Published on Arab Voices

A Hitchhiker’s Guide to Fairness in Health Systems in the Arab World

Developing countries in the Middle East and North Africa (MENA) region spent 5.8 percent of their gross domestic product (GDP) on health in 2011, compared to 4.4 percent in 1995. On the surface, this rise in health spending may seem like MENA governments are prioritizing health. Yet, between 2006 and 2011 public spending on health as a proportion of government budget in the MENA region was the second lowest globally, after South Asia. As a result, the people are paying the price. Out-of-pocket expenditures on healthcare remained close to 47 percent of the total health spending throughout the period. These trends suggest that increased spending on healthcare is mainly due to increased private spending at the point of service and as such made health systems less fair and affordable for the people of MENA.


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A fair health system mitigates, if not eliminates, avoidable inequalities in health and healthcare. Today mothers in MENA are, on average, almost three times more likely to survive childbirth, compared to 20 years ago; and their babies are more likely to survive the first five years of their lives. Yet improvements in regional averages mask disparities among and within MENA countries. In Djibouti, the number of women who died during pregnancy or childbirth dropped from 290 per every 100,000 live birth to 200 between 1995 and 2010. Yet, Djibouti, along with Yemen, still suffers from one of the highest maternal mortality ratios in MENA and is ranked 128 out of 180 countries globally. Children in the poorer regions are also impacted by inequalities in health outcomes. In Tunisia, children of poor and illiterate parents in rural areas (the least advantaged) are three times more likely to die in the first month or year of their lives compared to children of wealthier, educated parents living in urban areas (the most advantaged).

A fair health system better targets health services to those most in need.In Yemen, the least advantaged children are six times less likely to get immunized than the most advantaged, while in Iraq they are twice less likely to receive prenatal care than the most advantaged. In Libya, the children of wealthy families are five times more likely to have a trained health professional attending their birth. Yet, in these three countries health spending as a percentage of GDP increased, between 1995 and 2011, from 4.8 percent to 5.5 percent in Yemen; from 1.7 percent to 8.3 percent in Iraq; and from 3.3 percent to 4.4 percent in Libya.

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A fair health system protects the poor from potentially catastrophic financial outcomes of health shocks. With “Blood pressures boiling in MENA”, the wallets of the people are not well protected. Today, more than one third of all money spent on health care in the region is out-of-pocket, exposing the populations to risks of impoverishment due to health expenses. In the face of these choices, one third of the Yemenis, one fifth of the Lebanese, and more than one tenth of the Egyptians often forego health care altogether.

A fair health system responds to people’s expectations for dignified care regardless of their gender, ethnicity, income, or socioeconomic status. A recent World Bank study on reproductive health and family planning in Egypt shows that about 15 percent of the patients were asked to make a family planning choice while they were on the examination table rather than in a more private setting. In approximately 28 percent of clinics, women were asked whether they had the consent of their husband for family planning. Moreover, only one out of every four health clinics has a separate room for counseling and physical examination of women, considerably curtailing the privacy of patients. 

Despite the increase in average health spending in the last two decades, health systems in MENA continue to suffer from inequitable health outcomes, low financial protection and insufficient responsiveness for the poor in the region. The World Bank’s new Health, Nutrition and Population Strategy for MENA (HNP) responds to this by focusing on the principle of fairness, along with accountability, to help realize the aspirations of the people of the region for better health care systems.

The World Bank launched the new MENA HNP Strategy in Tunisia, the birthplace of the Arab Awakening, in May 2013. It was followed by several events in the region, including a five country launch to be held on October 23, 2013 in Istanbul, Turkey. To date, the MENA HNP Strategy has resonated with people. In the words of a Tunisian senior government official “The Arab revolution has led to a revolution within the World Bank. The language of the strategy is the language of the people.” The hope is that this amplified voice will not only lead to increases in government health spending, but also translate into more fair health outcomes for MENA.


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