by JULIE POUCHER HARBIN, EDITOR, ISLAMiCommentary, on JANUARY 17, 2013:
It’s been barely two years since Tunisian street vendor Mohamed Bouazizi set himself on fire in front of a government building in Tunisia. Just prior a policewoman had demanded he hand over his wooden cart laden with fruits and vegetables because he didn’t have a sales permit, and reportedly slapped him when he refused – publicly humiliating him.
This act of self-immolation was a catalyst for the Tunisian Revolution that ultimately resulted in the ouster of President Zine El Abidine Ben Ali and his regime in January 2011, and inspired demonstrations by citizens throughout the region demanding social, economic and political change in what has since come to be popularly known as the Arab Spring.
By the end of 2011, the Egyptian President Hosni Mubarak, Libyan leader Muammar Gaddafi and Yemeni President Ali Abdullah Saleh were no longer in power.
Major protests also broke out in Bahrain, Algeria, Iraq, Jordan, Kuwait, Morocco, and Sudan; and smaller protests occurred in Lebanon, Mauritania, Oman, Saudi Arabia, and Djibouti. A revolution-turned-civil-war is ongoing in Syria.
Protests against ruling governments were triggered by a range of concerns (depending on the country) including human rights violations, dictatorship, corruption, and economic decline, and many countries in the region haven’t seen the end of the civil unrest — including in those where new leaders have been chosen.
For example, Egypt, which elected controversial President Mohammad Morsi last Spring and accounts for roughly one-quarter of the Arab world’s 350 million people, is, at present, not only facing a political crisis, but an economic one.
According to an Associated Press story earlier this month, the unrest since the fall of Hosni Mubarak two years ago “has scared away foreign investors and crippled the vital tourism industry, both key foreign currency earners for Egypt.”
“Foreign currency reserves long used to prop up the currency have fallen by more than 50 percent since before the uprising and now stand at $15 billion,” according to the AP, and the Egyptian central bank has warned that the reserves are at a “critical minimum level” needed to cover debt payments and buy vital imports.
Egypt is currently in talks with the IMF about a $4.8 billion loan to help with a widening budget deficit, and Qatar recently came through with $5 billion in loans and grants with an agreement to invest $18 billion over the next five years.
Masood Ahmed, who led an IMF delegation that met with Morsi earlier this month (Jan. 7), said in a statement following the meeting that the IMF wants to see Egypt move to “a more inclusive model of economic growth through a socially-balanced homegrown program.”
This past summer and fall, Enis Baris (Sector Manager Health, Nutrition & Population, Human Development Department, Middle East and North Africa Region (MENA), World Bank) painted a murky picture of the socio-economic landscape across the MENA region – in public presentations before the Duke Global Health Institute in Durham (NC) and the World Health Summit in Berlin — and warned of dire health consequences for the future.
An experienced medical doctor, manager and technical expert in development and research by background, Baris (above photo) addressed some of the root causes of the Arab Spring and what it’s outcomes mean for the future of healthcare, employment, civil society, and governance in the region.
He kicked off his presentation The Arab Spring: What’s Health Got to Do With It at Duke by showing a video (top) — The Voice of the People on Health: Aspirations for the Future produced in June 2012 by the Middle East and North Africa Health Policy Forum (NGO) — in which various citizens in the MENA region were interviewed about medical care. As Baris pointed out, they were angry about inadequate health systems, including systemic corruption, inequalities in health care, poor communication by providers, and financial barriers to care.
“When there are frustrations, when people cannot get what they need, obviously it becomes part of the overall dissatisfaction,” said Baris. “And we believe strongly that there is good correlation between the people’s uprising in some of the countries in the Middle East and dissatisfaction with what they receive from the public healthcare systems.”
When Egyptians were asked if there had been any changes in their perception over the previous year:
- 48% said access to healthcare was more or less the same, 38% said it was somewhat worse or much worse, and around 12% noticed an improvement.
- 52% said unemployment was somewhat or much worse, 32% said no change, and around 12% noticed an improvement.
Living on the Edge
The MENA region, defined by the World Bank, includes 20 countries and 355 million people. About 85% of the population live in Middle Income Countries, 8 % in High Income Countries (including Saudi Arabia, Oman, Qatar, Bahrain, UAE and Kuwait) and 7 % in Low Income Countries (including Djibouti and Yemen).
Baris pointed out that while some countries in the region have an abundance of natural resources such as oil and natural gas, many countries are importers. A lot of these countries are spending “their precious cash” in order to get these things.
“A big problem is that in most countries in the region, governments heavily subsidize food and oil costs, which keeps prices down for the populace. Governments make up the difference by paying out of their own pocket,” he said.
How long can that last?
The stability of the political situation is key to economic stability.
“It is a fragile region. It has never been free of war. There’s always been some kind of an armed conflict and I think this is something we have to keep in mind. People have that in the back of their mind,” he said.
While Baris noted there has been much socio-economic progress in the region — life expectancy is up, the under-5 mortality rate has come down, the maternal mortality rate (except in a few countries like Yemen, and some rural areas in Tunisia and Egypt) is down, and absolute poverty is relatively low — he cautioned that “there are a lot of people living on the edge” and it only takes a financial or political crisis to push them over.
“People can quickly fall into poverty,” he said.
A reduction in tourism revenues in Egypt and Tunisia, for example, caused by political instability and uncertainty, has been damaging for seasonal workers and the informally employed.
Many people, Baris said, are informally employed, working the kind of jobs that “don’t advance their career and lack the basic benefits and security that more stable jobs would bring.”
High youth unemployment “is a very big issue” in the MENA, Baris said.
In fact, in some countries like Tunisia and Egypt, university graduates are the most affected by unemployment (2006 Egypt Labor market survey and a 2009 Tunisia Labor Force survey).
“In many of these countries, and you will see this in Latin American countries as well, they keep people in school as long as long as possible,” Baris said. “You (university student) study 4, 5 years at the expense of the government but the skills that you have will not really help you find a good job. They ask you what are your computing skills? What are your analytical skills? And you don’t have much to show for it. And then you fall into that situation where you are totally dissatisfied and disenchanted.”
“A lot of literature is coming out from social sciences showing that one of the reasons behind the Arab Spring and Arab revolutions is basically that educated people revolted, saying ‘We educated ourselves for so many years’, but now they don’t have skills, and don’t know what they are going to do, and where they are going to work.”
Keeping the “Youth Bulge” Healthy
And then there is the issue and consequences of the “youth bulge.” The World Bank notes that the relative number of young people as a percentage of the population is very high in the MENA, and fertility rates are declining in most MENA countries.
And while they may be young and seem healthy now, it appears they won’t be healthy as they age. Eventually, like America’s baby boomers, their numbers and their health issues will cost the system.
“We still have in this region a young and relatively healthy population, but they don’t necessarily have the healthy behavior. As they are getting older, as they reach adulthood, late adulthood, we are expecting them to have all kinds of problems, multiple non-communicable diseases,” said Baris. “This will have not only health consequences, but economic consequences. People will not be working for a longer period of their productive years and they will be costing a lot to the system.”
“We are predicting that non-communicable diseases … will increase more significantly in our region than many other parts of the world.”
In fact the World Bank, based on Bank and World Health Organization (WHO) data, expects a 38% increase in non-communicable diseases from 2008-2030, measured in disability- adjusted life years (a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death).
One of the goals of the World Bank and their partners, Baris explained, “is to find a way that we can keep this youth bulge healthy over the coming years.” Health systems in the region must also be prepared, and work on prevention.
“This is the biggest challenge for the governments and also international agencies like us,” said Baris. “We have to be strategic about what’s going to happen over the next 35-40 years.”
In fact, the Bank has healthcare projections all the way out to 2050, and it’s not pretty:
- 2010: Young and healthy population; low cost of healthcare; and low HIV prevalence
- 2025: Youth bulge becomes middle-age bulge; increasing non- communicable diseases prevalence; rising demand for healthcare and rising costs an
- 2050: An ageing population with high costs of care; high rates of disability; premature deaths among working population with poor health profile; and a high dependency ratio
Trimming the Fat
One of the biggest health threats in the region is obesity. In fact it’s a worldwide epidemic, that kills 2.6 million people a year. The Global Burden of Disease Study 2010, published just last month in The Lancet, shows that more people are dying worldwide from diseases connected with obesity than from malnutrition (except in sub-Saharan Africa).
An increase in diabetes cases in the MENA is already evident Baris said.
Baris said that obesity could reach 30 % of the adult population in some countries of the MENA and 20% in others, with women being the most vulnerable, especially those who are economically well off. Already nearly 45% of females and almost 30% of males in Saudi Arabia are obese. Morocco has the lowest rate of female obesity at a little over 10%. Childhood obesity is highest in Libya, followed closely by Egypt, Syria and Lebanon. Male obesity is highest in Saudi Arabia and Iraq.
Some factors leading to obesity in the MENA, Baris said, include lifestyle, limited or bad public transportation, and lack of parks – “anything that might keep one in the house and not moving around.”
Meanwhile, many people living in Djibouti, Yemen and some parts of Egypt are suffering from malnutrition (some acute and some chronic) and the height for age is lower than expected.
Other health challenges relate to geography.
In Algeria or Libya, Saudi Arabia and Egypt, Baris said explained, there are places where you have a very large population but other large areas of the country “where there is almost nothing.” Finding a way to deliver health services to outlying populations is a challenge. There are also very few water sources in the region. (the MENA region has the least water of all regions, and the Latin American – Carribean region has the most).
In Many MENA Countries, Health Not a Priority
Baris said that in many of the MENA countries, except the GCC where they have more money, governments actually spend very little, as a percentage of their GDP, on health. Health is not really a priority.
People do not necessarily buy health insurance, for all kinds of reasons, and when they get sick, they spend out of pocket, a figure that looks to have risen since the Arab revolutions in at least one country in the region.
Of total health spending in 2009, for example, Egyptians spent about 60% out-of-pocket on health care, and the government spent 40%.
According to the latest estimates, now Egyptians spend an about 75% out of pocket on health, and the government spends 25%.
“In OECD countries, with the exception of the US, you will usually find the government picking up 70-75% of total health expenditures, but in most of the MENA countries, you will find that the government spent 5,6,7,8 % of the GDP on health,” said Baris. “So in our region (MENA) when you look at the government budgets, which we do a lot at the Bank, you realize how much they put into education, into health and social things and it’s not that much.”
Corruption a Major Issue
The least corrupt country in the MENA region according to Transparency International is Qatar, and the most corrupt is Iraq — at 175, one of the most corrupt countries in the world.
The healthcare system is not immune.
For example, among the findings of a 2011 World Bank Health Facilities User Survey in Morocco (ranked 80 in the world and in the middle of the MENA rankings), was the fact that citizens had been making informal payments for services that were supposed to be free of charge – to doctors and receptionists – so that they could jump the line or get better service. This is not particular to Morocco, Baris, said but is seen in other countries in the MENA as well.
“When I saw this data, I was encouraged,” he said. “You normally cannot access to this kind of data. People will not tell you – out of fear of retribution.”
The Moroccan government posted the results of the survey on its web site, which Baris said “is a great positive step in the right direction” in battling corruption, and the government has decided to create an entity to measure the degree of corruption in various sectors, including healthcare.
Good Governance is Where Everything Starts
Baris pointed out that government accountability is weaker in MENA than in many other regions, with negative consequences on efficiency and quality of public services. Access to information, budget transparency and overall freedom of the press are also major issues in MENA.
However, while there had been historically “very little involvement of civil society” in the MENA, Baris said, since the Arab Spring, civil society and press freedom are growing, especially in Tunisia, which he says “is a very encouraging development.”
“Without good governance you can’t have efficiency, you can’t have equity, you cannot have responsiveness, you cannot have patient satisfaction and you cannot improve health outcomes. This is where everything starts.”
The World Bank’s overarching strategy in the MENA is to strengthen governance, accelerate growth, ensure economic and social inclusion, and create jobs. Last year the Bank contributed $5 billion to the region.
“What we really need to do in our region is to make sure that we invest heavily in governance in every possible way. … You want the society to move on from that (demonstrations in the streets) and have better governance so you don’t have this repeating every 50 years or so with a big risk of disruption of the social order but also with huge financial and fiscal implications.”
*Above charts and graphs courtesy of Enis Baris; World Health Summit powerpoint here
Video of the talk at Duke Global Health Institute below
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