September 26, 2012 1:13 pm
Uprisings highlight health shortfalls
Political changes brought about by uprisings in the Middle East and north Africa(Mena) have touched almost all countries in the region and created a sense of optimism and hope for social and economic reform. While most attention has focused on security and political implications of these changes, they also imply significant consequences for population health, welfare and social protection systems.
Many Mena countries face significant short-term health dangers that have arisen as a result of the uprisings. These include the deaths and injuries from the uprisings themselves, which have been considerable and – in Syria at least – continue to rise. Population displacement is an ever-worsening problem, especially in countries neighbouring Syria, from which more than 500,000 people are estimated to have fled with the associated effects such as post-traumatic stress disorders, particularly among children. A major short-term risk is damage to public health systems. Although outright collapse of these systems is unlikely in those countries that have remained stable, it is more likely in Libya and Syria. Available evidence from Iraq on the consequences of such service degradation on population health is not encouraging.
Mena countries remain subject to a variety of long-term health dangers, many of which were apparent before the uprisings but have been thrown into stark relief by them. High levels of unemployment are endemic across the region, especially among young people. This is exacerbated by the unequal status of women, who suffer from high rates of illiteracy and low levels of political and economic participation despite often playing a leading role in the uprisings. Over the past few years, these challenges have been compounded by rapid food price rises that have placed considerable pressure on household incomes when many Mena countries rely heavily on food imports. Unfortunately, many countries are poorly positioned to respond because of longstanding neglect of welfare systems that could protect their populations from impacts of disruptive economic change as a result of political transition. To these challenges may be added the long-term legacy of current violence – the toll of which remains unclear.
Levels of total healthcare expenditure across the region have in some cases been comparable to that of high-income countries, yet returns on health investment have in reality been variable. Indeed, this has masked the limited reform programmes and lack of sustained government investment in health and healthcare. Mena countries generally possess low levels of direct government health spending, low rates of coverage and are accustomed to high out-of-pocket expenditure. Public health capacity in many countries across the region is acknowledged to be weak. This stems in part from chronic under-investment: between 1990 and 2006, Mena governments invested between 1.7 per cent (IMF data) and 2.8 per cent (WHO data) of GDP into health, making the region an outlier globally for its low spending in spite of its upper-middle income status.
These vulnerable health and welfare systems have arisen over the past 20 years in a context of accelerated transitions to market economies driven by uncritical reductions in public social spending and privatisation without accompanying social protection mechanisms. The focus in healthcare has been on technological advancement rather than public health prevention, governance reform and the inclusion of health as an important aspect of human security.
Mena governments face considerable challenges in responding appropriately to these vulnerabilities at a time of change. A re-prioritisation of government expenditure towards public health will necessitate difficult reductions elsewhere, including defence. Given that six of the world’s top 10 military spenders (in percentage of GDP) are Arab states, this change will perhaps be the most challenging of all. Research evidence from major social and political transitions elsewhere (including eastern Europe since 1989) suggests that priority areas to be considered by Arab governments should include:
1. Ensuring adequate resources are put into public health system development, at a time when there are many competing spending priorities
2. Guarding against rapid socioeconomic change in the interests of radical reform
3. Tackling vested interests that may seek to co-opt transitions to advance neoliberal reforms in a sector whose nature as public good is dominant
4. Increasing transparency and monitoring through stronger surveillance systems
Whether new governments of the Arab spring can address these longstanding threats to stability by serving the people who have in some cases given their lives, or are ultimately co-opted by vested interests seeking personal financial gain, will crucially determine prospects for health and welfare in the region for decades to come.
Adam Coutts, is a policy consultant based in Beirut specialising in social welfare, employment and public health. Sharif Ismail, is based at Imperial College, London. Mark Dempsey, is a former regional director for the Financial Services Volunteer Corps working win Iraq from 2009 – 2012.
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