Published on Arab Voices

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Since the revolutionary spirit seized the Arab World about a year ago, I could not help asking what, for me at least as a health professional, was the obvious question: how much did the voice of protest have to do with the deep dissatisfaction among vast segments of the population about the parlous state of their health systems?  

Scanning the blogs and tweets from the Middle East and North Africa (MENA) region didn’t help.  The outpourings there concerned mainly employment and education. And justifiably so given the very high unemployment rates in the region, especially among the youth, and the mismatch of skills that make an average young graduate’s efforts to find a job fruitless, if s/he does not have the right connections to land one.  

ImageYet I couldn’t help but wonder whether we were experiencing the phenomenon of “si la jeunesse savait et si la vielllesse pouvait” (roughly: if youth had known and if the elderly had been able). In other words, what would the story be if the youth who knew how to use social media and tweet also knew what the poor, the disenfranchised and the sick had to go through to obtain a modicum of appropriate health care? What if the older, the sicker and the poor knew how to tweet and blog?  Is there a silent majority out there who divest themselves of their assets and is routinely impoverished just to pay for the health care they should be entitled to?  

While we have some reliable data on how much people spend out-of-pocket for services they are meant to receive free of charge, we remain in the dark about the murkier sides of the interaction, the under-the-table transactions between the care providers and the people.  We know that about half of the health expenditures in the region are out-of-pocket. More importantly perhaps, these expenditures add an additional 23 percent to the poverty count in MENA. What we did not know until after we started receiving a new stream of data from post-revolution household surveys, is that in Egypt for instance, 97 percent of respondents in one survey did not know about user-fee exemptions for the poor.

Another more recent survey conducted by the Instance Centrale de Prévention de la Corruption (ICPC) in Morocco revealed that one in two hospital admissions involved under-the-table payments, with slightly lower rates for access to pharmaceuticals or blood products and just regular visits.

I was at a consultation in Beirut recently with the representatives of public health institutions in the Eastern Mediterranean. The take-home message was unequivocal: improve governance and accountability in the health sector for greater equity in access to health care. This jives well with findings of a recent survey in Egypt where 38 percent of respondents thought that the situation in health care had gotten worse and that, together with education, is the second most important area needing major investment, much more than infrastructure, private sector development or even democracy programs.

Popular wisdom, especially among us the development workers, is that we can only manage and improve what we can measure.  Yet Albert Einstein once said so beautifully: "Not everything that counts can be counted, and not everything that can be counted counts."  Our challenge therefore is twofold: measure or count – and I don’t mean only quantitatively – what the perceived or expressed health and care needs are in MENA countries. And two: exert extra effort to advocate for them to be counted, really counted. 

My intent is that this blog can be a platform for the latter and that you will help me raise the noise on this. The virologist in the movie Contagion said blogging was “graffiti, albeit with punctuation”.  He meant it as a bit of an insult but I’m happy to give it a try, for blogging offers a platform to convey our personal views and opinions and that blogs make us more prone to listen to what the others say, even if it is only in reaction (and self-interest) to what we blog about. Not many fora can make such a claim. So help me scrawl on the walls of MENA consciousness about the Health of the Revolution!


Enis Barış

Senior Advisor-Consultant, Global Health

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