Health and development in the Arab world: which way forward?

Short abstract

International efforts to improve health and welfare often overlook Arab countries. Arab peoples aspire to make progress in these areas but are not empowered to bring about change.

Considering its resources, the Arab world has achieved less than expected in health and development. In fact, the consequences of war, sanctions, and occupation in Iraq, Sudan, and Palestine have resulted in regression rather than progression. What is being proposed to address this? Last year, there were two international events that directly concern health and development in the Arab world. The first was a high profile conference on public health for health policy makers in Beirut organised by the World Bank and the World Health Organization, during which a document on the public health situation and prospects was released.¹ The second was the publication of the Arab Human Development Report 2002, cosponsored by the United Nations Development Programme (UNDP) and the Arab Fund for Economic and Social Development.² Although both events painted a challenging picture for development in the Arab region, they identified different sets of impediments to progress, priorities for development, and solutions. A critical look at these events may help identify important steps towards improving health in Arab countries and propelling development.

Figure 1.

Iraqi children queuing for food: wars and sanctions have gravely affected public health and development in one of the richest Arab countries

JASSIM MOHAMMED/AP PHOTO

Arab Human Development Report

The Arab Human Development Report 2002 is the first report from the United Nations Development Programme that concerns a single region. It was written by a group of Arab intellectuals and experts with known concern for the Arab world. They used old and new methods to summarise data from different resources into indices that are compared with other regions.

General development

The Arab world, despite its wealth and natural and human resources, fared poorly in many aspects of development (box 1 and bmj.com). Important problems include illiteracy, especially among women; lack of job opportunities, especially for young people; and slow economic growth because of loss of traditional economies, low productivity, and lack of innovation and competitiveness. Military spending is triple that of other regions. Rapid expansion of Arab populations threatens progress, especially in countries with limited resources such as Egypt. There are important developmental gaps related to distribution of oil wealth—for example, between the neighbours Saudi Arabia and Yemen.

Summary points

The Arab Human Development Report 2002 outlines important obstacles to development, especially freedoms, women's status and knowledge but provides few realistic solutions

Health policy in the Arab world has not adequately focused on sociopolitical determinants of health

The international agenda for health development in Arab countries must be expanded to include the effects of conflict and the political climate

Improved coordination of development efforts between Arab countries is urgently needed

Public participation in developing agendas and community projects is essential to improve health

Health development

Arab countries have made substantial progress since the 1950s in reducing infant and child mortality, improving life expectancy, and increasing access to health care. Major problems, however, remain (box 1 and bmj.com). Public health challenges include high maternal mortality, malnutrition, wide disparities between rural and urban areas and different countries, emphasis on curative rather than preventive care, relatively weak public health institutions, variable quality of health care, lack of capacity in policy making, and unresponsive and inequitable health systems.

Impediments to progress

The report links current development status with external and internal conditions. The main external factor is the Arab-Israeli conflict. Military spending is a direct impediment to development, especially in countries directly bordering Israel. Indirectly, the conflict impedes development because Arab governments use the pretext of security to restrict freedoms and political and civil rights and exclude broad public participation.

The report also examines the role of internal factors in the traditional social and political fabric of the Arab world, including conservative power institutions and non-democratic leaderships. It identifies lack of freedom, disempowerment of women, and inadequate production and use of new knowledge as the three key impediments to development.

Box 1: Key health and development statistics for Arab world

Population

Total population 281 million Growth rate 1.3-3.7%

Life expectancy 62.6 years for men and 65.2 for women

Disease burden

Distribution of cause of is 40% from communicable and other class 1 diseases, 45% from non-communicable diseases, and 15% from injuries

Indicators vary widely (for example, infant mortality rate ranges from 10.2/1000 to 75.3/1000 live births)

Health systems

Rank poorly compared with other countries

Expenditure on health as part of gross domestic product is 1.5-10.1% (public expenditure is 55%)

Social

Over 58 million people are absolutely illiterate and up to 50% of women are functionally illiterate

Most equal income distribution and lowest level of absolute poverty in the world

Economic

Combined gross domestic product only $531bn (£354bn)

Slow income growth (0.5%)

Unemployment 15% (but > 50% in Palestine)

Limitations of the report

The methodological and conceptual underpinnings of the report and its implications are being rigorously reviewed.³,⁴ However, one of the main limitations of the report is that it does not give many realistic solutions to propel development. It advocates synergy between “revitalized and efficient government, a dynamic and socially responsible private sector, and a powerful and truly grassroots civil society.” Although the aim is laudable, it would be difficult to achieve in many industrialised countries, let alone Arab countries.

The report does not discuss how Arab countries can secure the massive resources needed to pay for proposed development programmes. It fails to adequately emphasise the effect of global power relations on Arab development and the economic interests that favour maintaining the social and political status quo; industrialised countries benefit from a tight grip on the region's natural resources, especially oil, and maintaining the current trade surplus, especially through selling expensive arms to the region. Moreover, the report does not discuss the increasingly marginalised status of Arab countries in the world's political economy, especially after the terrorist attacks in the United States on 11 September 2001. With the war on Iraq under way, Arab countries have even less to say about the future of the whole region.

Although the report discusses social issues, the analysis is apolitical (with issues of class and power relations mostly absent). The section on health does not take good stock of public health capacities and relies excessively on official discourse on health development.

Despite the report's limitations, it's a welcome undertaking. The wide publicity the report has received in Western media, sometimes laden with anti-Arab racism,⁵ contrasts with the silence of Arab governments and dominant social and religious institutions about the findings or their responsibilities in producing and reproducing the current situation.

Policy making in health development

The conference on “meeting public health challenges in the 21st century” was jointly organised and funded by the World Bank, WHO, and WHO's Eastern Mediterranean Regional Office. It brought together health and finance ministers and other senior health policy makers and thus represents a reasonable gauge of current thinking, both international and local, about public health problems and solutions in the region. Intended to instigate action, the conference surveyed current and rising public health problems and discussed approaches to solving them.

Diagnosis of public health problems and their determinants

The conference highlighted the burden of non-communicable diseases. It mentions tobacco as a priority risk factor, together with the rising incidence of HIV and AIDS and the continued existence of major communicable diseases. However, it did not examine other public health priorities that require urgent attention, especially those linked to political conflict. These include the catastrophic health and economic situation in Palestine,⁶ Sudan,⁷ and Somalia⁸; the consequences of embargo on the people of Iraq⁹ and Libya; and the difficult conditions of the large refugee population in Jordan after the last Gulf war.¹⁰ Additionally, the conference report did not mention some of the critical obstacles to health development identified in the United Nations report such as economic conditions, social power structures, democratic practices, and the status of women. Sensitivity to criticisms of “outside interference” undermined the usefulness of the conference.

Strategies for improving public health

The conference emphasised the importance of public health approaches, including population based prevention and health promotion, integration of health services, institutional capacity, and locally acceptable reforms of the health sector. However, few people see action in public health separately from action on socioeconomic and political levels. For example, preventing the public health crises in several Arab countries, including Iraq, could have been done only through political interventions. Additionally, although this was a regional conference, it did not discuss regional cooperation in combating common public health problems. In an era when lack of effective coordination characterises Arab relations, joint work in health could create much needed success stories.

Steps towards change

With the enormous challenges facing Arab countries today, it is easy to lose sight of the possibility of change. Nevertheless, they must find a way to improve their lot. Debate is needed about the priorities, scope, and tools for improving health and enhancing development. The Arab world has the resources, capable people, and public will for change. What is needed is a vision for the future that considers all complex issues, admits to no easy solutions, and proposes gradual and realisable steps. How can this vision be developed and realised? I believe several key issues need consideration:

Role of citizens—Public involvement is crucial in setting the right agenda and enacting it. Occupied with food, liberty, and liberation, however, the average citizen of an Arab country rarely thinks of health as a priority. Increasing public knowledge of health issues and giving citizens, especially women, rights and responsibilities are essential. The pioneering work of the Arab Resource Collective (www.mawared.org) in spreading essential health knowledge deserves wide support.

Increasing inter-Arab cooperation—Although it's unfashionable to speak of Arab unity, coordination of both policies and programmes can promote health and development. Cooperation has contributed to improved health status in the rich Gulf countries,¹¹ but continued poor health indicators in neighbouring Yemen are unacceptable and indicate the need for more cooperation. The resources and experiences of the people and non-governmental organisations should also be pooled, not just those of governments. The Reproduction Health Working Group, a voluntary interdisciplinary and regional group supported by the Population Council (www.popcouncil.org/me/rhwg.html), is a bright example of innovative work deserving wider replication.

Role of international agencies—The report and conference are welcome signs of increasing international interest in Arab health, but public health and development communities need to coordinate. The approaches proposed at the conference form the basis for developing public health, but the agenda must be expanded to include the social, economic, and political conditions within which public health functions. Regional and country offices, rather than head-quarters, must have bigger roles. International aid and support, however, will achieve little without pushes from within the Arab world.

Developing an agenda—An enlightened and empowered Arab population and responsive governments can, with international support, develop a local agenda for health action. A platform with broad representation, especially of citizens, is needed and must be given powers to implement consensus recommendations. The opportunity is great. Arab governments want reforms but don't want to start with sensitive areas such as liberties and transparency. Health can be a safer entrance. For example, several Arab countries are now experimenting with programmes for healthy cities, neighbourhoods, or villages based on public participation. Such programmes, in which the usual top down approach is replaced by partnerships between government and citizens, offer instructive guides that can be replicated in other fields of development.

Box 2: Priorities for public health

• Reducing inequalities by putting emphasis on the most disadvantaged groups

• Population based prevention and essential care with proved cost effectiveness

• Strengthening primary health care and integrating fragmented health services

• Strengthening public health institutions

• Supporting community based and community designed health improvement initiatives

Addressing emergencies—Whatever agenda is agreed, action to prevent suffering and death caused by conflict must come first. The looming humanitarian crisis and collapse of infrastructure in Iraq,¹² which follows two decades of senseless wars and sanctions, is a priority, but the catastrophic situations in Palestine, Sudan, and Somalia cannot wait for attention. Although international aid is important, local and regional initiatives are indispensable to addressing emergencies and can contribute to developing needed infrastructure. The community based work of the Union of Palestinian Medical Relief Committees (www.upmrc.org), for example, needs more support.

Priority actions in public health—The Arab world needs to increase spending on health, especially to decrease the disproportionate out of pocket spending by the poorest people. Nevertheless, redirecting current resources from curative services to other areas of health care can accomplish a great deal (box 2).

Arab countries must find their own solutions for health and development. However, the world can, and should, help. Past colonialism helped produce today's geopolitical map of the Arab region and the consequent waste and suffering. Much can be done to change the current situation in which resources are squandered on conflict and oil exchanged for arms. Convergence of local will for change with solidarity of people elsewhere will maximise the Arab world's chances of pursuing a new course for development that meets its people's hopes and improves their health.