Background Non-communicable diseases (NCDs) account for over 60% of annual global deaths, disproportionately affecting low- and middle-income countries. This trend undermines progress toward Sustainable Development Goal (SDG) 3.4, which seeks to reduce premature mortality from NCDs by one-third by 2030. Despite the availability of effective and relatively affordable interventions, addressing NCDs requires sustained, coordinated efforts and robust monitoring systems. Facility-based monitoring offers a dynamic alternative to static surveys, enabling continuous assessment of healthcare quality and utilization. Methods This study followed a systematic approach to develop standardized global and national NCD monitoring indicators, using the Donabedian model as a conceptual framework. It focused on four major NCD categories: hypertension and cardiovascular diseases (CVDs), diabetes, chronic respiratory diseases, and cancers. The methodology included systematic scoping reviews from inception up to November 2021 and a multi-round Delphi process involving global experts to assess the validity and feasibility of proposed indicators. This study was funded internally by WHO. There were no payments to participants. Findings The final output consisted of 81 validated indicators—22 core and 59 optional. These indicators demonstrated high feasibility and relevance for facility-based monitoring of NCD service delivery. They provide actionable metrics for assessing and improving the quality of care across diverse health system settings. Interpretation This study highlights the urgent need for comprehensive, context-sensitive NCD monitoring frameworks. The proposed set of indicators offers a validated foundation for improving NCD care delivery and aligns with efforts to achieve SDG target 3.4. Ongoing updates and local adaptations will be essential to ensure continued relevance and effectiveness. Funding This study was funded internally by WHO.

Noncommunicable diseases (NCDs) are the leading causes of mortality and morbidity among Palestinians, accounting for 71.8

Objectives:This study aims to assess the prevalence of the current use of tobacco and e-cigarettes; to identify temporal trends, and to assess factors influencing tobacco use among adolescent Palestine refugees. Methods:The Global Youth Tobacco Survey (GYTS) was conducted in United Nations Relief Works Agency (UNRWA) schools in Gaza, Jordan, Lebanon, Syria and the West Bank (including East Jerusalem) in 2022. Prevalences were presented as rates with 95 % confidence intervals, stratified by location and sex. A time series analysis of 2008-2022 was performed. Results:Among 13-15-year-old Palestine refugees (n = 9193), 24.7 % (95 % CI [21.0-27.7]) of boys and 16.4 % (95 % CI [14.4-18.7]) of girls currently use tobacco products (including cigarettes, smoked tobacco products such as waterpipe, and smokeless tobacco). E-cigarettes are used by 18.1 % (95 % CI [15.4-21.2]) of boys and 9.3 % (95 % CI [7.5-11.5]) of girls. Tobacco and e-cigarette use is highest in the West Bank and lowest in Gaza. The prevalence of tobacco use has remained largely unchanged since 2013-2014. E-cigarette use among girls increased in Lebanon, Jordan, and the West Bank, but decreased in Gaza. Additionally, 39.7 % (95 % CI [36.4-43.1]) of adolescents are exposed to secondhand smoke in enclosed public spaces. Conclusion:The decline in tobacco use has stagnated over the past decade, and e-cigarette use among girls is on the rise, except in Gaza. Immediate and stringent enforcement of national and school policies, along with continued targeted gender-sensitive programs, are essential to curb the rising trend of e-cigarette use and maintain progress in reducing tobacco consumption.

The Eastern Mediterranean region covers a population of more than 700 million individuals and 22 countries and territories, sharing histories, culture, and languages. The countries and territories of this region also have large differences in demographics and human development. Population ageing and growth is predicted to more than double the number of new cancer cases in the region over the next few decades, from 782 000 in 2022 to close to 1·8 million by the year 2050. At the same time, cancer control capacity is low, with large inequalities between and within countries, further aggravated by political instability and conflicts. From 2013, the International Agency for Research on Cancer and the WHO Regional Office for the Eastern Mediterranean have been working together to strengthen cancer surveillance to inform regional and national cancer control. Based on an exposition of the cancer patterns, this Policy Review summarises remaining opportunities and barriers in ensuring high-quality cancer surveillance in all WHO Eastern Mediterranean countries and territories.

Breast cancer is the most diagnosed female cancer and the most common cause of cancer death in women in the Middle East and North Africa (MENA) region. In this study, we aimed to describe the current patterns of breast cancer among women in the MENA region and estimate the burden for the year 2050. We used the estimates of the breast cancer incidence and mortality from the GLOBOCAN 2022 database and predicted the burden of breast cancer in 2050 according to different scenarios. With 118,200 new breast cancer cases and 41,000 deaths, breast cancer contributed to 25% of cancer incidence and almost 20% of cancer mortality among women in MENA. The highest incidence rates were in Algeria and Iraq (≥60/100,000) and the lowest rates in Saudi Arabia and Yemen (<30/100,000). The highest mortality rates were in Iraq, Syrian Arab Republic, Algeria, and Sudan (>20/100,000), and the lowest in Saudi Arabia (7.6/100,000). While the incidence rates were low compared to other world regions, the mortality rates (16.9/100,000) were higher than in any other world region except Sub-Saharan Africa. The incidence rates for women <50 years in MENA were 5.5 times lower than in women aged ≥50 years, and lower than for women <50 years in Western countries. By 2050, the burden of breast cancer is estimated to increase to 219,000 new cases and to 88,900 deaths (86% and 117%, respectively). Scaling up cancer control to curb the rising burden alongside improved surveillance is vital to develop targeted interventions and improving outcomes.

Objective We provide an overview of the latest estimates of five gastrointestinal (GI) cancers in the Eastern Mediterranean Region (EMR) countries to guide cancer control policy.Methods We extracted the number of cases and deaths for oesophageal, gastric, liver, colorectal and pancreatic cancers from the GLOBOCAN database produced as estimated by the International Agency for Research on Cancer for the year 2022. Age-standardised incidence and mortality rates (ASR) per 100 000 person-years were estimated for the 22 EMR countries, cancer site and sex.Results The estimated 173 000 new cancer cases and 139 000 deaths from the five GI cancers corresponded to 22.2% of the incidence and 28.7% of the mortality burden in the EMR. Across all cancers (for both sexes combined), colorectal cancer ranked third (6.9%; ASR 8.9), followed by liver cancer (6.2%; ASR 8.4) in terms of incidence, while liver cancer (9.6%; ASR 8.1) and gastric cancer (6.4%; ASR 5.5) were the third and fourth leading causes of cancer-related mortality in the region, respectively. Marked differences in cancer incidence and mortality rates were observed between the 22 countries, particularly the 10-fold variations seen in liver cancer incidence.Conclusion GI cancers currently account for an important fraction of the cancer burden in the EMR; the present analysis seeks to inform tailored decision-making according to the country-specific GI cancer profiles.

Objectives To evaluate progress in the implementation of the WHO Eastern Mediterranean Regional Office (EMRO) Regional Framework for Action on Diabetes Prevention and Control, identify implementation barriers and facilitators, and provide recommendations for accelerating progress, with a particular focus on fragile, conflict-affected and vulnerable settings (FCVs).Design Mixed-methods study combining secondary analysis of quantitative data from WHO datasets with qualitative synthesis of inputs from WHO consultative meetings with EMR member states.Setting 22 countries of the WHO EMR, including 10 classified as FCV and 12 as non-FCV according to World Bank and WHO classifications.Participants Quantitative data were drawn from the 2021 WHO Country Capacity Survey targeting all EMR countries and other WHO sources. Qualitative data were based on insights from 16 country representatives during a regional WHO EMRO webinar, including non-communicable diseases programme managers, policy leads and WHO country office staff.Results Among the 22 countries analysed, only 10% (1/10) of FCVs had a national diabetes action plan compared with 67% (8/12) of non-FCVs. A sugar-sweetened beverage tax was implemented in 75% (9/12) of non-FCVs but in just 10% (1/10) of FCVs. For diabetes management, detailed national guidelines were available in 30% (3/10) of FCVs compared with 83% (10/12) of non-FCVs; insulin was available in primary care in 50% (5/10) of FCVs compared with 83% (10/12) of non-FCVs. Surveillance systems were less robust in FCVs: while 70% (7/10) collected data on diabetes status, only 30% (3/10) had a national diabetes registry, compared with 83% (10/12) of non-FCVs.Conclusions Addressing diabetes in the EMR requires strategic collaboration and tailored approaches for FCVs, including strengthened governance, preparedness, integrated care, medication access and surveillance. Prioritising primary healthcare and embedding diabetes prevention and control in universal health coverage and emergency response frameworks is critical to reducing inequities and improving health outcomes in fragile contexts.

Background: Harnessing digital technology for health service provision is inevitable, especially after the dramatic increase in demand during the COVID-19 pandemic and the observed global disruption of health services especially for People Living with Noncommunicable Diseases (PLWNCDs). Aims: To document and share experiences, challenges and lessons learned from the use of digital health interventions (DHIs) for noncommunicable disease (NCD) service delivery during the COVID-19 pandemic in the Eastern Mediterranean Region (EMR). Methods: We conducted a documentary research on the use of DHIs for continuity of NCD services during the COVID-19 pandemic in EMR. We collected our data using a questionnaire that was developed and administered by email to WHO NCD focal persons at the ministries of health of all EMR countries. Using the WHO classification of DHIs we then mapped the various interventions and the stakeholders involved. Results: Seven countries - Islamic Republic of Iran, Jordan, Oman, Qatar, Saudi Arabia, Sudan, and United Arab Emirates - shared their documentations. Documented DHIs used by countries to overcome the disruption of services during the pandemic were mostly on the use of client -to -provider telemedicine for NCD services. The level of implementation varied between countries. NCD and mental health helplines and COVID-19 prevention awareness campaigns for PLWNCDs were the most mentioned interventions. Conclusions: DHIs for NCD service provision were implemented during the COVID-19 pandemic in all settings: highmiddle- and low-income countries in the EMR. There is a high potential for incorporating DHIs within health systems to increase access to health services beyond the pandemic. Documentation, regulation and national capacity -building for mainstreaming DHIs in public health services in the EMR are strongly encouraged, based on each country's needs.

Introduction Comprehensive local data on adolescent health are often lacking, particularly in lower resource settings. Furthermore, there are knowledge gaps around which interventions are effective to support healthy behaviours. This study generates health information for students from cities in four middle-income countries to plan, implement and subsequently evaluate a package of interventions to improve health outcomes. Methods and analysis We will conduct a cluster randomised controlled trial in schools in Fez, Morocco; Jaipur, India; Saint Catherine Parish, Jamaica; and Sekondi-Takoradi, Ghana. In each city, approximately 30 schools will be randomly selected and assigned to the control or intervention arm. Baseline data collection includes three components. First, a Global School Health Policies and Practices Survey (G-SHPPS) to be completed by principals of all selected schools. Second, a Global School-based Student Health Survey (GSHS) to be administered to a target sample of n=3153 13–17 years old students of randomly selected classes of these schools, including questions on alcohol, tobacco and drug use, diet, hygiene, mental health, physical activity, protective factors, sexual behaviours, violence and injury. Third, a study validating the GSHS physical activity questions against wrist-worn accelerometry in one randomly selected class in each control school (n approximately 300 students per city). Intervention schools will develop a suite of interventions using a participatory approach driven by students and involving parents/guardians, teachers and community stakeholders. Interventions will aim to change existing structures and policies at schools to positively influence students’ behaviour, using the collected data and guided by the framework for Making Every School a Health Promoting School. Outcomes will be assessed for differential change after a 2-year follow-up. Ethics and dissemination The study was approved by WHO’s Research Ethics Review Committee; by the Jodhpur School of Public Health’s Institutional Review Board for Jaipur, India; by the Noguchi Memorial Institute for Medical Research Institutional Review Board for Sekondi-Takoradi, Ghana; by the Ministry of Health and Wellness’ Advisory Panel on Ethics and Medico-Legal Affairs for St Catherine Parish, Jamaica, and by the Comité d’éthique pour la recherche biomédicale of the Université Mohammed V of Rabat for Fez, Morocco. Findings will be shared through open access publications and conferences. Trial registration number NCT04963426.

We cannot prevent cancer, detect it early, diagnose, treat, and palliate it without reliable data. Continuous, systematic collection, analysis, and interpretation of cancer-related data are essential to effectively plan, implement and evaluate cancer control activities and policies. Enhancing routine health information systems to ensure that cancer-related data are well captured is essential, just as fostering functioning cancer surveillance systems, particularly population-based cancer registries (1,2). Population-based cancer registries play a critical role in the planning of national cancer control and prevention strategies, monitoring and evaluation of cancer care services, as well as cancer epidemiological and clinical research (1).

Background:Mental health has been identified by the World Health Organization as an integral component of the COVID-19 response. Aims:This study aimed to estimate the impact of COVID-19 pandemic on mental, neurological and substance use disorders (MNS) services in the Eastern Mediterranean Region. Methods:The assessment was conducted through a web-based survey that was completed by national mental health focal persons and was analysed between June and August 2020. Results:School and workplace mental health services were wholly or partially disrupted in more than 70% of reporting countries. Fewer than 20% of the countries in the Region reported full operations of mental health services for children and adolescents or for older adults. The main reasons were travel restrictions, decreases in inpatient volumes due to the cancellation of elective care, decreases in outpatient volumes due to patients not presenting, and health authority directives for the closure of outpatient services. The majority (85%) of countries responded by establishing MNS helplines using telemedicine/teletherapy and digital psychological interventions. The fragile and conflict-affected states relied mostly on implementing infection prevention and control measures at MNS service facilities. Gaps were identified in the areas of addictive behaviours, substance use and neurology research related to the pandemic. Conclusion:The assessment highlights the need to strengthen capacities for monitoring changes in service delivery and utilization, and documents evidence on what works in different settings during the different phases of the pandemic to facilitate informed decisions related to the nature and timing of adaptations to service delivery.

BACKGROUND:Availability of stage information by population-based cancer registries (PBCR) remains scarce for diverse reasons. Nevertheless, stage is critical cancer control information particularly for cancers amenable to early detection. In the framework of the Global Initiative for Cancer Registry Development (GICR), we present the status of stage data collection and dissemination among registries in the Middle East and Northern Africa (MENA) region as well as the stage distribution of breast cancer patients. METHODS:A web-based survey exploring staging practices and breast cancer stage was developed and sent to 30 PBCR in 18 countries of the MENA region. RESULTS:Among 23 respondent PBCR, 21 collected stage data, the majority (80%) for all cancers. Fourteen registries used a single classification (9 TNM and 5 SEER), 7 used both staging systems in parallel. Out of 12,888 breast cancer patients (seven registries) 27.7% had unknown TNM stage (11.1% in Oman, 46% in Annaba). When considering only cases with known stage, 65.3% were early cancers (TNM I+II), ranging from 57.9% in Oman to 83.3% in Batna (Algeria), and 9.9% were stage IV cancers. Among the nine registries providing SEER Summary stage for breast cancer cases, stage was unknown in 19% of the cases, (0 in Bahrain, 39% in Kuwait). Stage data were largely absent from the published registry reports. CONCLUSION:Despite wide stage data collection by cancer registries, missing information and low dissemination clearly limit informing efforts on early detection. The use of two classification systems in parallel implies additional workload and might undermine completeness. The favourable results of early cancer (TNM I+II) in two thirds of breast cancer patients needs to be interpreted with caution and followed up in time. Although efforts to improve quality of stage data are needed, our findings are particularly relevant to the WHO Global Breast Cancer Initiative.

Background:The COVID-19 pandemic has adversely affected the delivery of noncommunicable diseases (NCDs) services globally as health systems are overwhelmed by the response to the pandemic. Aims:The World Health Organization (WHO) Regional Office for the Eastern Mediterranean conducted an assessment to evaluate the impact of COVID-19 on NCD-related services, programmes, funding and consideration of NCDs in COVID-19 response. Methods:Data were collected from countries of the WHO Eastern Mediterranean Region (EMR) in mid-2020 through a web-based questionnaire on NCD services-related infrastructure, policies and plans, staffing, funding, NCD services disruptions and their causes, disruption mitigation strategies, data collection on comorbidity, surveillance, and suggestions for WHO technical guidance. The data were exported into Microsoft Excel and summarized. Countries were grouped according to socioeconomic level. Results:Nineteen of the 22 countries in the EMR responded: 95% had NCD staff reallocated to support their COVID-19 response. Lower-income countries were less likely to include NCDs in their pandemic response plans and more likely to report disruption of services. The most commonly disrupted services were hypertension management (10 countries 53%), dental care (10 countries 53%), rehabilitation (9 countries 47%), palliative care (9 countries 47%) and asthma management (9 countries 47%). Conclusion:The COVID-19 pandemic has disrupted the continuity of NCD-related services in EMR countries. The ability to mitigate service disruptions varied noticeably between countries. The mitigation measures implemented included triaging of patients, novel NCD medicines supply chains and dispensing interventions, and the use of digital health and telemedicine. Guidance and support for systems resilience, preparedness and response to crises are recommended.

The Eastern Mediterranean Region (EMR) faces massive challenges that threaten people's livelihood and health due to multiple factors, including socioeconomic disparities, conflicts and emergencies in many countries of the Region. The COVID-19 pandemic has further exacerbated these challenges and significantly disrupted access to essential health services. As highlighted in recent flagship reports, the region is unlikely to achieve health-related Sustainable Development Goals, unless crucial changes are made in the way the goals are pursued. Effective implementation of digital health technologies could provide opportunities to enhance the response to the pandemic, as well as improve the access to health services and develop stronger and more resilient health systems.

Data from population‐based cancer registries (PBCR) are critical for planning, monitoring and evaluation of cancer control programs, but are frequently underutilized by key stakeholders. As part of the ongoing partnership of the International Agency for Research on Cancer (IARC) and the WHO Eastern Mediterranean Regional Office (EMRO) in cancer surveillance, we designed a cancer registry survey to assess the level of involvement of PBCR in national cancer control planning across the region. A questionnaire on registry characteristics, their contribution to cancer control and perceived barriers, was sent to 14 countries with operational PBCR. We obtained replies from Bahrain, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Qatar, Saudi Arabia, Tunisia and the United Arab Emirates. We found a high participation of PBCR in cancer control planning (all registries involved, 46% routinely) and the evaluation of screening (92% registries involved, 46% routinely), but a much lower level of participation in palliative care and rehabilitation activities. Specified barriers included poor governance, a lack of awareness by policy makers, insufficient resources and a limited availability of data electronically, including mortality data. Appropriate planning to ensure the sustainability of PBCR (including the employment of permanent staff), increasing training, building research capacity and ensuring an efficient provision of high‐quality data to policymakers, were among the proposed solutions. The results of our study reinforce the need for further tailoring of activities in support of cancer registration and enhanced networking among stakeholders, toward improving quality and use of cancer registry data for cancer control in the EMR.

Background: Three global reports published by the World Health Organization (WHO) report trends in the prevalence of tobacco smoking from 2000 to 2025 based on data from national surveys. Aims: The is study aimed to: (i) compare current and projected prevalence rates of tobacco smoking presented in these reports for males ≥ 15 years in countries of the Eastern Mediterranean Region; and (ii) assess changes in the prevalence rates in the context of changes in tobacco monitoring and control policies in these countries. Methods: Regional and country-level data on tobacco smoking were extracted from the trend reports. Percentage point differences between the estimated prevalence of tobacco smoking in 2010 and the projected prevalence in 2025 were calculated for countries with available data. Data on implementation of national surveys and policies on tobacco use were obtained from relevant WHO reports. Results: In the latest trend report (2019), the prevalence of male current tobacco smoking is projected to decrease by less than 2 percentage points in the Region (from 33.1% in 2010 to 31.2% in 2025). The projections for male tobacco smoking for 2025 in the 2019 report are more encouraging than in the 2015 report in seven of the eight countries of the Region. For five of these seven countries, implementation of tobacco monitoring and tobacco control policies improved over the same period. Conclusions: Countries of the Region need to conduct additional national tobacco-use surveys to improve the accuracy of prevalence estimates and projections. Such data can help guide policy-makers to implement policies to control tobacco smoking.

National cancer control planning is crucial for countries in the WHO Eastern Mediterranean region. This region is challenged with an increase in cancer incidence leading to substantial disease burden, premature deaths, and increasing health-care costs in most countries. Huge inequity in cancer control planning and implementation exists between and within the countries. Over half of the countries (12 [55%] of 22) have standalone comprehensive National Cancer Control Plans and six (27%) have non-communicable disease plans that include cancer. The implementation of cancer plans has common challenges related to weak governance structure, few coordination mechanisms within countries, and inadequate human and financial resources. In most countries, the plan is not costed. Yet, the majority of countries (20 [91%]) reported having fully or partially funded plans. Additionally, political instability and conflicts affecting over half of the countries in the Eastern Mediterranean region have enormously affected cancer planning and implementation, both among the affected countries and those that host large numbers of refugees. In this Policy Review, we used the WHO regional framework for action on cancer to systematically analyse the status of cancer control planning and implementation across the six domains of cancer control, from prevention to palliation. We highlight the gaps, and the opportunities for bridging these gaps, to achieve scale-up on implementation of cancer control programmes in the Eastern Mediterranean region.

Background: Three global reports issued by the World Health Organization (WHO) track and report on trends in the prevalence of tobacco smoking from 2000 to 2025 based on data from national surveys. Aims: This review aimed to compare regional and country-level projections for current tobacco smoking as presented in the WHO trend reports. These changes were considered in the context of improved monitoring and tobacco control policies. Methods: Regional and country-level results in the WHO trend reports were considered in terms of the projected percentage point increase of current tobacco smoking between 2000 and 2025. Data on national surveys and policy implementation came from the relevant WHO reports. Results: In the 2019 trend report, the prevalence of current tobacco smoking among males is projected to decrease by less than 2 percentage points by 2025. Eight countries featured in both the 2015 and 2019 WHO trend reports. Seven of these countries indicated a more encouraging projection (a decline in their projected increase between 2000 and 2025) for current male tobacco smoking in the 2019 report than in the 2015 report. For five out of these seven countries, their monitoring and tobacco control policy implementation improved over the same period. Conclusion: Countries in the Region should implement additional national surveys to improve the accuracy of prevalence estimates, allow further projections to be performed and motivate policy-makers to make positive policy changes. Solutions to under-reporting biases during surveys should be considered. Governments should use trend projections to guide effective tobacco control policies to reduce tobacco use in the Region.

Cancer is a major contributing cause of morbidity and mortality in the Eastern Mediterranean region. The aim of the current study was to estimate the cancer burden attributable to major lifestyle and environmental risk factors. We used age-, sex- and site-specific incidence estimates for 2012 from IARC's GLOBOCAN, and assessed the following risk factors: smoking, alcohol, high body mass index, insufficient physical activity, diet, suboptimal breastfeeding, infections and air pollution. The prevalence of exposure to these risk factors came from different sources including peer-reviewed international literature, the World Health Organization, noncommunicable disease Risk Factor Collaboration, and the Food and Agriculture Organization. Sex-specific population-attributable fraction was estimated in the 22 countries of the Eastern Mediterranean region based on the prevalence of the selected risk factors and the relative risks obtained from meta-analyses. We estimated that approximately 33% (or 165,000 cases) of all new cancer cases in adults aged 30 years and older in 2012 were attributable to all selected risk factors combined. Infections and smoking accounted for more than half of the total attributable cases among men, while insufficient physical activity and exposure to infections accounted for more than two-thirds of the total attributable cases among women. A reduction in exposure to major lifestyle and environmental risk factors could prevent a substantial number of cancer cases in the Eastern Mediterranean. Population-based programs preventing infections and smoking (particularly among men) and promoting physical activity (particularly among women) in the population are needed to effectively decrease the regional cancer burden.

Background: Childhood cancer is a priority in Egypt due to the large proportion of children with cancer and the limited resources to achieve optimal care and outcomes. Accurate estimates of childhood cancer survival are lacking in Egypt due to paucity of data in population-based cancer registries. We, therefore aimed to estimate survival rates and trends in survival for the largest cohort of children with cancer in Egypt between 2007 and 2017.Methods: We used data from the largest cohort of children with cancer available in Egypt at the Children’s Cancer Hospital 57357–Egypt (CCHE), with population-based analysis. We analyzed routinely collected data of 15,779 children with cancer, aged 0-18 years, diagnosed between 2007-2017, based on ICCC-3 criteria and followed-up until 31st July 2018. Overall survival was estimated using the Kaplan Meier method and trends in survival were determined by single year of diagnosis using Cox regression, and by diagnosis periods using log rank test. Survival rates were stratified by age, gender, cancer type/sub-type, stage at diagnosis and disease risk variables. We also compared age-standardized survival rates from CCHE/Egypt to international benchmarks, identified cancers with significantly lower survival, highlighted potential reasons for inferior outcomes, and provided recommendations in practice and policy to improve survival outcomes.