This chapter argues that health is an essential pillar of growth, and that ensuring Universal Health Coverage is a key pre-requisite for equitable and inclusive development. MENA health systems are far from meeting this challenge, because of clear developmental failures and lack of political will, not to mention wars. At present, MENA health systems are fragmented, inefficient, and deficient, delivering often mediocre, urban centered, tertiary care. They exclude large swathes of the population, particularly the poor, resulting in persistent disparities and inequities. Because of privatization, the neglect of public health, and defective social protection, MENA citizens shoulder some of the highest financial burdens amongst developing regions, which worsen and deepen poverty. To meet its health challenges and achieve inclusive development, governments need to revamp their public health sectors, and play a more central role in protecting the poor and vulnerable. MENA must invest in health, equity and development.
TopBackground And Introduction
Mainstream macroeconomic views of Middle East and North Africa (MENA)1 continue to depict the region as benefitting from significant historical improvements in health and education delivered by its old social contract, though concerns may be voiced about inequalities of outcomes or about the quality of public goods and services.2 However welcome, achievements in health outcomes (e.g. life expectancy) are not exclusive to MENA: they are displayed by most middle income countries. Since the 2001 report on Macroeconomics and Health, it has been shown that national health indicators in these countries cannot be used to draw any firm conclusions about health or of health systems.
In MENA’s case, such limited macro-level analysis focused on a few “visible” outcomes is incompatible with three bodies of evidence. Firstly, the upheavals associated with the Arab Spring exposed with widespread dissatisfaction with the status quo and many structural problems, including pervasive inequalities and deficient social protection mechanisms. In this context, Alami and Karshenas (2012) argue that: the region suffers serious deficiencies in health; public resources allocated to the sector were typically below international norms; and many people were being left behind because of waning government commitments. Earlier, Salehi-Isfahani (2010) and El-Laithy (2011) noted an increasing shift from the principle of universality to the ability to pay. Secondly, since the late 2000s, a spate of sectoral studies, typically based on household surveys, noted deficiencies and inequities in access to and delivery of healthcare. Thirdly, World Health Organisation (WHO) country and regional reports3 point to systemic problems if not widespread crises.
Arguably, the question is not whether health outcomes improved historically, but why there are still so many failings, and why do improvements continue to elude many people. The aforementioned macro-approach recognises there has been non-inclusive growth in the region, but is unable to relate it to these problems, and has little to say about unmet needs or relevant public policy. That would require looking at health in a more meaningful way that would, inter-alia, reflect its centrality to both development and social justice. Using this perspective, this chapter proposes a more relevant diagnosis whose policy recommendations are compatible with sectoral evidence. It shows that MENA health systems face a double whammy of not coping with current needs or with the looming epidemiological transition to Non-Communicable Diseases (NCDs). It echoes the sectoral call for action, arguing that MENA countries need to reverse the neglect of public health sectors, address the structural deficiencies that underpin the observed inequities, and work towards Universal Health Coverage (UHC). The latter also means addressing other aspects of public policy, particularly extending social protection to the poor and vulnerable.
To demonstrate its case, the chapter proceeds as follows. Firstly, in the next section, it traces the rising importance of health equity and of UHC. UHC aims to provide to key promotive, preventive, curative, and rehabilitative health interventions for all, at an affordable price (OECD, 2013; Stuckler et al., 2010). It then demonstrates the considerable convergence between UHC and an inclusive growth (IG) strategy, the former becoming a barometer for success in health policies. The third section applies these approaches to MENA. It shows the deficiencies in health outcomes and systems, and traces the retreat of public health spending in the region. The fourth section outlines the financial burden of healthcare and consequences of ill health in MENA. A key result here is that Out of Pocket spending (OOP) on heath in MENA is perhaps the worst amongst middle income countries. The fifth section categorises these deficiencies and placing them in an international context, while section six outlines the political economy that led to this neglect, and derives policy suggestions. The last section concludes, stressing the need to go beyond health targets, and the need to put back development, equity, and inclusiveness into political priorities.