Situational analysis of health systems for ear and hearing care in the World Health Organization (WHO) Eastern Mediterranean Region: A systematic review and evidence synthesis to inform national policies and strategies

In the Eastern Mediterranean Region (EMR), 78.1 million people experience hearing loss of any degree, with 22.1 million having disabling hearing loss, projected to reach 51.7 million by 2050. Unless global action is taken, the worldwide burden could reach over 700 million people with disabling hearing loss by 2050. This systematic review presents the first comprehensive health systems analysis of ear and hearing care (EHC) in the region. Following PRISMA guidelines, we analysed 146 articles through the WHO health systems framework to identify systemic barriers to effective EHC integration. Our findings reveal significant health systems challenges: fragmented governance with limited cross-sectoral coordination; inadequate financing with heavy reliance on out-of-pocket payments; critical workforce shortages across the region; and inequitable service distribution between urban and rural areas. While progress has been made with initiatives such as neonatal screening programs and primary care integration, these achievements remain limited in scope. Socioeconomic factors create additional barriers, affecting both hearing loss development and healthcare access. Alternative service delivery models, including telemedicine and task-sharing, show potential but lack systematic implementation. The economic burden of unaddressed hearing loss in the EMR ($30 billion annually) contrasts with potential returns of up to $7 per dollar invested. We propose five key actions: integrating EHC into universal health coverage, establishing comprehensive services across care levels, implementing awareness campaigns, developing monitoring systems, and promoting implementation research. This analysis provides evidence-based recommendations for health system reforms to address hearing loss while optimising resource allocation in diverse EMR contexts. • The first comprehensive health systems analysis of Ear and Hearing Care (EHC) in the Eastern Mediterranean Region • Consanguinity, genetic factors, otitis media, and noise exposure appear to be the main risk factors for hearing loss in the region • Five policy recommendations address critical gaps in governance, financing, workforce, and service delivery • Integration of EHC into universal health coverage could yield economic returns of $7 per dollar invested • Task-sharing and telehealth approaches could optimise the limited specialist workforce across diverse contexts