Download the    Health Brief [152k pdf] ; Also available in French and Arabic While the MENA region has made significant improvements in health outcomes, particularly through reduction in mortality rates among infants and children, it faces new challenges and risks that could its achievements to date.  Substantial risks of cost escalation in the health sector exist due to these epidemiologic changes, rapidly changing technologies in the global market, and move towards market liberalization in the MENA region. The existing health financing and service delivery systems in the region show varying capacity to respond to these challenges: in terms of mobilizing new financing sources, the tax burden is already high in most countries and additional taxes could blunt job creation and discourage participation in the formal sector; consumer out-of-pocket expenses on health care is on the rise across the region, and is leading to impoverishment of families; and investing in inefficient health services could further strain public financing. Strategic options exist to address these problems, but would require the health system to move from rigid input-based structure towards a performance and incentive-based system; and from ad hoc financing to a system that better balances subsidies, savings, and risk-pooling arrangements. Efficiency gains in health services would translate into improved fiscal sustainability, better labor market incentives and labor productivity, and overall higher social welfare. New institutional capacities and governance structures are needed to improve the performance of the public sector programs as well as create an enabling regulatory environment which promotes the growth of an effective, safe and viable private health sector. Demographic transition.  The MENA countries have achieved notable improvements in the health status of their citizens, as evidenced by an almost ten year increase in life expectancy between 1980 and 2003 (an average life expectancy of 59 years in 1980 to 69 years in 2003) and halving of infant mortality rate over the same period (from 90 deaths per 1,000 live births to about 40 per 1,000 live births). Many countries in the region introduced active population policies that have contributed to significant reductions in total fertility rates, starting from a regional average of over 6 births per women in 1980 to just below 4 births per women in 2003. Concurrent improvements in girls’ access to education and female participation in the labor force have likely contributed to reductions in family size. But MENA region was a relative latecomer to demographic transition, and the average total fertility rate remains significantly higher than that of other developing regions at comparable income levels (for example, developing countries of East Asia and Latin America have average total fertility rates of just over 2). As the decline in fertility rates lagged behind decline mortality rates, the region is now faced with a rapidly expanding youth population. The resulting "youth bulge" represents both an opportunity and a challenge to social and economic growth (see MENA Social Protection Strategy). Epidemiologic transition.  Although the relative size of the elderly population will remain small in the MENA region, the average share of non-communicable diseases is expected to rise from the current 45 percent of the disease burden to 60 percent by 2020. For example, there is an increasing use of tobacco, and adult mortality attributable to tobacco is expected to rise from 2.4 percent in 1990 to 9.5 percent in 2020. The MENA region also has one of the highest road accident rate in the world, second only after Sub-Saharan Africa, and injuries as a share of the disease burden is expected to increase from the current 13 percent to 21 percent by 2020. Accidents, violence in the region, as well as disease and congenitally caused disabilities, contribute to an overall disability prevalence rate estimated between 3.5 to 10 percent in the MENA region. Emerging diseases. The outbreak of Highly Pathogenic Avian Influenza (HPAI) in the bird population and limited number of human cases in 2006 highlighted the importance of strengthening public health surveillance systems in the region, and the ability to respond to these emerging global pandemics.  Although HIV/AIDS prevalence in the general population remains low in the region, there are indications that HIV is spreading among high risk groups. For example, the rise in drug trafficking in Afghanistan is leading to increasing number of intravenous drug users in the neighboring countries such as Iran. This, in turn, will contribute to the spread of HIV/AIDS and associated diseases such as tuberculosis. Djibouti is already facing an HIV/AIDS epidemic in the general population. Unless strong and decisive preventive measures are taken now, the rest of the MENA region could face a rapid spread of HIV/AIDS into the general population. Addressing equity and access to health care.  Public spending on health care accounts for about half of total health spending in the region, while household out-of pocket spending account for nearly half of total health spending. This heavy dependence on direct household spending on health signifies that many individuals and households have relatively little financial protection (health insurance) in the event of a catastrophic illness or injury. There are significant gaps in health coverage in most countries in the region, particularly in rural areas and among informal sector workers and their families. Investments in the health systems will need to be closely linked with the development of a well-targeted social safety net. Promoting financial sustainability and accountability. Higher spending will not necessarily translate into effective results, especially if investments are not directed towards the most cost-effective interventions or to the priority target groups. The existing health systems in the region, especially in the public sector, are not efficiently managed nor appropriately organized to meet the changing needs of the population. There is also an active and growing private health sector which remains largely unregulated and whose role is often not well defined within economic development plans. New institutional capacities and governance structures are needed to establish an enabling regulatory environment which promotes the growth of an efficient, safe and viable private health sector.  Investments in modern management systems and practices, rational investment plans, and appropriate cost containment measures, including substantial investments in preventive public health programs, are essential for the MENA countries to translate their investments in health into inclusive and sustainable growth. The MENA region comprises countries at widely different levels of social and economic development. This is reflected in great disparities in the health outcomes of the population, as well as divergent challenges and needs of the health sector. In terms of health outcomes and health systems, the MENA countries fall broadly into the following groups: (i) The low income countries (Yemen and Djibouti) continue to show poor health outcomes associated with poverty, and are not likely to meet the health MDG targets by 2015. Yemen and Djibouti currently have the highest infant mortality rates and maternal mortality ratios in the region. Yemen allocates only 5 % of GDP to health spending, the lowest in the region, and a mere $39 per capita. Djibouti spends a higher percent of GDP (7 %) on health, but this higher expenditure level does not translate into effective health services or health outcomes. Djibouti is the only country in the region where HIV/AIDS has reached a generalized epidemic stage, which is consuming a large share of available health resources. (ii) The middle income countries (Algeria, Egypt, Iran, Jordan, Lebanon, Libya, Morocco, Syria, and Tunisia) have made significant progress in improving the health outcomes of their populations, and are generally on track to achieving the health MDG targets by 2015. However, most of these countries still face significant rural and urban disparities in health outcomes and gaps in health coverage. For example, infant mortality rates among the poorest income quintile groups are twice the rates among the highest income quintile groups in Egypt and Morocco. Most of these countries also face structural inefficiencies that will require organizational and institutional reforms in the health system. (iii) A number of countries in the region (West Bank & Gaza, Iraq, and more recently, Lebanon) have experienced or are experiencing major reversals in the health status of the population due to conflicts. These countries face the dual challenge of meeting the most urgent health needs of the population and reconstruction efforts, while at the same time developing a vision and programs for a future sustainable health system. These countries also face an additional burden of disease arising from physical disabilities and mental health problems as a consequence of the conflict. (iv) The Gulf Cooperation Council (GCC) countries enjoy good health outcomes that approach those of other high income economies. However, available data suggest there is considerable scope for improving the efficiency and quality of the health systems, as well as meeting the challenges of changing epidemiologic and demographic transition. The World Bank Strategy: A Flexible Approach to Meet the Diverse Health Needs of MENA Region Supporting the Millennium Development Goals (MDG) and meeting the basic health needs of the most vulnerable population. Priority attention will be given to countries and populations at risk of not meeting the health-related MDG. Child and maternal mortality rates and malnutrition among women and children remain very high in the poorest countries of the region (Djibouti and Yemen), as well as among the indigent population in the middle income countries (e.g., Upper Egypt and rural Morocco). The region also faces a high risk of emerging diseases, such as HIV/AIDS, that will disproportionately affect the vulnerable population. Reaching these groups will require a multifaceted approach; a traditional, supply-driven approach to expanding access to health services will not be sufficient. The Bank’s strategy will expand support to community-based programs that empower community members, including women, in meeting the health needs of their families. Investing in the development of a more equitable and efficient health system.  The Bank provides investment support and technical assistance to the middle income countries in the region in order to enhance the performance of and enable the health systems to meet the changing needs of the population. These investments are crucial for averting the risks associated with health systems in transitions, including widening income disparities in access to health care and fiscal deficits. The Bank is supporting a range of programs in these areas, including: (a) expansion of health insurance coverage to the uninsured population; (b) developing institutional capacities and regulatory systems to ensure quality of care and patient safety, e.g. in pharmaceuticals and medical devices; (c) promoting public-private partnership for a more efficient and affordable health care; and (d) expansion of multi-sectoral public health programs to promote healthy lifestyles and reduce the impact of behavioral, environmental and other risk factors that contribute to an increasing share of morbidities and mortalities in the region. Promoting greater transparency and evidence-based policy-making. There is an urgent need to build regional capacities in health planning and policy analysis, and in health care management, and to develop research and evaluation capacities to support an effective and evidence-based policy and planning process. In response to these needs, the Bank has been actively supporting capacity building in the area of health policy, financing, and planning in the region, in close collaboration with the World Bank Institute.  The Bank also is supporting the establishment of a Middle East and North Africa Health Policy Forum, which is expected to become an independent, regional forum for promoting exchange of knowledge and experiences among nongovernmental organizations, academic institutions and government on health policy and planning in the MENA region. Health programs for countries in conflict or post-conflict situation. In Lebanon, West Bank & Gaza, and Iraq, the Bank assistance is focused on combining emergency operations that meet the urgent health needs of the population with institutional and systems development programs that will enable the countries to develop a sustainable health system. Greater attention is also needed to the needs of the population with disabilities. Technical Cooperation Program (TCP). Based on country requests, the Bank provides a fee-based policy advice and technical assistance to the non-borrowing countries in the region (Gulf Cooperation Countries) as well as to Borrowing members. All dollar figures are in US dollar equivalents. September 2008 For more information, please contact:
In Washington: Dina El Naggar, Phone: 1 (202) 473-3245; Fax: 1 (202) 522-0003; Email:delnaggar@worldbank.org |
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