Arab World ailments ill-served
From the exhilaration of popular revolution to the tragedy of ongoing conflict, the Middle East and North Africa (MENA) region has occupied a prominent place in the headlines. Yet there is another, often silent, drama that is not receiving the attention it deserves. It is playing out in both rich and poor countries, albeit in different forms. A series of alarming statistics reveal an ongoing deterioration in the overall health of the people of the region. This trend is aggravated by underfunded public health systems that provide limited and low quality care.
MENA governments commit on average only eight percent of their national budgets to healthcare. This compares with an average of 17 percent in OECD countries. One significant consequence of this low spending is that individuals are made to shoulder the majority of the costs for care. It often forces households, poorer ones especially, into making the difficult choice between spending on health or other necessities, such as food and education.
The region is currently paying a high social cost for the lack of attention paid to public health, and these costs will grow ever more severe in the absence of concerted action. Obesity is nearing epidemic proportions in MENA, with some of the highest rates in the world. In Egypt, half of all women are obese and one fifth of all men – landing them in the Global Top 20 for Obesity. Among women, Kuwait ranks second globally with 55 per cent of its female population considered obese. Other Middle Eastern countries which made it to the Global Top 20 for female obesity include the United Arab Emirates (UAE) (42%), Bahrain (38%), and Jordan (38%). The obesity rates are not much better for men. Within the top 20 countries globally, 30 percent of Kuwaiti men are obese followed closely by UAE (25%), Saudi Arabia (23%), and Bahrain (21%).
Obesity is closely linked to chronic diseases, such as diabetes, high blood pressure and heart disease. In fact, heart disease is the leading cause of death and disability in the Arab world, while high blood pressure is the second leading cause (and has been for the past 20 years).
At the same time, alongside obesity, there are high levels of child under/malnutrition and stunting across the region. In Egypt 30 percent of children below five years of age are stunted, while 20 percent of children within the same age category are obese. The statistics also reveal significant regional inequalities, with children in rural areas experiencing higher rates of stunting. In Yemen, the statistics for malnutrition and stunting have reached emergency proportions. Close to 60 percent of children are stunted and are at increased risk of death due to malnutrition. Other countries that have a high burden of child under-nutrition include Morocco, Iraq, Libya and Syria.
While under-nutrition can threaten the lives of young children, it also has long-term effects such as impaired cognitive development. This can affect everything from school performance to productivity and earnings in later adult life. Undernourished children may be particularly sensitive to weight gain as adults, with an increased risk for diabetes and cardiovascular disease.
Turning to young people and young men specifically, the main cause of death currently is road traffic accidents. In one year 35,900 young men died due to traffic injuries (2010). Although death due to traffic accidents is the third largest killer in the Arab world – for people of all ages – (a total of 73,500 people of all ages perished in 2010) young people are disproportionally affected. Also a large killer of children after their first year of life, with the 3,950 casualties in 2010, road traffic accidents are robbing the region of its future generations!
Depression is the leading cause of illness for women in MENA. It is especially women between the ages of 15 and 49 that are affected. In fact, the prevalence of depression among women in MENA is ranked higher than any other region. While men in MENA are also more prone to depression, the percentage gap between men and women is higher in MENA than all other regions, with the notable exception of Latin America and the Caribbean.
Despite all of these daunting health challenges governments are not focusing on preventive interventions. Prevention could result in tremendous future savings - but most importantly it could improve long-term health and protect people from future suffering. There are several factors that impact health, many of which lie outside the health sector itself, such as education, sanitation, roads, and environment. Preventive care can be achieved through inter-sectoral policies aimed at behavioral risk factors.
The Arab world presents a good environment for successful prevention. The region has high literacy rates and relatively good media coverage; critical elements for effective, mass scale public information campaigns. In addition, school enrollment rates are high so targeted school-based interventions on road safety, diet and nutrition etc. could work well. The challenges, therefore, are more about leadership, which is essential to establish the vision and strategies for effective public policies that advocate for better public health.
With low government spending on healthcare, households in the middle-income countries must cover almost 40 percent of all health care costs themselves. Patients in the low income countries have to cover a full 55 percent of healthcare costs out of their own pockets. Unfortunately, many cannot afford these medical expenses so people either chose to forgo much needed medical care or face impoverishment as a result.
The low public financing for health compromises both access and quality of care. Patient experiences at health facilities across the region are characterized by long waiting lines, absent providers, lack of privacy and informal payments. Satisfaction with existing health services is very low region-wide. As an Egyptian woman expressed it: “A public hospital is where you lose your life…a private one is where you lose your money.”
In order to address the health challenges, fair and accountable health systems have to be developed according to the new World Bank report “Fairness and Accountability: Engaging in the Health Systems in the Middle East and North Africa.” It recommends:
FAIRNESS refers to the absence of systematic disparities that could be avoided through prevention and care; just distribution of the burden of costs according to people’s ability to pay; and equitable response to the needs, rights and expectations of those seeking health care. In order to achieve fairness governments need: a) Well-targeted mechanisms that focus on vulnerable groups, b) Reducing high out-of-pocket expenses and expanding breadth of coverage, and c) Creating systems that are responsive to patients through training, regulation, and feedback.
ACCOUNTABILITY can be defined as responsibility and answerability. It is the obligation to ensure that health care services are effective, safe, cost-conscious, and patient-centered. In order to achieve accountability governments need: a) Monitoring of health care delivery through routine systems that track health delivery in real time and identify gaps and weaknesses, b) Tracking of health expenditures to ensure efficiency and curtail waste and corruption, c) Providing transparent information to patients so they know what health expenses are covered and making patients’ aware of their rights through a ‘Patient Bill of Rights’, d) Promoting Citizens’ Report Cards, where patients can provide feed-back, e) Tracking patient safety information to improve quality with warnings on such things as adverse drug effects, and f) Let service providers know that they will be held accountable but also provide incentives to improve the quality of care.
The region is at a critical juncture with the opportunity to transform its health system. Investing in health is investing in people, including children, youth and women – the future of the Arab world.
There is no time to waste.