Eastern Mediterranean Health Journal

The government of Saudi Arabia has given high priority to the development of health care services at all levels: primary, secondary and tertiary. As a consequence, the health of the Saudi population has greatly improved in recent decades. However, a number of issues pose challenges to the health care system, such a shortage of Saudi health professionals, the health ministry's multiple roles, limited financial resources, changing patterns of disease, high demand resulting from free services, an absence of a national crisis management policy, poor accessibility to some health care facilities, lack of a national health information system, and the underutilization of the potential of electronic health strategies. This paper reviews the historical development and current structure of the health care system in Saudi Arabia with particular emphasis on the public health sector and the opportunities and challenges confronting the Saudi health care system.

This study aimed to update and re-validate the scoring system of Fahmy and El-Sherbini for measurement of socioeconomic status in health research in Egypt. The new socioeconomic status scale has 7 domains with a total score of 84. Intra-and inter-observer variability and the internal consistency of the scale were assessed. A linear regression model was performed to determine the relative importance of each domain to the total score. Kappa coefficient was used to measure the agreement between the socioeconomic levels of the new and the old scales. There was a strong correlation between most of the 7 domains of the scale. Cronbach alpha for the scale was 0.66. The education domain contributed to 0.898 of variation in total score. There was a moderate agreement (kappa = 0.76) and strong positive significant correlation (r = 0.93) between the socioeconomic levels and scores of both scales. We conclude that the new socioeconomic status scale is valid and reliable.

In April 2012, an outbreak of acute respiratory illness occurred in a public hospital in Zarqa city, in Jordan; 8 health care workers were among the 11 people affected, 1 of who later died. The cause of the outbreak was unknown at the time and an epidemiological investigation including laboratory testing carried out immediately afterthe outbreak was inconclusive. Following the discovery of novel coronavirus infection (nCoV) in the Arabian peninsula in September 2012, stored respiratory and serum samples of patients from this outbreak were retested and the diagnosis of nCoV was confirmed in 2 deceased patients. This paper describes the epidemiological findings of retrospective investigation carried out in November 2012 and highlights the likelihood of nosocomial transmission of nCoV infection in a health-care setting. A total of 2 laboratory-confirmed and 11 probable cases were identified from this outbreak of whom 10 were HCWs and 2 were family members of cases.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. AIMS: To synthesize data on the worldwide prevalence and severity of COPD by geographical region, age groups, and smoking status in a systematic review. METHODS: A systematic search was performed following Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. International databases including PubMed, Scopus and Web of Science were searched for population- based studies published between January 2004 and May 2015 that reported the prevalence of COPD anywhere in the world. The prevalence of COPD was calculated based on World Health Organization (WHO) regions and sex and severity stages using metaprop. Meta-regression and subgroup analysis were applied to determine the sources of heterogeneity. RESULTS: Sixty papers were screened with a combined subject sample size of 127 598. The prevalence of post-bronchodilator COPD was 12.16% (10.91-13.40%). The pooled prevalence of COPD was 15.70% (13.80-18.59%) in men and 9.93% (8.73- 11.13%) in women. Among all WHO regions, the highest prevalence was recorded in the Region of the Americas (14.53%), and the lowest was recorded in the South-East Asia Region/Western Pacific Region (8.80%). Meta-regression model variables were: sample size, WHO region, study quality score, level of gathering data, publication year, and sampling methods that justified 29.82% of heterogeneity detected among COPD prevalence rates worldwide. CONCLUSIONS: Global prevalence of COPD among men is about 5% higher than among women. The most prevalent stage of COPD is stage 1.

A prevalence survey on hepatitis B and C infections was carried out to obtain national estimates and assess epidemiological dynamics and underlying risk factors. Overall prevalence of hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (HCV) of 2.5% and 4.8%, respectively, reflected a combined infection rate of 7.6% in the general population, consistent with an ongoing high burden of chronic liver disease (CLD). There was significant association of these viral infections with a range of risk factors led by reuse of syringes. These findings validate currently implemented strategies by the national programme for the control of hepatitis viral infections, including universal vaccination of newborns and high-risk groups, support of auto-disable syringes, promotion of infection control and patient safety, public health education, and management of needy CLD patients as a poverty-reduction health intervention.

BACKGROUND: Saudi Arabia has invested heavily in its health care system by establishing health care infrastructures to improve health of the nation. However, it remains to be seen whether it is efficient and effective in providing health care services needed. Primary health care, which is the basis of universal health coverage, needs to be assessed on its performance, challenges and future opportunities to serve the Saudi Arabian population. AIMS: This review aimed to identify challenges within the Saudi Arabian health care system with a focus on primary health care services, and to analyse the interrelated factors in order to suggest remedial reforms to further strengthen and improve the health care system. METHODS: A narrative review of previous studies and governmental reports was undertaken to extract, analyse, synthesize and report the findings. RESULTS: The review found a number of key areas for improvement in the primary health care system. These areas include: the scope, structure, infrastructure, financing, increased demand, increased costs and workforce capacity. Other critical challenges include inequitable access to health services, quality and safety of services, the growing burden of chronic diseases, lack of an effective information system, management and leadership issues, and gaps in the referral system. CONCLUSION: The Saudi Arabian health care system needs comprehensive reform with a focus on primary health care.

Cognizant that every human has the right to the highest attainable standard of health, the World Health Organization (WHO) is promoting the health and well-being of all by all. To achieve this mission in the Eastern Mediterranean Region (EMR), a strategic vision was adopted calling on Member States and partners to anchor solidarity and action to achieve Health for All by All in the Region. The vision focuses on the need to address the environmental causes of diseases while targeting the Sustainable Development Goals (SDGs), and fulfilling the human rights to live in a healthy environment.

Obesity has become an epidemic problem worldwide, and in the Eastern Mediterranean Region the status of overweight has reached an alarming level. A prevalence of 3%-9% overweight and obesity has been recorded among preschool children, while that among schoolchildren was 12%-25%. A marked increase in obesity generally has been noted among adolescents, ranging from 15% to 45%. In adulthood, women showed a higher prevalence of obesity (35%-75%) than men (30%-60%). Several factors, such as change in dietary habits, socioeconomic factors, inactivity and multiparity (among women) determine obesity in this Region. There is an urgent need for national programmes to prevent and control obesity in the countries of the Region.

Background: National public health institutes are central to public health emergency governance, however, their governance models and operational roles in the WHO Eastern Mediterranean Region remain insufficiently examined. Aim: To explore the governance structures, roles and practices of national public health institutes in managing health emergencies across the Eastern Mediterranean Region. Methods: Using the methodological framework developed by Arksey and O'Malley and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we identified and reviewed 24 articles published between 2017 and 2024 on the role of national public health institutes in health emergency governance across the Eastern Mediterranean Region. Results: NPHIs in the EMR operate under diverse governance models, including autonomous, ministry-integrated and hybrid structures. They perform key functions, including disease surveillance, laboratory diagnosis, workforce development, policy guidance, and coordination. Their effectiveness is often constrained by fragmented governance structures, inadequate finance, political challenges, and weak integration into national emergency frameworks. Their activities demonstrate the potential to strengthen emergency response capacity at the national level. Conclusion: Strengthening legal mandates, securing sustainable financing, enhancing collaboration, and embedding NPHIs within national preparedness strategies are essential to building resilient and responsive health systems in the EMR.

Background: National public health institutes are science-driven agencies that lead surveillance, laboratory services, risk assessment, and emergency preparedness and response at country level. It is therefore essential to understand their role in the management of disease outbreaks. Aim: To examine the role of national public health institutes in disease outbreak management in the Eastern Mediterranean Region by comparing the detection, reporting and response across countries that had and did not have a national public health institute, and across crisis- and non-crisis-affected contexts. Methods: Using the framework method, we reviewed and analysed publicly available data reported during 2023–2024, in accordance with the standards for reporting qualitative research, describing disease outbreak detection, reporting and response in the Eastern Mediterranean Region, including the role of national public health institutes and other national institutions. Results: Outbreak surveillance and response were nationally led and structurally integrated in non-crisis countries/ territories that had a national public health institute, while in countries/territories that did not have a national public health institute they were led by the Ministry of Health through the central laboratories. In crisis-affected settings, regardless of whether they had a national public health institute or not, response was surge-oriented and carried out by multiple actors. National public health institute contribution was constrained by infrastructure destruction, insecurity and reliance on external support. Countries/territories with stronger national public health institutes documented outbreak events, while outbreaks were underreported in disrupted settings. Conclusion: National public health institutes were associated with stronger institutional capacities for outbreak detection, coordination and verification. Strengthening EMR epidemic preparedness requires investments in NPHIs, workforce and laboratory capacity, alongside the enabling conditions such as water sanitation and health, supply chain continuity and partner coordination to enable them to continue to deliver services during shocks.

Background: The armed conflict in Sudan has disrupted essential health services and displaced millions of people since April 2023, with an estimated 30.4 million people requiring humanitarian assistance as of 2025. Aim: To assess the operational strengths, challenges and gaps in the WHO-led health emergency response in Sudan across incident management system domains. Methods: From July to August 2025, we conducted a descriptive operational review of WHO and partner documents on the health emergency response in Sudan for April 2023 to July 2025 and held a structured consultation with 48 WHO headquarters, Eastern Mediterranean regional office and Sudan country office staff. We analysed the findings using the WHO Emergency Response Framework 2.1 and 6 incident management system domains. Results: Through the WHO-supported services, nearly 300 000 people received treatment for trauma and emergency conditions, more than 500 000 received primary health care and nearly 294 000 were reached through the mobile health teams. More than 700 000 people have received medicines for chronic diseases. Insecurity, funding shortage, workforce gaps, weak surveillance, and logistic constraints have limited service coverage, particularly in hard-to-reach areas. Fragmented coordination and data systems further reduced operational effectiveness. Conclusion: Strengthening leadership, coordination, surveillance, financing, and operational systems is essential to sustain lifesaving interventions and reduce morbidity and mortality in Sudan.

Background: Digital tools, such as the District Health Information Software 2, were effective in supporting timely disease surveillance during the 2022 and 2024 floods in Pakistan. Aim: To assess the adaptation of Pakistan’s routine integrated disease surveillance and response system for emergency surveillance during the floods using the District Health Information Software 2. Methods: Through the District Health Information Software 2, we collected daily data on 20 priority diseases from 75 districts in 4 provinces of Pakistan affected by the 2022 and 2024 floods. We conducted 12 key informant interviews and 4 focus group discussions with health officials, who were involved in surveillance and emergency response, from facilities that submitted at least one daily report during the peak periods of the floods. We analysed the quantitative data using Epi Info 7.2 and qualitative data using ATLAS.ti. Results: The District Health Information Software 2 was used to track disease trends, detect hotspots and guide targeted response. The software helped improve reporting performance, with >85% of 426 priority facilities submitting complete and timely daily reports, compared to only 40–50% in 2022. In 2024, reporting compliance reached 73% in Khyber Pakhtunkhwa, 70% in Balochistan and 95% in Sindh. Government ownership, partner coordination and staff uptake of digital tools contributed to the system performance improvements, while internet disruption, staff turnover and parallel reporting systems remained key challenges to data reporting. Conclusion: Pre-existing platforms such as District Health Information Software 2 can be rapidly adapted for emergency surveillance. However, sustained impact requires investments in strengthening digital infrastructure and building surge capacity, streamlined reporting, and policy integration.

Background: Decentralisation may strengthen health systems and advance Universal Health Coverage in conflictaffected Sudan, but this is yet to be sufficiently examined. Aim: To examine how decentralisation shapes progress towards Universal Health Coverage in conflict-affected Sudan. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for Scoping Reviews guidelines, we searched published documents focusing on health sector decentralisation in conflict-affected settings on PubMed, Scopus, Google Scholar, and JSTOR, as well as reports and policy documents from several related international organizations. Results: Our findings showed major structural weaknesses in health care decentralisation in Sudan, including wide disparities in workforce distribution and the closure of nearly 70% of hospitals in conflict-affected states. Evidence showed improvements where financing and accountability were strong, but weaker performance where authority was fragmented. Inadequate funding and capacity contributed to stockouts, disrupted referrals and widening inequities. Conclusion: Decentralisation can support progress towards UHC in conflict-affected settings when backed by predictable financing, adequate capacity and clear accountability. Progress in Sudan will depend on conflict-sensitive governance that strengthens local decision-making while maintaining system-wide coordination.