Overview

This is the seventh report in the Global Evidence Review on Health and Migration (GEHM) series. The publication examines how health systems are responding to the health needs of migrant and displaced populations in the context of climate change. Drawing on a review of 95 health system interventions across WHO’s six health system building blocks, it highlights current approaches, evidence gaps, and opportunities for strengthening migrant-inclusive and climate-resilient health systems.

Key findings include the adaptation of existing interventions to new scenarios as well as innovative new practices. The review also identified main gaps in the evidence, particularly regarding longer-term interventions, broader planning and preparedness, and building resilience into health systems.

Policy considerations are proposed to support more adaptive, inclusive, and coordinated responses to the health impacts of climate change on migrant and displaced populations. These include proactive long-term strategies to ensure migrant-inclusive health systems through a whole-of-route approach, and meaningful engagement of affected communities in policy, planning, and delivery.

Ensuring that health systems are both migrant-inclusive and climate-resilient is critical for advancing health equity and system preparedness in an increasingly unstable climate.

As the world gathered at COP29 in Baku, Azerbaijan, the World Health Organization (WHO), in collaboration with the United Nations High Commissioner for Refugees (UNHCR), the International Organization for Migration (IOM) and the International Federation of Red Cross (IFRC), convened a pivotal high-level event to address the intersection of climate change, migration, displacement and health.

COP29 brought attention to adaptation, loss and damage, emphasizing an inclusive process and outcomes. This includes integrating the health needs of migrants and refugees into national adaptation plans, scaling up investments in migrant-inclusive health systems and leveraging partnerships for community-centred solutions.

Hosted at the Health Pavilion, this event featured remarks from WHO Director-General Dr Tedros Adhanom Ghebreyesus and high-level government representatives from Azerbaijan, Malawi and Yemen alongside a youth leader and representatives from each of the co-organizers. The discussions underscored the urgent need for integrated action to protect the health and well-being of migrants, refugees and displaced populations.

“Up to 1.2 billion people could be displaced by 2050 due to climate-driven events. The climate crisis is a health crisis, including the health of migrants,” stressed WHO Director-General Dr Tedros Adhanom Ghebreyesus. Dr Tedros called on global leaders to take decisive action, stating, “we would therefore like to have migrant health included in the declaration at this and future COPs. In a rapidly changing world, it is critical that we work together, so that everyone, everywhere can access the health services they need.”

At this event, panelists shared national strategies and challenges in building health systems that are climate-resilient while also migrant- and refugee-inclusive. The panel emphasized the importance of addressing mental health needs in displaced communities and leveraging partnerships to create sustainable and scalable solutions. It also stressed the urgency of advancing evidence-based policies and fostering collaboration to address the triple nexus of health, climate change and migration. The event underscored the necessity to actively engage and reflect the voices and experiences of migrants, displaced populations and host communities.

As global efforts to combat climate change intensify, it is crucial to ensure that no one is left behind in order to effectively contribute to achieving Universal Health Coverage and Health for All. The panelists called on governments to include migrants and refugees in all policies, strategies and programmes related to climate change. WHO highlighted findings from the latest evidence brief, emphasizing long-term strategies that prioritize governance, workforce training and inclusive service delivery.

The discussions at COP29 highlighted the need for multisectoral collaboration to design health systems that are both migrant- and refugee-inclusive as well as climate resilient. Only then can we pave the way for a healthier, more sustainable future for all.

Quotes from panelists

Mr Vugar Mammadov​, Head of the International Cooperation Department, Ministry of Health, Azerbaijan, COP29 Presidency

“As populations are increasingly being displaced, it is crucial to move beyond short-term, reactive responses to the health needs of climate-affected migrants and displaced populations.”

Dr Galal Al-Zaoary, Director General of Environment, Climate Change and Health Administration, Ministry of Public Health and Population, Yemen​

“Strengthening climate resilience in health will be in coordination and partnership with WHO to access and provide training for the Ministry of Health, preparing a national strategy and using global tools to enhance WASH facilities and the health system.”

Mr Hendricks Mgodie, Climate Change and Human Health Manager, Ministry of Health, Malawi

“Providing a full package of healthcare services in migrant and displaced communities is very essential. There is also a need to conduct a participatory approach whereby knowledge and experiences on adaptation can be identified by the local communities facing the daily realities.”

Mr Andrew Harper, Special Advisor on Climate Action, UNHCR

‘’Forcibly displaced and stateless people must be included in national systems and climate preparedness and response policies and plans. Refugee hosting countries need international support to address climate related health challenges and build more climate resilient health systems for all.’’

Mr Christopher Richter, Migration Environment and Climate Change Specialist, IOM Regional Office, Bangkok

“IOM is committed to providing equitable access to health services for everyone, including internally displaced persons and migrants, in host communities and countries. Additionally, IOM ensures the health and well-being of people on the move and promotes their involvement in climate resilience and health adaptation processes.”

Dr Santino Severoni, Director, WHO Health and Migration

“It is paramount to invest into health systems, which means tackling all the functions of the system, starting from governance, healthcare workforce, training and service provision, to bring the issue of migration, health and climate change at the center to address short-term and long-term implications.”

Dr Petra Khoury, Director, Health and Care Department, IFRC​

“From the angle of communities, bringing sustainable financing before the crisis happens and continuing for the recovery phase is crucial. We do great during emergencies but phases before (preparedness) and after are not well financed.”

Mr Crispus Mwemaho, IOM COP29 Youth Delegate on Climate Migration and Health Justice Advocate

“We need to invest more in continuous medical education and capacity building on climate and health, with a particular focus on mental health. Without reliable data on the nexus between climate change and health, we lack the evidence necessary to influence global policies effectively and address these critical challenges. When we don’t meet these gaps, we are deepening and contributing to more crisis.”

We used the WHO HSS building blocks framework to identify how cross-border public health surveillance in MENA can be assessed and strengthened. Despite approaches differing by countries’ income levels and political contexts, the building blocks provide a unified framework for delineating the strengths and challenges of surveillance components we explored in the study: data collection, data analysis, and data sharing (Fig. 1). The definition of cross-border surveillance is anchored in the contribution of information from individual countries for sharing and collaboration across countries. However, each country must strengthen its collection, management, and analysis of data on all types of mobile populations to improve its ability to detect threats and contribute accurate, reliable, and timely information to its neighbors and partners. Figure 1 shows leadership and governance and health financing are instrumental across all three steps, information systems and health workforce are essential for both data collection and analysis, and service delivery and medical products are most critical for ensuring comprehensive data collection across all types of mobile populations. In this review, we delve into each building block, explaining challenges and recommendations to strengthen each important element of an inclusive, secure, and functional surveillance system for cross-border information sharing. Each of the blocks described below has a path forward for examining and improving cross-border surveillance from a different component of the health system. Table 2 also delineates each recommendation’s application to the HSS building blocks.

Fig. 1 WHO Health System Strengthening Building Block: Components of cross-border surveillance and improved health outcomes Full size image

Governance and leadership

Leadership and governance are critical for improving disease information sharing across countries in MENA, both within and across countries. The WHO’s IHR governing framework for global health security includes requirements for information sharing in public health emergencies [21], but our review found implementation was mixed. While the literature highlighted gaps in IHR implementation [33, 34], some IDIs, mostly in higher income countries, reported strong implementation, capacities, and functionality of IHR focal points, with pride of their JEE results. On the other hand, another low-income country noted it had not participated in a JEE process since prior to the COVID-19 pandemic, but suspected its JEE would be an “exercise in building a very, very big list of gaps” (3.E.1). Challenges in IHR and information sharing reportedly persist due to political sensitivities, lack of trust, and operational barriers in implementing IHR and existing governance agreements. These challenges were explained in IDIs, particularly in interviews with regional stakeholders that delved into examples of countries sharing late or incomplete information that resulted in suboptimal management of outbreaks. Ethical and security concerns surrounding health data sharing are critical, leading discussions to focus primarily on aggregated, high-level information or de-identified details about threats or cases. As a result, the term ‘information sharing’ is more commonly used than ‘data sharing’ in the MENA region.

Regional governance structures, such as the Khartoum Declaration and Gulf Cooperation Council (GCC), also improve timely data exchange across borders. The example of the Gulf CDC, explained in IDIs, demonstrates how strengthened leadership and governance at a sub-regional level can improve information sharing during public health emergencies. The Gulf CDC, a collaborative network comprising Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates, aims to enhance information exchange between these six member states. Established in response to challenges in information transparency during the pandemic, Gulf CDC operates as a neutral entity trusted by countries to facilitate amendments to the IHR and agreements between nations. Amid and following the COVID-19 crisis, the organization ensured consistent communication between member states, with designated multisectoral focal points meeting weekly to discuss priority diseases and identified risks. The small size of Gulf CDC, political commitment from the existing GCC, and consistent communication platform have appeared to enable preliminary success, having a positive impact on information sharing relationships with neighboring countries.

The Gulf CDC approach to governance is also noteworthy in its multi-sectoral approach across countries. Effective governance also relies on multi-sectoral collaboration at the national level among stakeholders, including policymakers, healthcare providers, and local communities, for strengthening capacities and coordination [35, 36]. The One Health approach recognizes the interconnectedness of human, animal, both domestic and wild, plant and environmental health and aims to minimize disease threats by mobilizing different sectors to work together [37]. The literature, as well as most participants, agree that adopting a multi-sectoral approach with a One Health Framework is crucial for effectively controlling emerging zoonotic diseases, a strategy being implemented in some capacity by all countries interviewed. Each country interviewed and the literature findings highlighted the vital role of effective communication and collaboration between the human and animal health sectors in addressing disease outbreaks in emergency and conflict settings, particularly among refugees who rely on livestock as their primary source of income [38]. Although a few countries have yet to formally adopt a ‘One Health’ approach, all have established cross-sector communication and coordination mechanisms, either informally during emergencies or through formalized protocols. Oman and Yemen have adopted a multisectoral approach, which has been instrumental in containing vector-to-human transmission outbreaks. A participant from Saudi Arabia also elaborated on the vital role One Health played during the MERS outbreak in Saudi Arabia [36] and how that has been built upon:

“[In terms of One Health] we have shared committee with Minister of Agriculture, and we’re still seeking information about their positive cases in camels and our positive case cases in human beings. And actually, now the surveillance team in the regions is a unified surveillance team and a Minister of Agriculture representative there in the region, and a representative from Minister of Health in the region go together and do the surveillance to do activities together.” (5.A.3)

Similarly, a One Health Focal Point from a low-income country highlights inter-Ministry coordination growing with quarterly meetings for epidemic departments in both ministries:

“Coordination mechanisms exist, especially between the Ministries of Health and Animal Welfare. This need has been operationalized and institutionalized in recent years. One Health was a challenge because it was working between two ministries, Animal Welfare and Health. In recent times, people have tried to include the third sector, which is the environment, and as we know internationally, there is great interest in the One Health issue. So, [our country], being aware of these instructions, was fully engaged globally in the field of One Health.” (7.A.2)

Leadership and governance at the international level is thus impacting national multi-sectoral coordination momentum that facilitates information to avail for potential threats and cross-border collaboration.

Regional stakeholders also highlighted the need for continued efforts to operationalize data-sharing agreements and align definitions and indicators, which corroborated the literature [39]. Furthermore, three countries reported working on this. The literature suggests that international and bilateral governance to harmonize indicators and information sharing agreements, as well as expanded partnerships with academia and the private sector, can strengthen information sharing. Given the complex histories of borders and ongoing conflict in the region [40,41,42,43,44], academic and government partnerships were highlighted as an opportunity to bridge political turmoil [45] and strengthen surveillance capacity in vulnerable states, providing an opportunity to strengthen weaker health systems. International collaborations involving politically neutral academic institutions have demonstrated the ability to maintain partnership across countries in turmoil. For example, The Middle East Consortium for Infectious Disease Surveillance (MECIDS) is a regional collaboration of academic and public institutions aimed at facilitating IHR implementation and improving the laboratory capacity that facilitates information sharing across national reference laboratories of neighboring countries Israel, Jordan, and the Palestinian National Authority. [45, 46]. Furthermore, leadership to enhance coordination of public and private sector health facilities [47, 48] in surveillance efforts will improve coverage of surveillance data for all types of mobile populations, exemplified by the case of travel health services coordinated across both sectors in Oman [49].

Health financing

Governance, leadership, and multi-sectoral coordination to implement information sharing, One Health, IHR, and workforce supports within and across countries relies heavily on sustainable health financing. Sufficient funding for all sectors would improve data collection, analysis, and sharing to adopt a multi-sectoral approach. In particular, sustainable health financing will be critical for implementing a One Health framework to effectively control emerging zoonotic disease with the potential for cross-border spread. The One Health approach addresses health security by focusing efforts on areas prone to emerging threats, including monitoring zoonotic diseases, neglected tropical diseases, and vector-borne diseases. Although participants commonly referenced SARS-CoV-2 (COVID-19) and Middle East respiratory syndrome (MERS-CoV) as diseases of concern in the MENA region, the literature highlighted additional diseases that are high priority for certain countries, with a major demonstration of varying prevalence of vector-borne diseases across countries. As examples, Rift Valley Fever is a major concern in Saudi Arabia, Egypt, and Yemen [50, 51], Chikungunya poses a significant threat in Sudan and Yemen [34, 51, 52], and Dengue is a pressing issue in Oman and Saudi Arabia [51]. Further, Malaria is prevalent in Yemen, Oman, and Saudi Arabia, while Egypt faces a high rate of West Nile and Zika viruses [51].

The amount of funding a country receives also impacts its ability to respond to public health threats. The literature emphasized the financial challenges of meeting the IHR, especially in fragile and conflict-impacted countries. For example, Yemen faces significant financial challenges due to inadequate planning and resource allocation, intensified by its unstable political environment [53]. Although there are many qualified public health professionals capable of developing necessary health guidelines to mitigate the spread of diseases in Yemen, the ongoing conflict makes securing critical financial support challenging because of the lack of trust and willingness from donors and investors [53].

In Libya, on the other hand, a participant stated that their biggest financial challenge the country faces is in human resources:

“Human Resources is the biggest challenge as well as the finance. We have many, complicated procedures to be followed. To make new contracts, you need finance, and you need some approval from the health ministry, et cetera. That’s why there is a challenge.” (6.A.1)

Financial shortages are not limited to just low-income or conflict-impacted countries. For example, participants in a high-income country, reported financial challenges in human resources:

“The main challenge we are facing [is] human and financial resources, sometimes it is the economic situation. These financial matters are very difficult to control, however, we work with what we have. We even have shortages in some of the categories for health workers but we’ve been covering for each other. The health sector needs more and more support. The health budget is getting bigger however the spending is more than what is calculated. I think the health sector needs financial and human resources as well as materials.” (2.A.3)

Overcoming challenges related to sustainable funding across all sectors remains imperative. This includes ensuring adequate funding prioritization and allocation [37] across various ministries and establishing clear mandates for funding cross-cutting activities. The WHO Regional Office for the Eastern Mediterranean (WHO EMRO) comprehensive One Health framework (2022) outlines strategic steps to accelerate the implementation of the One Health approach within the Eastern Mediterranean region [37] and calls for identifying financial needs and possible funding mechanisms and specifies resource mobilization as a key responsibility for the regional One Health Quadripartite of UN organizations (Food and Agriculture Organization/UN Environment Program/WHO/World Organization for Animal Health) coordination mechanism Executive Board. The animal health sector faces significant funding gaps across countries in the region. Participants emphasized several key areas that require attention, particularly in the context of limited funding for multisectoral and One Health initiatives. These challenges include inadequate training for border staff, high turnover rates, and insufficient funds for monitoring animals across borders, particularly those crossing borders with migrants. The variation between the animal health sector and the more developed human health sector hinders the implementation of a comprehensive One Health approach in the region. To strengthen the multisectoral response engagement in the MENA region, it is crucial to prioritize funding and capacity building for the animal health sector. The financing and resource mobilization aspects of One Health are still developing in the region, and sustainable funding for animal surveillance, as well as increased collaboration among sectors, are necessary. By addressing these gaps, the region can enhance its ability to effectively implement or strengthen the One Health response system in the MENA region. To effectively control and contain disease outbreaks, it is vital to sufficiently fund different surveillance domains, including the IHR, human resources, and One Health and other multi-sector surveillance approaches.

Information systems

Cross-border surveillance relies on health information systems that facilitate data collection and analysis that avails quality, timely, and secure information to decision makers, however these processes and functionalities vary across the MENA region. The literature review highlighted several challenges, including data incompleteness, inconsistent definitions, and difficulties in reaching many mobile populations for data collection, such as travelers, nomads and illegal migrants, especially in emergency contexts [46, 54,55,56,57,58,59]. Participants also highlighted data quality challenges, whereas a regional participant expressed concern with the inconsistent definitions of varying information systems: “The different categories affect current cross border surveillance work because if we do not have a homogenous definition it means, especially when we’re reporting, we in most cases underreport.” (0.F.1).

We found evidence of innovative solutions in MENA that can be leveraged to provide reliable and timely data to decision makers on potential health threats. The literature recommended integrating migration health data into national health information systems (HIS) [54], adopting international definitions and indicators [60], and employing innovative methods like mobile applications, blockchain technology, geospatial mapping of human mobility, as well as respondent-driven sampling (RDS) to ensure reach of vulnerable populations who miss interaction with the formal health system, especially in emergency situations. Opportunities demonstrated include the potential of using mobile phone data to predict dengue outbreaks [61] and existing labor and household surveys to predict COVID-19 hotspots in Pakistan [62]. While technological advancements may facilitate more timely, complete, and better-quality data, considerations for personal privacy and the right to information protection need to be accounted for in deploying and communicating about new technologies [63, 64].

National surveillance systems that primarily draw information from health facilities are one of the main sources of information for countries. All countries interviewed reportedly had an electronic surveillance system, but these varied in scope and strength, as well as the importance of strengthening health facility information systems to capture data on mobile populations, as exemplified by the electronic surveillance systems in the Gulf region countries. The recommendations mentioned in the literature were not universally recognized in the perspectives of key stakeholders, even though the challenges identified were similar. Innovations and integrated electronic systems were most discussed and implemented by Saudi Arabia and Oman, where the governments have invested more in new technologies, as shown in Table 2. Regional-level stakeholders that work in surveillance also cited similar recommendations but did not necessarily have evidence of implementation. This suggests that further dissemination of existing innovations and resources in technology, data integration, and capacity building be shared with key stakeholders in MENA to provide additional ideas to resolve their challenges, with an attention to the low-income countries and conflict settings to ensure information systems are robust to include, but also protect the privacy of, health and mobility data on all populations, regardless of mobility status, in all countries in the region.

Ethical considerations in cross-border surveillance are critical to ensuring that the collection and use of health data respect individual privacy, minimize harm, and protect vulnerable populations who require additional consideration to ensure their health data is properly collected, stored, and shared. The WHO data-sharing policy provides a framework for international data sharing, emphasizing the anonymization of data to protect individual identities and prevent stigmatization or exclusion of populations [65]. Adopting such practices enables cross-border surveillance systems to address unique challenges effectively while safeguarding individual rights and are an important component of strengthening information systems.

Health workforce

Health Workforce underscores the need for surveillance systems to be implemented by well-trained, apportioned personnel who can effectively execute data collection and analysis. With increased globalization putting pressure on the public health workforce, members of the health workforce and other sectors (e.g., aviation, commerce) need to be trained in surveillance measures, specifically health facility staff, sub-national and national level surveillance staff, and POE staff. Workforce challenges were a common theme in both the literature and interviews and can be summarized into three challenge areas. First, inadequate training causes personnel to lack understanding and technical capacity to perform their roles [66,67,68]. Critically, the lack of trained personnel impairs the quality of data collection, timeliness of reporting, and underreporting of disease cases. Second, workforce supply issues caused by high turnover, absenteeism, and staff shortages result in incomplete detection of ill mobile populations, data reporting, and supervision. In both low- and high-income countries in MENA, POE are especially understaffed, due to their nature of being in remote and challenging environments to live. Low-income countries are further challenged by interruptions in pay and low salaries.

A participant from a low-income country shared the challenges in facing significant disruptions during the rainy season due to the inaccessible borders and communication breakdowns. To address these challenges, stakeholders integrated POE into sentinel site networks during emergencies and implemented a zero-reporting system to ensure consistent monitoring. A participant from a high-income country in the health sector also emphasized that the importance of surge capacity in the emergency context, often exacerbating human resource challenges:

“It always depends on the emergency situation. For instance, you usually build your capacity at a normal level, but it varies from one challenge to another. For example, during the COVID-19 pandemic, there were challenges in terms of hospital capacity, such as available beds. The capacity of the human resources is a key factor.” (2.G.1)

Staff shortages in other sectors involved in public health surveillance (e.g., agriculture, animal welfare) also impede public health surveillance, especially with a One Health approach. Third, coordinating personnel across multiple sectors and government levels, essential to One Health, is complex, resulting in delayed responses to outbreaks.

Solutions for addressing workforce challenges emerged from both literature and some IDIs. Target areas for training were identified as One Health [66,67,68], statistics/population dynamics and geospatial mapping [59], genomic epidemiology [69], and multi-country collaboration [33, 69, 70]. In tandem, adequate pay and incentives are needed to retain staff. Otherwise, resources used for training are wasted, and it becomes harder to coordinate teams who are unfamiliar with each other and operating procedure. Better coordination between state, federal and regional actors was highlighted to improve outbreak preparedness and response [22, 46, 71, 72]. Training personnel from other sectors or community leaders and volunteers and well-coordinated task sharing can help full surveillance workforce gaps [42, 73]. As demonstrated by Sudan in border regions, Community Event-Based Surveillance (CEBS) involves community leaders and volunteers who are trained on public health methods to detect and report notifiable diseases. Sudan trained more than 6000 volunteers for CEBS, and has supported the country significantly, although serious communication and implementation challenges resulted from the ongoing conflicts/wars [74, 75]. CEBS is a key surveillance strategy to utilize community level workforce to expand coverage of human resources available for early detection and response to disease outbreaks [76]. A One Health expert from Sudan emphasized the effectiveness of CEBS, stating:

“If you were to ask me what I consider effective in surveillance systems, I think community-based surveillance is a highly successful system as it supports the primary surveillance system. I train community volunteers in specific locations on specific packages, and they enhance reporting, bringing significant changes in reporting, addressing many gaps that might exist without such systems.”(7.A.2)

This can potentially be applicable throughout MENA regardless of country income level, including those with emergency, conflict, and migratory settings.

Essential medicines, vaccines and technology

Strengthening cross-border surveillance includes ensuring the availability and accessibility of essential medicines, vaccines, and technology for mitigating spread of disease across borders. This is crucial for all types of mobile populations for prevention, detection, and response intervention, monitoring, and data collection. MENA countries also must consider special attention to disease surveillance among travelers and attendees at mass gatherings, due to the potential for mass spread. Challenges in this area include maintaining a secure and reliable supply chain for medicines and vaccines, addressing data quality issues, and implementing advanced technologies for effective surveillance [64, 77]. High-income countries like those in the GCC often have better resources and technology to manage these challenges compared to low-income countries, which struggle with outdated guidelines and limited resources. For example, Saudi Arabia’s investment in traveler surveillance through health clinics and the use of blockchain with end-to-end encryption for secure data management to ensure integrity and privacy of testing and vaccine information of travelers [78, 79] illustrates the potential benefits of advanced technology and robust infrastructure in improving health outcomes and disease control [56, 80, 81].

A Ministry of Health infectious disease expert from Saudi Arabia highlighted their approach to addressing the unique challenges posed by mass gatherings, stating:

“Yet, we have the crowdedness, and we have the mass gathering in Ramadan and also in Hajj. So, what do we do to, to face all that? The first one is to increase the capacity of our healthcare workers in the point of entry, either the number of healthcare workers. As we do in each Hajj and each Umrah season, we add more healthcare workers to the point of entries. And instead of having one shift or two shifts, now we work for three shifts in all points of entry for all healthcare workers. And also we increase the training sessions for the healthcare workers around the kingdom.” (5.A.3)

This approach demonstrates how investments in workforce capacity and training can enhance preparedness and response.

Recommendations emphasize the need for multi-stakeholder engagement, improved cross-border communication, and the use of innovative technologies to enhance surveillance and data collection [45]. Deploying digital tools and technologies such as mobile applications, electronic wrist bracelets to provide real time data during mass gatherings, and blockchain can improve the accuracy and security of data on testing, treatment, and vaccinations, particularly for managing large volumes of travelers during events like Umrah and Hajj [77,78,79, 82]. The Ministry of Health representative highlighted the use of such innovations, stating:

“In the last Hajj, which is almost months ago, we used the bracelet for the Hajj, which contains the electronic bracelet. It has all the information about the Hajj and his or her health status, chronic diseases, or comorbidities. Also, those data can be easily obtained from those systems to one platform, which is the Hajj information system.”(5.A.3)

Successful implementations include Saudi Arabia’s integration of electronic bracelets and traveler health information into the national surveillance system, described by the Saudi Arabia participants, Egypt’s monitoring of respiratory and arboviral viruses among pilgrims [83], and the use of mobile application to collect data about vaccinations to support Syrian Refugees in Zaatari Camp in Jordan [84, 85]. Each data capture method must be applicable to the security concerns of its relevant target population. Strengthening these supply systems with technology requires international support and collaboration to ensure timely supply of essential medicines and vaccines, and the development of standard operating procedures for rapid response during public health emergencies. These efforts are essential for mitigating spread of disease amongst all types of mobile populations across borders.

Service delivery

Improved Service Delivery in the context of cross-border surveillance emphasizes the importance of healthcare access for all types of mobile populations who are often excluded from health monitoring. This in turn improves detection of new diseases and health threats. Yet in the MENA region, the challenges are acute due to climate change, political instability, and mass displacement [38, 43, 86, 87]. Low-income countries face challenges due to limited resources and healthcare infrastructure, leading to disparities in addressing health impacts, including those related to climate change. A regional stakeholder described the link of improved access to primary healthcare for all and improved surveillance and response:

“Regardless of your nationality, regardless of your migration status, you should be able to access healthcare. So, I think this would help because sometimes people fall ill and they’re scared of going to the hospital because they fear they may be turned in cause they do not have the right documents. But then if these access is given to everyone and people can easily access healthcare services at all levels, be it at points of entry or just in the community, we would be able to capture any disease before it spreads… rather than wait for an outbreak of a disease to occur at some particular center where we have a group of mobile populations…So if we do increase access to healthcare services to everybody, this would go a long way in trying to address some of the challenges that would come if people do not access healthcare.” (0.F.1)

Thus, ensuring surveillance data is available for certain vulnerable populations enables early response to potential outbreaks which subsequently reduces morbidity and mortality amongst these groups. However, refugees and other IDPs face unique challenges, such as continued movement and undocumented status, which may hinder the collection and accessibility of health information as stated by a health official in Yemen: “One major gap, I guess, for refugees is that, I guess they keep moving. And of course, because of the illegal status…I guess it would make it difficult just to access the information.” (3.E.1).

The literature and interviews further emphasize the importance of comprehensive data collection and integration of health data for refugees, internally displaced persons (IDPs), and migrants into national systems [54]. Key recommendations from the literature review include implementing cross-border health initiatives and expanding travel health services, which integrate disease surveillance into healthcare systems [49, 71]. Due to the high volume of international travel for business and religious tourism in MENA, travel clinics are useful for providing health education, vaccines, and other preventive care [49]. Enhanced surveillance systems, like EWARS, primary healthcare facilities and mobile clinics supported by international organizations like IOM [88], and digital tools, such as mobile health applications, are essential for improving health service delivery and equity in these contexts [42, 84, 85, 89, 90]. For example, The United Nations Relief and Works Agency for Palestine Refugees (UNRWA) provides healthcare to nearly 5.9 million registered Palestine refugees through 140 clinics using an electronic medical records (EMR) system [91]Specific strategies, such as using digital tools for real-time health information dissemination and establishing electronic health records, are highlighted for their effectiveness in improving service delivery. Countries hosting Palestinian refugees demonstrate how these approaches can enhance disease surveillance and healthcare delivery. As described by an UNRWA representative:

“We have electronic medical records and we provide primary healthcare in the 140 clinics in these five different places (Gaza, West Bank, Lebanon, Jordan, and Syria), and all of them are connected by internet and electronic medical records. It contains all the services we provide at health centers based on the refugee registration system, and it contains the health data, the maternal child health data, diabetes, hypertension data, outpatient data, and all the others.” (0.I.1)

This digital platform supports efficient information exchange and accurate data collection through automated data checks, encompassing primary care, maternal and child health, chronic conditions, outpatient visits, and communicable diseases. Addressing the challenges of movement across porous border areas, incomplete data, and limited inter-agency coordination is crucial for improving health services for all mobile populations in MENA countries, thereby ensuring health equity [54, 71, 92].

Limitations

Our findings have limitations. First, only English language searches were conducted, thus excluding anything in Arabic or French, common languages of the region. Furthermore, the gray literature and policy documents on the topic are expansive and we did not have access to all country reports and policy documents throughout the region, especially those in languages other than English. Thus, the findings are biased towards the English language, and those published online or in scholarly journals. Second, interviews were conducted with only seven countries in the region, and cannot be considered representative of all countries, but instead as key insights from specific contexts. The research team comes from the health sector and therefore there is some selection bias towards participants in the health sector, compared to those in animal health or other sectors. Those that responded to the invitation and volunteered to participate may be pre-disposed to a previous work and interest in the topic, leading to a selective participation bias. Different themes may have been found among the non-responders. The is also a possibility of social desirability bias in the interviews, as interviews were conducted by a research team that was funded by the US-CDC, who is a partner involved in public health surveillance throughout the region. Nevertheless, the lessons we gathered are critical to consider when moving forward with cross-border surveillance strategies in MENA.

Diagnosis and surveillance of malaria in africa

Diagnostically, the severity and high prevalence of malaria may require detailed clinical examination and laboratory investigation [77]. Culturally, laboratory diagnosis of malaria is performed with microscopic examination of thick and thin blood films stained with Geimsa stain [4]. Microscopy has been recognized by the WHO as the prime standard for malaria diagnosis [78], but the outcome is subjective, hence, there is a need for competent medical laboratory experts with extensive training and in-depth knowledge of detecting the malaria parasite microscopically. Regrettably, most non-endemic areas with the upsurge of imported malaria are characterized by limited laboratory technologists who are trained and experienced in identifying Plasmodium species [2].

This is significant because if performed by inexperienced individuals, particularly in areas where the disease is common, there is a risk of developing cases with low sensitivity [4] This can lead to either over- or under-diagnosis, resulting in the excessive use of anti-malaria drugs or neglecting treatment. Both of these scenarios can contribute to the facilitation and escalation of resistance by malaria-causing organisms or the occurrence of drug-induced pathological conditions. In addition, there have been reports of changes in the physical structure of parasites caused by excessive or incorrect use of drugs. These changes can lead to incorrect diagnoses of malaria, highlighting the importance of skilled microscopists who can accurately identify the species of parasites. This identification is crucial for effective treatment [2, 79]. Hence, it is imperative to assess the existing malaria diagnostic method in order to enhance the detection and monitoring of malaria in Africa, particularly among displaced populations. The classical method’s limitations have led to the development of RDTs, which offer more convenience and speed compared to classical microscopy. However, research has indicated that the dependability of the results from RDTs can be inconsistent [80, 81]. RDTs provide more accurate diagnostic outcomes by identifying several antigens such as Plasmodium lactate dehydrogenase (pLDH), aldolase, and histidine-rich protein 2 (HRP2) throughout the erythrocytic phase of the parasite’s life cycle [77].

At present, there are multiple methods for diagnosing malaria known as RDTs. However, the effectiveness of these methods can vary depending on factors such as the area, environment, and the presence of the disease and parasites [4]. Through the progress made in diagnostic science, researchers have identified several drawbacks of RDTs, including subpar product performance, inadequate quality control, and limited ability to address these deficiencies [82]. In order to improve the recognized constraints, scientists have conducted ongoing research that has resulted in significant advancements and discoveries in molecular techniques, particularly polymerase chain reaction (PCR) assays such as classical PCR, isothermal PCR, and real-time PCR [83]. Real-time PCR (RT-PCR) is advantageous due to its timeliness, reduced need for human resources, and ability to provide quantitative data [79, 84].

The utilization of molecular technologies in malaria diagnosis initiated the age of detecting malaria at a minimal level and identifying the specific species of the malaria parasite [85]. Nevertheless, the Plasmodium RT-PCR protocols, although seemingly advantageous, have certain drawbacks. These include limitations in species differentiation [79, 86], a restricted number of species identification [81, 87], and the need for prior genus identification and additional post-PCR analysis [88]. Consequently, these factors contribute to the prolonged duration of malaria diagnosis and surveillance.

Moreover, relying just on symptomatic persons who seek medical care for malaria treatment is not sufficient for successful malaria management, as asymptomatic individuals will not be identified [89]. Efficient methods such as mass screening and treatment (MSAT) and mass drug administration (MDA) have proven to be efficient in reaching those who do not show symptoms [90]. The MSAT methodology utilizes a resource-intensive method to identify active cases of malaria, employing a selective screening strategy similar to previous programs aimed at controlling infectious diseases [91].

The length, severity, and proximity to conflict or war zones are connected with higher rates of malaria parasites and a greater prevalence of malaria sickness [92]. This statement is highly accurate because conflict has a direct correlation with several risk factors, such as the failure of control programs, which can lead to an increase in malaria transmission [93]. Unfortunately, new geostatistical data shows that there has been a rise in these types of crises in sub-Saharan Africa, accompanied by other complexities [94]. An optimal strategy for controlling and eliminating malaria should prioritize the prompt identification and management of infections caused by the malaria parasite [17].

Given the substantial influence of war on the effectiveness of malaria control efforts, it is crucial to investigate ways that enhance the diagnosis and monitoring of malaria as a long-term intervention. The absence of surveillance for malaria identification, prevention, and control in Africa is closely associated with inadequate access to competent healthcare and the substandard diagnosis of malaria. The presence of data on the present diagnosis and surveillance would enhance comprehension of the relationship between malaria epidemiology and political, social, and economic instabilities, as well as local and national population displacements, in different African countries. Therefore, the insufficient information on the diagnosis and monitoring of malaria is the cause of the limited comprehension of the epidemiological data on malaria in Africa [95].

Challenges facing effective surveillance of malaria among displaced people in Africa

Effective malaria surveillance remains a challenge, especially among the displaced people irrespective of the different diagnostic and surveillance methodologies, for example, PCRs and RDTs available on the African market. Most of these methodologies rely on systematic data and information collection relevant to epidemic prevention, which is often problematic and difficult to obtain in displacement settings [96]. These displacement settings are characterized by disruptions in routine health services, minimal resources for data collection, and aggregation, and poor coordination among different stakeholders, such as CHW. Besides, some of these displacement settings have cross-border scenarios that may have multiple governments and international agencies involved [97]. For example, Eshag et al. demonstrate a limited presence of resources and control options necessary for malaria elimination in some of the displacement sites in Darfur Sudan [9]. The absence of these resources was attributed to the unstable atmosphere characterized by conflicts and upheavals and the outcome was an increased malaria prevalence noted at a 61.2% prevalence proportion [9]. The political instability in these displacement sites creates significant barriers to the establishment of specific data collection methodologies, especially those that require attention to detail, such as the evaluation of the mosquito vector species [9].

Moreover, malaria diagnosis and surveillance are particularly challenging in tropical regions facing CHEs, especially in war-torn zones housing IDPs. The negative impacts of violent conflicts, such as the destruction of infrastructure (Fig. 2.), impediments to transportation and delivery of medical supplies, the mass emigration of qualified medical personnel, and the overall displacement of populations, are well documented in the literature. These factors collectively hinder effective malaria surveillance and control in such settings [19]. These challenges cumulatively pose great threats to the healthcare system, worsen living conditions, deter access to basic healthcare, and heighten the risks and susceptibility to infectious diseases [19, 98]. As a result of the poor healthcare system, increased morbidity and mortality are experienced which are principally caused by infectious diseases like malaria in sub-Saharan Africa [27]. For instance, the DRC was reported to face an upsurge in malaria-induced morbidity and mortality during and after serious social conflicts [17]. Also, the Central African Republic has consistently been bedeviled with frequent violent conflicts and political crises over the years resulting in the displacement of residents. The worst hit is the impact on the healthcare system where medical essentials and drugs were looted from hospitals and other healthcare facilities throughout the country making more people to become vulnerable to infectious diseases [19]. A survey study documented a malaria-induced mortality increase of 3.5-fold from a total of 5.5-fold death increase during violent conflict [23].

Fig. 2 Challenges facing effective surveillance of malaria among displaced people in Africa Full size image

Malaria surveillance is also hindered by logistical and physical access barriers among the displaced sites and populations. Often, individuals in communities that face upheavals and armed conflicts may relocate to remote and hard-to-reach areas with limited infrastructure, such as road networks. The DRC, for example, has approximately 2.7 million internally displaced people living in various displacement and settlement camps [18]. Some of these populations live in villages and camps, for example, Bilobilo camp and Mubi Village which are situated along the sparse equatorial Congo Forest and Lowa River [18]. The geographical location coupled with an unstable atmosphere characterized by rebel activity creates a major barrier concerning malaria surveillance. Notably, accessibility is not merely a geographical issue but also a political and security-related one, particularly in conflict zones where the risk of violence can prevent public health officials from carrying out malaria surveillance and control activities.

Funding availability to the different camps housing displaced people has been critical in determining the magnitude of malaria surveillance. Often, the surveillance and vector control methodologies are constrained in the absence of sufficient finances that are relevant during the procurement process and offset health worker wages. For example, between 2020 and 2021, a community surveillance project to determine the prevalence and test-positivity of malaria among 12 resettlement sites was implemented by the Mozambican Ministry of Health [12]. The surveillance strategy was particularly funded by the Norwegian government and further supported by volunteer doctors from the “University College for Aspiring Missionary Doctors Africa.” The project demonstrated a test-positivity of 23.3% and 58.2% among individuals living in Sofala and Cabo Delgado provinces in Mozambique [12]. Further, the project categorically described the spatial–temporal patterns of malaria distribution in these provinces offering substantial information to the Mozambican Ministry of Health.

The presence of external support in the form of this funding demonstrates the impact that can be achieved concerning malaria surveillance in African nations. With these prevalence and spatial–temporal trends, different national strategies can be effectively developed to overcome the epidemic and improve the quality of life of individuals. However, most of the African countries are constrained by their budget allocations, and some lack access to external funding creating barriers to effective malaria surveillance. Additionally, humanitarian health interventions, especially in resettlement camps, often operate under emergency conditions with short-term and unpredictable funding [74]. Thus, long-term investments, which are crucial for sustainable malaria control, are frequently insufficient and unavailable. Additionally, financial uncertainty affects the procurement of necessary supplies like ITNs, antimalarial drugs, and diagnostic equipment impeding successful surveillance. These challenges create significant public and global health concerns hindering the achievement of global targets, such as the “global technical strategy” which focuses on a mortality reduction of 90% by 2030, the “global vector control response 2017–2030 strategy,” and the “Sahel Malaria Elimination Initiative” as set by the WHO [99].

Effect

Inadequate surveillance of malaria among displaced populations exacerbates the risk of malaria infection. The absence of effective surveillance systems makes it difficult to detect and treat cases early, leading to higher rates of severe malaria and fatalities. For example, a study conducted in a refugee settlement in Sub-Saharan Africa found that children from displaced communities who were hospitalized with severe malaria exhibited more severe symptoms and were over twice as likely to die compared to local children [16]. This was often attributed to delayed access to medical care, geographical obstacles, and logistical challenges, with distance to healthcare facilities being a factor in a quarter of cases.

The primary causes of malaria-related fatalities included anemia resulting from prolonged infection, malnutrition (Fig. 3), and parasitic worm infections [16]. Furthermore, insufficient monitoring of malaria treatment in refugee settings may contribute to the development of drug-resistant malaria strains, adding complexity to treatment efforts and burdening already strained healthcare systems [100]. The economic ramifications of high malaria prevalence among displaced populations are profound. These groups already occupy lower rungs on the economic ladder, and studies have indicated that their low socioeconomic status can perpetuate malaria transmission and its associated burden [101].

Fig. 3 Impact of malaria on displaced people in Africa Full size image

Malaria treatment is financially draining, especially among displaced families, who are already struggling with limited resources. Some of the minimal resources are mostly redirected to, sourcing basic needs, such as food and shelter. Thus, the absence of enough resources allocated for managing the disease condition limits the promotion of adequate healthcare. The health effects of malaria among displaced communities are very severe, resulting in higher rates of illness and death. Witnessing loved ones suffer or succumb to malaria can exacerbate trauma and mental health issues, particularly among vulnerable groups such as children and survivors of conflict or natural disasters [102].

As expected, displacement also frequently leads to restricted healthcare access and insufficient preventive measures, intensifying the disease’s impact, however, improved diagnostic methods and efficient monitoring systems are crucial for managing the disease, as they allow for early detection and treatment. This is essential for minimizing the number of complications and deaths caused by malaria in these areas [102]. Displaced people in Africa are also affected socio-economically through certain events, policies, or actions on the social and economic aspects of a society that displacement brings with it coupled with the fight against malaria [101].

Illness-induced decrease in output, along with the financial costs of treatment, can sustain poverty in people who have been forced to leave their homes, where there are already few economic options available, the additional burden of malaria can have a severe impact on the financial stability of both individuals and families but enhancing diagnostic methods and disease monitoring can lead to improved health results, potentially mitigating the economic consequences of malaria on these communities [101].

Also, the psychological effects of malaria extend beyond the immediate signs of the disease. The constant possibility of transmission creates an atmosphere of anxiety and uncertainty, especially among vulnerable populations like displaced youngsters and pregnant women. The mental well-being of individuals in displaced communities can be significantly impacted by anxiety, stress, and trauma resulting from this dread, leading to wide-ranging implications that can increase the burden of malaria infection among displaced populations. The uncertainty surrounding access to timely healthcare produces a pervasive sense of anxiety and helplessness [102]. A study undertaken by the WHO revealed that pregnant women who contract malaria exhibit more severe symptoms and have greater risks of negative outcomes, including miscarriage, intrauterine demise, premature delivery, low-birth-weight neonates, and neonatal death. This underscores the pressing need for enhanced diagnostic and monitoring techniques to detect and manage malaria among displaced African communities [19], especially among displaced pregnant women who have a high risk of infection [103].

Enhancing diagnostic and surveillance technologies would not only facilitate the detection and treatment of malaria cases among displaced populations but also assist in tracking the spread of the illness [16]. Over time, enhanced surveillance techniques have resulted in the timely identification of malaria epidemics, facilitating immediate intervention and preventive actions in developed countries. Thus incorporating these tactics into Africa’s current healthcare systems, especially amongst displaced people will improve the overall administration and regulation of malaria [102].

To effectively combat malaria among displaced people in Africa, it is essential to implement comprehensive measures that incorporate improved diagnosis methods, surveillance systems, and socio-psychological assistance. Immediate measures are required to alleviate the condition’s effects, considering its connection with socioeconomic inequalities, physiological, and health challenges. Also, effective collaboration between the healthcare, policy, and humanitarian sectors is crucial for developing targeted interventions that prioritize the health and well-being of vulnerable people. Finally, allocating resources to comprehensive strategies not only preserves lives but also promotes resilient and fair societies where access to healthcare is considered a fundamental human right [102].

Key facts

The world is off track to make significant progress towards universal health coverage (Sustainable Development Goals (SDGs) target 3.8) by 2030. Improvements to health services coverage have stagnated since 2015, and the proportion of the population that faced catastrophic levels of out-of-pocket health spending increased continuously since 2000. This global pattern is consistent across all regions and the majority of countries.

The UHC service coverage index increased from 45 to 68 between 2000 and 2021. However, recent progress in increasing coverage has slowed compared to pre-2015 gains, rising only 3 index points between 2015 and 2021 and showing no change since 2019.

The proportion of the population not covered by essential health services decreased by about 15% between 2000 and 2021, with minimal progress made after 2015. This indicates that in 2021, about 4.5 billion people were not fully covered by essential health services.

About 2 billion people are facing financial hardship including 1 billion experiencing catastrophic out-of-pocket health spending (SDG indicator 3.8.2) or 344 million people going deeper into extreme poverty due to health costs.

The COVID-19 pandemic further disrupted essential services in 92% of countries at the height of the pandemic in 2021. In 2022, 84% of countries still reported disruptions.

To build back better, WHO’s recommendation is to reorient health systems using a primary health care (PHC) approach.

Scaling up PHC interventions across low and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030.

Overview

Universal health coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. It covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care across the life course.

The delivery of these services requires health and care workers with an optimal skills mix at all levels of the health system, who are equitably distributed, adequately supported with access to quality assured products, and enjoying decent work.

Protecting people from the financial consequences of paying for health services out of their own pockets reduces the risk that people will be pushed into poverty because the cost of needed services and treatments requires them to use up their life savings, sell assets, or borrow – destroying their futures and often those of their children.

Achieving UHC is one of the targets the nations of the world set when they adopted the 2030 Sustainable Development Goals (SDGs) in 2015. At the United Nations General Assembly High Level Meeting on UHC in 2019, countries reaffirmed that health is a precondition for and an outcome and indicator of the social, economic and environmental dimensions of sustainable development. WHO’s Thirteenth General Programme of Work aims to have 1 billion more people benefit from UHC by 2025, while also contributing to the targets of 1 billion more people better protected from health emergencies and 1 billion more people enjoying better health and well-being.

Progress towards UHC

Prior to the COVID-19 pandemic, progress towards UHC was already faltering. The impressive pace of progress in expanding service coverage prior to 2015 did not continue as the UHC service coverage index (SDG indicator 3.8.1) increased only 3 points to 68 by 2019 and stagnated at this level through 2021. This indicates that in 2021, about 4.5 billion people were not fully covered by essential health services. The portion of the population incurring catastrophic out-of-pocket health spending (SDG 3.8.2) increased continuously from 9.6% in 2000 to 13.5% in 2019 when it surpassed 1 billion people. Moreover, in 2019, out-of-pocket health spending dragged 344 million people further into extreme poverty and 1.3 billion into relative poverty. In total, in 2019, 2 billion people faced any form of financial hardship (catastrophic, impoverishing or both).

The global pattern of the recent stagnating progress in service coverage while catastrophic health spending increases continuously is consistent across all regions, country income groups and most countries at all income levels.

Inequalities continue to be a fundamental challenge for UHC. Even where there is national progress on health service coverage, the aggregate data mask inequalities within-countries. For example, coverage of reproductive, maternal, child and adolescent health services tends to be higher among those who are richer, more educated, and living in urban areas, especially in low-income countries. On financial hardship, catastrophic out-of-pocket health spending is more prevalent among people living in households with older members (age 60 years or over). People living in poorer households, rural areas and in households with older family members (those aged 60 and older) are more likely to be further dragged into poverty by out-of-pocket health spending. Monitoring health inequalities is essential to identify and track disadvantaged populations to provide decision-makers with an evidence base to formulate more equity-oriented policies, programmes and practices towards the progressive realization of UHC. Better data are also needed on gender inequalities, socioeconomic disadvantages, and specific issues faced by indigenous peoples and refugee and migrant populations displaced by conflict and economic and environmental crises.

At the height of the COVID-19 pandemic in 2021, essential services were disrupted in 92% of countries. In 2022, 84% of countries still reported disruptions. In 2021, some 25 million children under 5 years missed out on routine immunization. There were glaring disparities in access to COVID-19 vaccines, with an average of 34% of the population vaccinated in low-income countries compared to almost 73% in high-income countries as of June 2023. Potentially life-saving emergency, critical and operative care interventions also showed increased service disruptions, likely resulting in significant near-term impact on health outcomes.

As a foundation for and way to move towards UHC, WHO recommends reorienting health systems using a primary health care (PHC) approach. PHC is the most inclusive, equitable, cost-effective and efficient approach to enhance people’s physical and mental health, as well as social well-being. It enables universal, integrated access to health services as close as possible to people’s everyday environments. It also helps deliver the full range of quality services and products that people need for health and well-being, thereby improving coverage and financial protection. Significant cost efficiencies can be achieved and most (90%) essential UHC interventions can be delivered through a PHC approach. Some 75% of the projected health gains from the SDGs could also be realized through PHC, including saving over 60 million lives and increasing average global life expectancy by 3.7 years by 2030.

Strengthening health systems based on PHC should result in measurable health impact in countries.

Can UHC be measured?

Yes.

The UHC target of the SDGs measures the ability of countries to ensure that everyone receives the health care they need, when and where they need it, without facing financial hardship. It covers the full continuum of key services from health promotion to prevention, protection, treatment, rehabilitation and palliative care. Progress on UHC is tracked using two indicators:

coverage of essential health services (SDG 3.8.1)

catastrophic health spending (and related indicators) (SDG 3.8.2).

More information can be found in this questions and answers page.

Detailed data is provided in the WHO Global Health Observatory Data Repository for UHC. Country profiles can be downloaded from https://data.who.int/.

Based on this data, WHO publishes global reports on UHC every two years. See the reports here.

WHO response

UHC is firmly based on the 1948 WHO Constitution, which declares health a fundamental human right and commits to ensuring the highest attainable level of health for all.

As a foundation for UHC, WHO recommends reorienting health systems towards primary health care (PHC). In countries with fragile health systems, WHO focuses on technical assistance to build national institutions and service delivery to fill critical gaps in emergencies. In more robust health system settings, WHO drives public health impact towards health coverage for all through policy dialogue for the systems of the future and strategic support to improve performance.

But WHO is not alone: WHO works with many different partners in different situations and for different purposes to advance UHC around the world.

Some of WHO’s partnerships include: