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Obstacles to Compliance with the International Health Regulations 2005: An Ecological Study in Countries in the World Health Organization's Eastern Mediterranean and African Region

By Maha Nasreldeen

Background:
The International Health Regulations (IHR) represents the first strong regulation designed to protect world health security. The Regulations originated in the nineteenth century in 1851 with specific areas of work covering threats to public health. However, the Regulations were still concentrating on non-infectious health hazards till recently in 1999 when the Regulations proved to be outdated. WHO proposed a draft of new Regulations consisting of the previous scope of infectious health hazards but added other kinds of non-infectious health hazards that might constitute a Public Health Emergency of International Concern (PHEIC). Countries agreed on the proposed Regulations draft presented in the World Health Assembly (WHA) in April 1999. The revised Regulations came into force in 2007. This study looked at obstacles facing countries trying to implement the IHRs, focusing more at problems on the ground level of implementations.


Methods:
The study used two sets of data: (i) questionnaires sent to people in IHR implementation authority in WHO EMRO (Eastern Mediterranean Region) and AFRO (African Region), countries responded were; Ghana, Zimbabwe, Iraq, Yemen and Somalia, a request letter with the questionnaire sent to above countries asking their permission and agreement to fill in and return a questionnaire, (ii) interviews conducted with the national authorities in Sudan who were involved in the implementation of the Regulations, interviews conducted and recorded in Arabic language, translated then by PI from audio to text; then again translated to English for the research purposes. All responses and summarized and sent to each individual’s for correction/ approval,  A total of seven participants from Sudan national authorities, and six countries representative from EMRO and AFRO region were participated in the interviews and the questionnaire in this study.


Results:
The study found that the coordination between involved sectors in the implementation of the Regulations is considered the greatest obstacle facing countries’ implementation. In addition the following were found to be major obstacles:  political will and country prioritization; available human resources; countries’ internal situations such as civil war or economic collapse, the effect of country position as a failed state. The later emerged as a big concern and barrier to fully compliance. Five out of six states which participated in this research were in 2011 failed state index (Somalia, Iraq, Sudan, Zimbabwe and Yemen). From these five, four are in under sanction by UN Security Council (Somalia, Iraq, Sudan and Zimbabwe).


Conclusion:
The study concluded that countries have to increase their efforts on coordination by country’s implementing authorities and between sectors involved in the implementation, also raising awareness activities in order to gain more political will and support to influence country priorities. The WHO should keep in mind the special circumstances of the failed states, giving them special consideration, and close support. Sanctions and failed state label were considered as strong reasons for not complying, each one weakening the state capacity to comply with its obligation. Failed states already lack resources and infrastructure and sanction will worsen the situation more, and countries will get in more issues of not complying with or being in allied with international laws. WHO also should increase technical and financial support to the implementation of the Regulations and work more closely with the countries’ by increasing frequency of monitoring and progressing reports, also sharing countries experience for more collaboration and acceleration to the implementation process.