Reshaping Public Health Post-Pandemic:

The Covid-19 pandemic resulted in interruptions to the delivery of essential health services, especially in low- and middle-income countries. Investment in PHC is essential to mitigate the risks of future pandemics and maintain the accessibility and delivery of essential health services during emergencies. Investment in the health workforce is another dimension for a successful response. In their technical series on primary care called “Closing the Gaps Between Public Health and Primary Care Through Integration” the WHO identified six models for integrating public health into primary care as an essential approach for reshaping public health.

In conclusion, the seventh EMPHNET Regional Conference highlighted the importance of achieving public health resilience in the EMR through breaking barriers and adopting effective strategies that work within the structure, governance, and financing of each health system across all its levels. The conference provided an opportunity for public health experts and entities to discuss challenges hindering public health resilience in the region, share expertise and lessons learned, and showcase the accomplishments of public health professionals. The conference included several preconference workshops and roundtable discussions on various public health topics. These shed light on the latest scientific findings and important lessons learned from the Covid-19 pandemic. Overall, the conference provided a promising platform to explore ways to achieve public health resilience in the EMR and to build capacity to recover from crises and adapt to future challenges.