By Randa Alami (Department of Economics, SOAS, University of London, UK)
Since the 2001 Sachs report on Macroeconomics and Health, health has been re-instated as key ingredient of growth and development. Together with the momentum generated by the Millenium Development Goals (MDGs), this led to the adoption in December 2012 of a UN Resolution on Universal Health Coverage (UHC), which is about the provision of affordable, accessible and good quality care for all. Both strands emphasised the need to go beyond national health outcomes to look at the building blocks of health systems, which in turn, determine fairness in access and delivery, and shape the financial risks associated with ill-health. Indeed, poor health can compromise the acquisition of both human capital and income, thereby perpetuating poverty. A key implied policy direction in working towards UHC is a prioratisation of health equity, because of its implications for social justice, poverty reduction, and satisfying unmet needs. By the same token, there is a considerable overlap between UHC and inclusive growth, since ensuring good health for all is a pillar of an inclusive growth process.
This paper explores examines health and health policies in MENA (excluding the GCC countries) in this context, arguing that UHC is key strategy for achieving inclusive growth and social justice in the region. It starts by taking stock of existing sectoral evidence on key health outcomes and structural features of current health systems, debunking the myth that MENA displays consistently good health outcomes, and questioning the validity of the simplistic policy conclusions based on these. In fact, outcomes are characterised by severe disparities and inequities in terms of income, locality, and gender. Large swathes of the population, particularly poor mothers, are barely achieving what rich quintiles achieved ten years ago: they are unlikely to do so if current policies continue. Equity in delivery and access are further compromised by the systems’ focus on often mediocre tertiary care centred on large urban centres. They are still described as mismanaged, inefficient, and fragmented (between levels of care, civilian/military, insured/uninsured).
Sectoral literature also documents a clear shift to the provision and access to healthcare on the basis of the ability to pay, which in turn contributed to forgone healthcare and high OOP. Indeed, a striking feature of the region is that citizens have been shouldering most of the financial burden of healthcare. The high levels of OOPs are mostly driven by: the neglect of primary health care, privatisation, poor coverage, and the inability to respond to the epidemiological transition. This burden means that, far from being eased by a golden social contract, poverty and inequality in MENA are seriously under-estimated. Another deficiency of this contract which contributes to high financial risks due to healthcare, is that health insurance is mostly contributory and linked to formal sector employment, or restricted by a lack of coverage and limited packages.
Underpinning this situation has been a policy of more or less explicit neglect of the public sector (be it in terms of financing, equipment, or staff), the macro-reflection of that being the fact that public health spending and budgetary allocations in MENA are below the norm for middle income countries. Consequently, the key policy message is that governments and public health sectors need to play a greater role, particularly in funding and covering the healthcare needs of the poor and the vulnerable. This message and the general relevance of UHC for health policies in MENA has been advocated by regional specialists for some time. Therefore, arguably what is missing is a political will and long-term vision that go beyond piecemeal solutions to sectoral problems. By the same token, achieving inclusive growth in MENA requires a political commitment to put development and social justice back onto the agenda, and to tackle the political exclusions that led to regional, income, and health inequities in the first place. Using Amartya Sen approach, health problems in MENA, particularly health inequities, are not about medical conditions, but about the lack of political engagement and inadequacies in social policy.