The Path Towards Universal Health Coverage in the Arab Uprising Countries Tunisia, Egypt, Libya, and Yemen

Series

Health in the Arab world: a view from within 3 The path towards universal health coverage in the Arab uprising countries Tunisia, Egypt, Libya, and Yemen

Shadi S Saleh, Mohamad S Alameddine, Nabil M Natafgi, Awad Mataria, Belgacem Sabri, Jamal Nasher, Moez Zeiton, Shaimaa Ahmad, Sameen Siddiqi

The constitutions of many countries in the Arab world clearly highlight the role of governments in guaranteeing Published Online provision of health care as a right for all citizens. However, citizens still have inequitable health-care systems. One January 20, 2014 component of such inequity relates to restricted fi nancial access to health-care services. The recent uprisings in the http://dx.doi.org/10.1016/ S0140-6736(13)62339-9 Arab world, commonly referred to as the Arab spring, created a sociopolitical momentum that should be used to The is the third in a Series of achieve universal health coverage (UHC). At present, many countries of the Arab spring are considering health fi ve papers about health in the coverage as a priority in dialogues for new constitutions and national policy agendas. UHC is also the focus of Arab world advocacy campaigns of a number of non-governmental organisations and media outlets. As part of the health in the Department of Health Arab world Series in The Lancet, this report has three overarching objectives. First, we present selected experiences of Management and Policy, other countries that had similar social and political changes, and how these events aff ected their path towards UHC. American University of Beirut, Beirut, Lebanon (S S Saleh PhD, Second, we present a brief overview of the development of health-care systems in the Arab world with regard to M S Alameddine PhD, health-care coverage and fi nancing, with a focus on Egypt, Libya, Tunisia, and Yemen. Third, we aim to integrate N M Natafgi MPH); WHO historical lessons with present contexts in a roadmap for action that addresses the challenges and opportunities for Regional Offi ce for the Eastern progression towards UHC. Mediterranean, Cairo, Egypt (A Mataria PhD, S Siddiqi MD); Department of Planning and Introduction four countries, perhaps because of the early stage of their Development, Ministry of Public Attainment of the best possible health is a human right, revolutions, are far from stabilising. For example, large Health and Population, Sana’a, and is part of WHO’s constitution.1 Additionally, the public demon strations in the summer of 2013 in Egypt Yemen (J Nasher MD MSc); Tunis, Tunisia (B Sabri MD); Sadeq constitutions of many countries in the Arab world show against its elected President Mohammad Morsi were Institute, Tripoli, Libya the role of government in guaranteeing provision of followed by a military intervention that overthrew Morsi (M Zeiton MRCS); and Offi ce of health as a right for all citizens. However, many countries and instituted a transitional government. We argue that, the Minister of Health, Cairo, have inequitable health-care systems, contributing to the despite the obvious dynamism in the contexts of these four Egypt (S Ahmed MBA)* poor wellbeing of their citizens. A component of such countries, the Arab uprisings still present an important *Dr Ahmed no longer works for the Offi ce of the Minister of inequity is restricted fi nancial access to health-care socio political enabler for pro gression towards UHC. We Health services, as manifested by fairly high levels of out-of- base this argument on the premise that revolutions in Correspondence to: pocket spending on health care. This inequity is further recent history—mostly after World War 1—although vary- Dr Shadi S Saleh, American shown by the millions of people, especially those in low- ing widely in terms of genesis, duration, and motivating University of Beirut, Beirut, income and middle-income countries, who face catas- ideology, have often embraced major changes in eco nomic Lebanon [email protected] trophic spending or fall into poverty after sickness.2–5 policies and governmental role in the provision of social Many reasons have been suggested for the recent programmes, including those related to health care. See Online for appendix uprisings in the Arab world (often referred to as the Arab An essential enabler for the successful integration of spring or Arab uprisings), including high unemployment, more equitable and comprehensive health policies is the corruption, major abuses of human rights, and—most early endorsement of a clear roadmap for progression importantly with regard to progression towards universal towards UHC as health-care systems are modernised, health coverage (UHC)—lack of equitable social provision. restructured, or re-engineered. In this report in the Series, we focus on four countries in the Arab world that have had uprisings: Egypt, Libya, Tunisia, and Yemen (fi gure 1). Although uprisings are also Tunis occurring in other countries in the region at the time of Tunisia Mediterranean Sea writing, these four were selected for two main reasons. Tripoli First, all had new governments instituted, albeit with Cairo Libya varying functional structures because of the nature of the Egypt transitional phase. Second, the four countries represent the diversity of the region with regard to wealth, Red health-system characteristics (eg, fi nancial protection Sea Yemen portfolios), and social context (tables 1, 2), yet share the Sana’a common theme of longstanding regimes that contributed to inequity (appendix). The sociopolitical contexts of these Figure 1: A map showing Egypt, Libya, Tunisia, and Yemen www.thelancet.com 1 Series

2001 2011 Yemen Egypt Tunisia Libya Yemen Egypt Tunisia Libya Key socioeconomic indicators Population size (millions) 18·537 65·420 9·729 5·328 22·879 78·728 10·459 5·603 GDP per capita (US$) 465 1258 2160 6072 1137 2257 3852 10 722 Population younger than 15 years 47·7% 37·7% 31·0% 39·0% 45·0% 31·7% 24·2% 31·1% Unemployment rate 12% 13% 16% 11% 16% 9% 13% ·· Literacy rate in people aged 15 years and older 47% 61% 67% 82% 62%* 71% 78% 89% Gross primary school enrolment ratio† 59% 95% 99% 106% 75% 94% 98% 97% Gross secondary school enrolment ratio total† 35% 82% 65% 97% 37% 92% 75% ·· Poverty headcount ratio at national poverty line (% of population)* 20·1 16·7 32·4 ·· 34·8 22 3·8 ·· Gini index (rank)‡ ·· ·· ·· ·· 37·7 (71) 30·8 (20) 41·4 (98) ·· Key health services indicators Proportion of population with access to local health services 50% 100% 95% 100% 50% 100% 95% 100% Proportion of 1-year-old infants immunised in 2010 BCG vaccine 73% 98% 91% 99% 65% 98% 98% 100% Diphtheria, pertussis, and tetanus vaccine 76% 99% 98% 95% 87% 97% 98% 98% Oral polio vaccine 76% 99% 98% 95% 88% 97% 98% 98% Measles vaccine 82% 97% 92% 95% 73% 96% 97% 98% Hepatitis B vaccine 21% 99% 94% 95% 87% 97% 98% 98% Key health outcome indicators Life expectancy at birth (years) 61·1 69·3 71·9 69·5 61·1 73·2 74·5 72·3 Infant mortality rate (per 1000 livebirths) 67·4 25·5 20·0 24·4 68·5 16·5 17·8 14·0 Maternal mortality ratio (per 100 000 livebirths)§ 383 74 56 63 269 43 36 40

Data from the WHO Regional Oﬃ ce for the Eastern Mediterranean,6,7 unless otherwise stated. GDP=gross domestic product. *Data from the World Bank.8 †Gross primary and secondary school enrolment ratios measure the proportion of children enrolled in primary or secondary education (respectively), regardless of age; these measures can exceed 100% because of the counting of overaged and underaged students. ‡Gini index9 represents the score for the most recent year released by the World Bank; ranking based on ascending order of Gini index. §Data from Hogan and colleagues.10

Table 1: Selected key socioeconomic and health indicators for Egypt, Tunisia, Libya, and Yemen

2001 2011 Yemen Egypt Tunisia Libya Yemen Egypt Tunisia Libya Total per-person expenditure on health (US$) 15·3 65·9 115·0 344·0 64 113 240 417 Government per-person expenditure on health (US$) 5·6 13·9 47·0 216·0 18 47 130 276 Total expenditure on health as a proportion of GDP 3·9% 4·8% 5·3% 3·9% 5·6% 5·0% 6·2% 3·9% Government expenditure on health as a proportion of total health expenditure 1·2% 1·1% 2·3% 3·2% 28·0% 41·7% 54·0% 66·1% Out-of-pocket expenditure on health as a proportion of total health expenditure ·· ·· ·· ·· 71·0% 57·0% 40·0% 33·9% Government expenditure on health as a proportion of total government expenditure ·· ·· ·· ·· 4·3% 5·9% 10·4% 5·5% Ministry of health budget as a proportion of government budget 4·0% 3·3% 9·6% 11·3% 3·6% 4·0% 6·8% 5·7%

Data from the WHO Regional Oﬃ ce for the Eastern Mediterranean.6,7 GDP=gross domestic product.

Table 2: Selected key indicators for health expenditure for Egypt, Tunisia, Libya, and Yemen

In this Series paper we have three complementary with present contexts into a roadmap for action that objectives. First, we aim to present selected historical addresses the challenges and opportunities for pro gression experiences of countries that had substantial social and towards UHC. To address these objectives, enhance political changes, and how these changes aff ected their methodological rigour, and increase the validity of reported path towards UHC. Second, we present a brief historical analyses and conclusions, we use a combination of a overview of three distinctive phases in the development of review of literature about historical experiences of coun- health-care systems (specifi cally fi nancing) in four countries that underwent substantial social and political tries of the Arab spring, from political independence (early changes and how these aff ected the path towards UHC, and mid-20th century) until the onset of uprisings in 2011, and an assessment of the structure, processes, and out- with a focus on the sociopolitical factors that shaped this comes (or indicators) of the health-care systems in the development. Lastly, we aim to integrate historical lessons four coun tries. This analysis is supplemented by expert

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opinions from key stakeholders in the health systems of sociopolitical changes and substantially aff ected the each of the four countries and from regional health development of social benefi ts.24 The German and French systems. The roadmap towards UHC combines an scenarios also hold true for reforms after World War 2 in analytical synthesis of literature with the contextualised several western European countries.25,26 opinion of health-system stakeholders. Latin America provides additional examples of progress towards UHC resulting from governments’ response Historical examples of sociopolitical to organised demands for public health policies. The transformations and developments in demands for public health were a main pillar of opposition health-care systems movements to military dictatorships in countries such as The transformation of health-care systems from inequality Argentina, Brazil, and Chile. For example, the health for all to equality has been argued to be a natural outcome (or vision in Brazil emerged during the years of political an underlying predecessor) of political transformations opposition and at the end of the military dictatorship that driven by social-equity agendas (fi gure 2). This dynamic started in 1964.27 The reform of the Brazilian health sector, between social equity and UHC was described in the at the same time as democratisation, was driven by civil 2008 WHO World Health Report,13 which explicitly stated society rather than by governments, political parties, or that “demand from the communities that bear the burden international organisations.28 Furthermore, the Cuban of existing inequities and other concerned groups in civil revolution was linked with the nation’s health-care society are among the most powerful motors driving system.29,30 In fact, Cuba remained faithful to the basic universal health coverage reforms”. Evidence from the premises of its system and has been praised by many scientifi c literature further substantiates this argument by for social equity and health outcomes.31–34 After the suggesting that revolutions driven by such an agenda form 1959 revolution, Cuba succeeded in attaining considerable a solid path to a more equitable and healthier society.14–22 advances for many health outcomes.35,36 For example, several movements in European countries The Middle East is not an exception to this trend of placed pressure on political leadership to move forward sociopolitical transformations associated with notable with health-system reform. Germany is often thought of as reforms of health-care systems. For instance, the Turkish the source of social health insurance because it was the military coup of 1960 was an important turning point in fi rst European country to enact mandatory state-supervised Turkey’s history, paving the way for major reconstruction legislation, in the Bismarck era of the late 19th century, in of the constitution of the republic. This major event was an attempt to contain social unrest in German workers complemented with substantial developments in Turkish during the industrial revolution.23 Likewise, in postwar health care with the introduction of the Law on the France, strike waves and mass demonstrations shaped Nationalization of Health Care Delivery (Law Number 224)

Countries with universal health coverage Countries with no universal health coverage

Figure 2: Global overview of countries with universal health coverage Based on data for health coverage from Stuckler and colleagues11 and Garrett and colleagues.12 www.thelancet.com 3 Series

and the Law on Population Planning (Law Number 554).37 initially supported by western powers to undermine the These laws acknowledged that health-care services should hold of the Ottoman Empire on the Arab world. This be delivered equitably, continuously, and in accordance movement eventually resulted in most Arab countries with the population’s priorities. They were soon followed gaining independence from colonialism in the mid-20th by an attempt to establish a national health service with century (appendix). the endorsement of the 1961 Law on the Nationalization of Health Care Delivery, with a vision to provide free (or Phase 1: health-care systems in the era of post- partly free) health care subsidised by contributions from monarchy socialism citizens and allocations from the government budget The modern political history of Egypt, Libya, Tunisia, and (tax revenue).37,38 In 2003, the Turkish health-care system Yemen, as for most countries in the Arab world, can underwent its most profound change with the implemen- be traced back to the 1950s and 1960s when ruling tation of the Health Transformation Program. As part of monarchies were toppled by military coups in most the Health Transformation Program, the Social Security countries. The resulting states were labelled republics, Institution became the sole payer of health care, and in with mostly military leaders assuming power. Pan-Arab case of defi cits, with contributions from employers, nationalism gained popularity, especially with the employees, and the government.39 Health policy and leadership of Gamal Abdul Nasser of Egypt and his active health-care coverage was one of the main platforms that attempts to achieve Arab unity. During that period, the propelled the present Turkish Government, led by the ramifi cations of the Cold War resulted in both the east Justice and Development party, into power in two camp (led by the Soviet Union) and the west camp (led by consecutive elections (2007 and 2011). The Health the USA) manoeuvring for strategic alliances with Transformation Program showed favourable health countries and regions around the world. Partly aff ected outcomes for the population since its inception.37,38 by the appeal of socialism (a basis for the revolutions Although many of the substantial health-care reforms against monarchies), several Arab countries sided with were products of major sociopolitical changes, some the east camp. As a result, strong economic, political, systems underwent reforms as a result of social pressure and military ties were established between the Soviet and political will and vision. For instance, Mexico Union and Egypt, Yemen (before and after its unifi cation), achieved UHC by establishing the System of Social and Libya,47–49 along with other countries in the Arab Protection in Health to provide coverage for its 11 million world. In Tunisia, socialism was even more pronounced, uninsured families by 2010.40–42 The political pillar of the because the ruling party in the post-revolution era until reform for the Mexican health-care system was wide the late 1980s was the Socialist Destourian Party.50 public participation and involvement of empowered Socioeconomic development in the Arab world, includ- citizens, in addition to a government administration with ing that in the health sector, during this era was mostly led a will for reform.40 Such a model was also observed in by the state. The socialist approach of the ruling regimes southeast Asia, where governments sought to implement and parties was translated into movement towards a health-system reforms backed by social support for UHC welfare state, with health care as an integral component. implementation.43–46 However, these global examples of All four countries legislated for free access to health care in sociopolitical transformations and associated health- their new constitutions. The notion of free access to health system transformations did not occur in many countries care needed the development of new state fi nancing in the Arab world that underwent similar sociopolitical structures, or absorbing of existing private systems into changes in the 20th century. the public sector.51 The health-care systems of the four countries, as for others in the Arab world, resulted from a Economic and political context of health-care merging of the functions of fi nancing, delivery, and system evolution organisation of health services under state control.52 An interrupted path towards UHC However, although the evolution into welfare states The four countries examined in this report have diverse provided many citizens with free access to health and other political, economic, and health profi les (tables 1, 2), but social services, serious concerns were expressed with share a similar chronological and contextual pattern of regard to the fi nancial sustainability of the free health-care change and development of their health-care systems. policy. Financing of health services by the social security Evolution in health-care systems is strongly aff ected by systems led to budget defi cits in several instances, and social, political, and economic factors that shape govern- resulted in many health-care facilities lacking necessary ment public policy, including that for health care. supplies and medications.53–55 Additionally, physicians and The Arab world endured centuries of non-self- other providers in countries such as Yemen and Egypt governance that started with the rule of the Ottoman were poorly paid, which created demotivation and Empire and was followed by that of European colonial ultimately contributed to poor care in public facilities.52 powers (ie, France, Italy, Spain, and the UK) after Another issue was concerns with the overuse of health World War 1. A strong movement for Arab independence services because of free access policies.56 Of the four started to emerge in the late 19th and early 20th centuries, countries, Yemen was perhaps the most disadvantaged

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during this phase, with persistent armed confl icts between programmes. In Egypt, Anwar Sadat’s policy of infi tah the government and tribal groups that led to further (meaning openness or open door), announced in deterioration in the social services infrastructure, placing October, 1974, aimed to reduce the state’s dominant role the country at the bottom of the human development in the economy and reorient the country towards ranking among all other Arab countries.57,58 private initiatives and investments.65 However, in the Mubarak era the government’s role in social welfare Phase 2: the era of privatisation and cost recovery programmes was reduced more substantially; spending In the late 1980s, as a result of challenges in sustaining for health did not match the needs of the population of fi nancing and quality of services for free access to and resulted in high out-of-pocket expenditures and health care, the governments of Egypt, Libya, Tunisia, worsening of quality of services.66,67 The delivery of and Yemen looked for alternative ways to supplement health care in Egypt was not equitable, with people the public fi nancing of health. This period coincided having low incomes spending dis proportionately larger with an increased interest of international funding amounts on health than did those with higher agencies, mostly the World Bank and the International incomes.68,69 Similar to Egypt, the gap between health- Monetary Fund, in expanding of their investment care demand and supply in Tunisia grew, worsening portfolios into social development projects. This shift inequity in access to health services despite the develop- for investment beyond classic projects for economic ment of the public sector and earlier improvements in growth (eg, trans portation and energy) was encouraged living standards.70–75 Since the 1980s, the government by development theories that by the 1980s advocated the initiated active privatisation policies aimed to increase importance of meeting individuals’ basic needs (eg, private investment in health-care delivery.76 The result health, nutrition, and education).59–61 The shift was was a substantial increase in the number of private accom panied by an emphasis on issues such as health-care facilities. The increasing demand for care in privatisation and role reduction of the public sector, as the private sector was mainly caused by a gradual per the Washington Consensus.62,63 This consensus disengagement of the state from the provision of care emphasised macroeconomic stability and integration services and by increased active privatisation policies.52 with the international economy, with fundamental For instance, the Gini index of inequity (measuring the elements including: public expenditure priorities, tax extent to which consumption expenditure for indiv- reform, fi nancial and trade liberalisation, increased iduals within an economy deviates from a perfectly foreign investment, privatisation, and a reduced role of equal distribution, with a Gini index of 0 representing the state.62 In 1987, the World Bank promoted a report perfect equality and an index of 100 implying perfect that called for the introduction of user fees (ie, payment inequality) in Egypt and Tunisia is 30·8 and 41·4, contributed by patients at the point of care) as a main respectively (table 1).9 component of cost-recovery schemes and a solution for In Yemen, phase 2 co-incided with the unifi cation of defi cits in public health budgets,64 although the World the formerly divided country. Perhaps counterintuitively, Bank later reversed its position on user fees. such reunifi cation did not support development of As a result, reduced public spending in social sectors social services, nor did it put an end to the longstanding resulted in major defi cits in health—including lack of armed confl icts.77 In contrast, in the post-reunifi cation drugs and competent professionals. These defi cits era, state-subsidised social programmes (including contributed to patients seeking private care, leading to health) seriously deteriorated in Yemen. This deterior- what is referred to as passive privatisation. Additionally, ation was exacerbated by the economic crisis of the early governments engaged in active privatisation policies, 1990s.58 These events increased the pace of liberalisation including outsourcing of some clinical and non-clinical reforms with market tactics to subsidise the failing services to private providers and investors in medical public sector at the expense of both equity (Yemen’s industry. New liberal reforms were accompanied by Gini index rank is 71) and quality.57 Since the mid-1990s, some political reforms aimed at reduction of the these reforms of economic adjustment programmes government’s role in economic development and (introduced by international fi nancing institutions) weakening of planning functions. The World Trade have concentrated on privatisation and the fl ow of Organization pressured countries to accelerate free trade foreign direct investment.78 Such modest reforms not in goods and services and to encourage private invest- only failed to improve access to and quality of public ment in medical industries, including in pharmaceutical health services, but also increased the previously low and medical equipment companies. levels of inequity in the country.52,57,79,80 As part of structural adjustment programmes Libya, by contrast with Egypt, Tunisia, and Yemen, did initiated by organisations following the Bretton Woods not follow the neoliberal movement that called for system, several countries in the region (including, approaches of minimum interference from government Egypt during the Hosni Mubarak era and Tunisia and unrestricted markets for social services sectors (eg, during the Zine El Abidine Ben Ali era) started health and education).81 However, Libya undertook steps gradually to withdraw state subsidies for social to support transition to a more market-based economy, www.thelancet.com 5 Series

including applying for World Trade Organization the assets at the cheapest price because they will be sold membership, reducing subsidies, and considering at book value and then by selling health services with a privatisation strategies.82 for-profi t margin, even though it used to be off ered at service cost by the HIO [Health Insurance Organization], will ultimately change health insurance from a social Phase 3: no global reversal of privatisation for countries right, to a commercial project.” in the Arab world For many people, the eff ects from promotion of A year later, in 2009, another insurance law was privatisation poli cies and structural adjustment proposed that echoed most of the earlier draft, most programmes, especially in developing countries, were prominently in the introduction or increase in formal problematic.83 Findings from a comprehensive analysis user fees. The planned implementation of new of the eff ects of user fees suggested that the fees failed to regulations for health insurance would have made deliver the benefi ts outlined in the World Bank agenda patients contribute a large proportion of the costs of their for 1987 reform report,84 and were a barrier to access for medical treatment (up to 25%) and prescriptions (up to low-income and vulnerable populations.85–87 Additionally, 30%).99 The draft was discussed in a parliamentary contrary to beliefs at their introduction, user fees proved session in April, 2010, but its adoption was postponed to be ineffi cient because their high administration costs because of concerns of the Minister of Finance at the were almost equal to revenues, with little evidence of time about the Egyptian Government’s ability to fi nance their eff ect to reduce frivolous demand and redirect the plan. patients to cost-eff ective services.84,88,89 In view of this In Tunisia, almost 95% of the population has insurance fi nding, many countries and international agencies coverage, either through government schemes for poor began to reconsider the structure of health fi nancing sys- and vulnerable groups (30%), or through social health tems,84,90–95 beginning with World Health Assembly insurance for workers in public and private sectors Resolution 58.33, entitled “sustainable health fi nancing, (65%) served by a national health insurance fund.100 universal coverage and social health insurance”, which Despite the presence of strong schemes for population was passed in 2005.96 The resolution urged member health coverage, the trend for privatisation has states to restructure their fi nancing to make prepayment continued. Between 1990 and 2008, the number of the dominant method of fi nancial contribution, hence private hospitals increased from 33 to 99, whereas the discouraging the use of point-of-service payments. increase in private bed capacity during the same period However, although most developing countries have was from 1142 to 2578 (2·3 times higher), with a low reconsidered privatisation policies and user fees, average number of beds (26) per hospital. Strikingly, supported by evidence and the changing philosophy of despite annual increases in the budget of the Ministry of international agencies, many countries in the Arab world Health (both running and investment), public facilities have done the opposite. were underfunded and medicines were often unavailable Egypt continued to allocate fewer resources to health, because of budget spending limits. As a result, a two-tier although demand for health care has increased because system of service provision has emerged—one for the of demographic changes (ie, population increases and rich, who can aff ord to pay for high-quality private shifts in the burden of disease). As a result, most of health-care services, and one for the poor, who cannot Egypt’s health spending (57%, with recent estimates aff ord to pay and are served by a failing public sector100— putting it as high as 72%) comes directly from household which has contributed to the erosion of Tunisians’ right out-of-pocket payments.6,97 At the same time, the Egyptian to health. Government has actively attempted to privatise health- At the same time, and as part of continued and growing care services. Several health-insurance laws were endorsement of structural adjustment reforms initiated proposed by the government in the years before the by the government in the late 1980s, user fees were uprisings. In 2007, based on a ministerial decree, an established in public facilities to compensate for Egyptian Holding Company for Healthcare was created. diminishing government budgets.101 More importantly, The decree moved all governmental health assets to the increase in private investment in health was accom- holdings of the newly established company for its for- panied by a gradual reduction in government share of profi t operations.66 The decree was negated by the total health expenditures, resulting from dis engagement Egyptian Court of Administrative Justice on Sept 4, 2008, of the government from social spending (including because it was unconstitutional.98 health).76,102 Out-of-pocket spending grew to nearly 45% in In its decision, the Court of Administrative Justice 2008. This increase is explained by several factors, emphasised that: including active and passive privatisation generated by a “…leaving health provision to the private sector without weak public sector, balance billing for insured patients in due regard to the reality of the economic situation of the the form of tariff s and co-payments, and provider- citizen and to the eff ect of that on the right to health. induced demand caused by dual practice (ie, doctors and Allowing the private sector to monopolise, control and other health-care staff holding more than one job) profi t from the diseases of the insured, fi rst by selling promoted in public health-care institutions. Findings

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from equity studies have shown an increase in the health-care services (Libya, with 37 hospital beds per number of households at risk of falling into poverty 10 000 people, has the highest number per person in sub- because of catastrophic health-care expenditures, further Saharan Africa6) provided in a two-tier system, with contributing to the level of inequity in Tunisia.103 deteriorating quality of care and resultant poor trust in In Yemen, phase 3 was characterised by further public health-care facilities. Additionally, out-of-pocket deterioration of state-subsidised health services, aggra- payments, which in principle should be similar to those vated by serious sex and geographical inequities in use, of the six countries of the Gulf Cooperation Council access, and quality of health services.104–106 The government (which have comparative national wealth), are sub- ran an ineffi cient and complex four-tiered health-care stantially higher at 31·2%.111 system (primary care in health centres and units, secondary care in district or governorate hospitals, tertiary care Arab uprisings in referral hospitals in Eden and Sana’a, and treatment In 2010, the onset of the Arab uprisings provided a overseas for selected individuals79) with a parallel stepping stone towards a new phase of substantial subsystem running in the unregulated private sector.71 sociopolitical change in the four countries. Faced with With regard to health fi nancing, structural economic and uprisings throughout the country, Zine El Abidine Ben Ali administrative reforms initiated by the government in fl ed Tunisia on Jan 14, 2011, after ruling the country for the mid-1990s introduced nominal charges for services 24 years. Protests in Egypt forced Hosni Mubarak to (user fees) as a complementary funding mechanism for resign in February, 2011, after serving for fi ve consecutive the health system. These charges (which informally terms (1981–2011). However, major instability persisted increased with time) became a substantial fi nancial in Egypt beyond 2011. The Government of Egypt, led by burden for many people in Yemen. Eff orts in the past President Morsi, was challenged by huge public demon- decade to institute a national health-insurance system strations (June 30, 2013), which were followed by a have not materialised. This failure is of concern, because military intervention that overthrew Morsi and his in the same period public expenditure on health adminis tration, and appointed a new interim president decreased (from 35% to 28% of total health spending) and cabinet. In November, 2011, Yemen’s President and out-of-pocket spending increased (from 57% to Ali Abdullah Saleh signed an agreement to step down 71%).6 Additionally, major discrepancies in the pattern of and called for early elections in February, 2012. On Feb 21, spending on health between rural and urban areas and 2012, presidential elections were held and Abdo Rabo the distribution of fi nances between the 21 governorates Mansour Hadi was elected as the new President of continued to increase.107 Yemen. In March 2011, a National Tran sitional Council Unlike the other three countries, Libya had good natural was formed in Benghazi, Libya, with the stated aim of resources that enabled it to pursue UHC. Although the overthrowing the Muammar Gaddafi regime and guiding country did not have a constitution, the right to free the country to democracy. After several months of health care was mentioned in some laws and bylaws. hostilities, the council took control of the capital Tripoli, However, erratic planning and poor use of valuable overthrowing the regime. In these uprisings, demo- resources prevented it from capitalising on the global graphic, social, and economic boundaries were non- push towards UHC. For example, in 2000 a major existent. For example, the presence and active decentralisation project was launched by the government, par tici pation of women in the uprisings in Yemen and which included the abolition of several ministries Egypt was highly visible and instrumental. This partici- (including health and education) and the transfer of pation is paving the way for more equitable policies as substantial powers (eg, management of human resources, shown in the new constitutions and governmental fi nancial independence, and planning) to regional policies of the Arab countries with the uprisings. authorities.108 This policy was accompanied by a huge increase in the public-service workforce, from about Towards UHC 400 000 people in 2000 to 930 000 in 2005. Overstaffi ng in A roadmap for action after the uprisings the public sector was accompanied by an ineffi cient policy Our assumption is that the Arab uprisings have created a of management of human resources and poor workforce sociopolitical momentum that should be capitalised on to planning (eg, poor mix of skills). Falling wages and achieve UHC. This assumption is guided by similar unclear structures of responsibility led to widespread major sociopolitical changes in other countries. Yet, such absenteeism and ineffi cient use of human resources. In a path is rife with challenges that need serious con- response to the failure of decentralisation eff orts, the sideration by policy and decision makers (panel). Perhaps government decided to recentralise the public adminis- the greatest challenge is one that is common to all tration in 2006. Most of the ministries were recreated at countries facing such major sociopolitical changes—ie, central level, but have remained fairly weak.109 In parallel, nation building and instating of democracy. Recent events the private sector has been passively encouraged to in Egypt, Libya, and Tunisia, and to a lesser extent in increase its involvement in service provision.110 This Yemen, are a reminder of the challenges that lie ahead to situation has resulted in a high level of supply of reach a stable state capable of planning for and reaching www.thelancet.com 7 Series

Panel: Challenges to reaching UHC in Arab uprising countries UHC cannot be viewed solely from a health fi nancing countries. Another related concern is effi ciency—specifi cally, perspective, hence we have adopted a health sector-wide fragmentation of fi nancing and the operation of public facilities approach to address the challenges presented below. (eg, low occupancy, long length of stay). Weak focus on primary health care Poor trust in public facilities Although the primary health-care model in Egypt includes If UHC is to be pursued, government facilities should play a key many community-based initiatives, it is applied as a medical part in the service delivery system. Such a role is not possible model and does not include a community-participatory with the present lack of trust from the public regarding the intersectoral approach. As a result, the system had a small quality of care delivered in public settings. In Egypt, the level of eff ect on health outcomes, particularly for disadvantaged out-of-pocket payments to private providers signals patient groups.112 In Tunisia, health-care facilities are located across the preference and trust in the private sector.117 In Tunisia, public country, allowing most of the population access to primary facilities have historically been the main provider of care for health-care services.101 Therefore, the system has a good the population. Although this role prevails to date, the increase logistical access portfolio; the only restriction is related to in the number of private providers and their scope of services fi nancial access, when individuals have to pay user fees to get over the past two decades is of potential concern, especially if care in public facilities (excluding preventive care). Yemen has coupled with the trend of decreasing capital investment by focused on primary health care as a cornerstone of government and operational defi cits in public facilities. In health-service provision because of its dispersed population Libya, the widespread distrust of quality of care in health-care and more than 130 000 inhabited settlements in harsh facilities meant that a multimillion dollar medical tourism geographical terrain. However, the main challenge to expand industry arose in neighbouring countries. In Yemen, both primary health services is the shortage of required fi nancing public and private facilities are perceived as being of poor and deployment of health staff to remote areas. quality and are not trusted.107 Unclear political landscape and social agenda Sociopolitical instability and persisting emergencies The election results in Egypt and Tunisia provided a stage for As with most uprisings that happened over history, the Islamic parties to ascend as majorities in parliament and, most post-uprising phase is characterised by lack of stability, both in probably, executive branches of government. However, these terms of security and societal functions,118,119 which is also election victories were based on disposing of existing regimes occurring in the Arab countries with uprisings. The general rather than clear social programmes. Moreover, there is lack of unrest has resulted in disruption of health and social services120 consensus (mostly between people supporting Islamic parties in aff ected areas with mass refugee displacement to and liberals) in some of the countries about the type of health neighbouring countries. As such, social programmes including systems that should be instituted (eg, regarding access to coverage and provision of health care cease to be the focus of reproductive health services). attention compared with ensuring of security and basic societal needs. Investment in health and fragmented fi nancing systems Investment in health is a major indicator of a country’s Underdeveloped health information systems and evidence commitment to the health of its citizens (eg, the Abuja for policy making Commitment in 2001). From a fi nancing standpoint, UHC can A properly functioning health information system has been be best achieved through mandatory prepayment. From a lauded as a cornerstone of any eff ective and equitable design perspective, this system is achieved through two routes: health-care system.121 Unfortunately, health systems in many national health insurance or service, or social health low-income and middle-income countries are characterised by insurance.113 Both approaches are challenging. First, in most a poor health information infrastructure,122 reducing their countries that implemented UHC using national health ability to respond to challenges and to monitor systems insurance or service models and general tax revenue for performance in a timely manner. This theme is common to fi nancing, the tax-revenue system was well functioning.114,115 most low-income and middle-income countries, including The problem in most low-income and middle-income many in the Arab world. In Yemen, an assessment of the countries, including Arab countries with the uprisings, is that national health information system in 2009 by the Health the tax-revenue infrastructure is poor. Additionally, the Arab Metrics Network123 showed that the system is highly countries with uprisings face unclear economic prospects. fragmented and ineffi cient with low-quality data. Egypt made Second, the social health insurance model relies heavily on some progress with the establishment of the Epidemiology fi nancing from the population or contributions from and Disease Surveillance Unit at the Ministry of Public Health benefi ciaries; the presence of a substantial informal private in 2000, but information generation and sharing is still sector in the four countries might restrict the ability of the seriously fragmented. 2,116 system to depend on wages as a basis for contribution, in (Continues on next page) addition to the problem of increased unemployment in these

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(Continued from previous page) requirements and challenges of a properly functioning health-care system has been a predecessor of health-care Governance and institutional capacity (managerial and reforms in several countries.128 In Egypt, eff orts have been organisational structures) at ministries of health and social made to decentralise institutional decision making to the insurance organisations governorates. However, most major decisions relating to One of the main challenges in the countries being assessed in organisational resources are still being made centrally, this report is that the existing governance and organisational especially at the Health Insurance Organization.117,127 Since the structures in the public health sector have not been modifi ed end of the uprisings, health-care professionals in Libya have for a long time124–126—in some cases not since the earlier formed infl uential lobby groups that have contested the revolutions that brought the previous regimes into power— administrative, managerial, and policy-making structures that which is of special relevance for two reasons. First, the nature previously existed in the public sector, especially the issue of of public health and health care has changed during the past decentralisation. Many hospital directors and senior few decades, necessitating a modifi ed approach to health and government fi gures have been relieved of their duties to wellbeing. Second, the health systems have grown in depth make way for candidates deemed more acceptable to the and breadth into complex systems with which existing public. However, many of the replaced candidates might only governance and organisational structures cannot cope have been guilty by association with the old regime. eff ectively and effi ciently.127 Reformation of these organisational structures to ensure compatibility with the UHC=universal health coverage. an optimum health system. We therefore present a roadmap for progression towards UHC (fi gure 3). Sociopolitical stability The main starting point for the path towards UHC is a country’s commitment to the right to health. The pro- Active societal posed roadmap acknowledges this right as a main pre- engagement requisite (as shown by societal values of solidarity and political and economic commitments of government). Many international entities discuss the notion of health as Commitment Strengthening • Estimation of Enhancing to a right, but the most used defi nition is that of the UN health sector UHC-related costs delivery platform health UHC stewardship and • Engineering of (geographical Special Rapporteur Anand Grover from 2006: “the right to as a governance health sector coverage, quality, right an eff ective and integrated health system encompassing (multisectoral financing staffing, etc) health care and the underlying determinants of health, coordination) (collection, pooling, which is responsive to national and local priorities, and purchasing) accessible to all. Underpinned by the right to health, an eff ective health system is a core social institution, no less than a court system or a political system.” However, even Evidence-based policy making before this defi nition, a general comment was adopted in Coordinated donor engagement 2000 by the UN Committee on Economic, Social and Cultural Rights that operationalised all previous provisions of the right to health. The comment outlined four com- Figure 3: A framework for progression towards universal health coverage in Arab countries with uprisings UHC=universal health coverage. ponents of the right to health: suffi cient availability and func tionality of public health and health-care facilities; fi nancial and physical accessibility to services and infor- Rather, the translation of that right into fi nancing, mation in a non-discriminatory manner; ethical and governance, organisation, and delivery is crucial.42,130 The culturally appropriate acceptability, factoring in sex- four Arab spring countries are deliberating health coverage specifi c and age-specifi c sensitivities; and good quality as a priority in dialogues for new constitutions, national and appropriateness of care.129 UHC, although mainly policies, political party programmes, and missions for concerned with accessibility, should go beyond the fi nan- non-governmental organisations, advocacy campaigns, cing component to ensure compliance with all four and media.131 In view of recent events in Egypt, the path the components in the Arab countries with uprisings. new government will adopt is unclear. At the time this However, the discussions about right to health in the report went to press, a constitutional review committee four Arab countries with uprisings have not encom passed had been instituted. In Tunisia, most political parties the practical aspect of health-care delivery. This aspect is of expressed commitment to provide universal access to great importance because fi ndings from studies in health-care services during the election of the constitutional countries that have constitutional rights to health show assembly, which was reaffi rmed by the democratically that the right does not translate into or ensure UHC. elected government after Oct 23, 2011. In Yemen, the new www.thelancet.com 9 Series

government has included strengthening of health services region. These issues have made substantive progress in its programme for action, increasing coverage and diffi cult and slow. The political instability in Yemen is improving quality of these services as part of commitments even more pronounced—the loss of the power of the for social and human development. In Libya, a national state has resulted in the appearance of armed groups in health systems conference was held in 2012. A roadmap several parts of the country. Additionally, there are for the future of health care was established that included a ongoing debates about how the post-uprising Yemen path towards UHC. should be governed. A federation is being discussed, among other options. About half a million people are Prerequisites and enablers estimated by the United Nations High Commissioner for Only through active societal engagement can the Refugees and the Offi ce for the Coordination of mistakes of earlier regimes be avoided. This engagement Humanitarian Aff airs to be internally displaced.135,136 This should be structured as an integral part of the path instability has postponed the social development agenda, towards UHC—eg, through engagement with civil including that of UHC, because of more urgent issues society organisations and creation of a public engagement ranging from security to refuse collection and traffi c. commission. The role of the commission would be to In the roadmap towards UHC, evidence-based decision solicit and receive feedback from stakeholder groups, making and policy is a cross-cutting theme across all individuals, and patients about existing or proposed health sector functions, which should start with design health-system elements or policies, and generate specifi c of new or enhancement of existing health information recommendations to decision makers. The important sys tems. A properly functioning health information role of societal engagement has been discussed as a key system is a cornerstone of any eff ective and equitable prerequisite for advancement towards UHC, whether in health-care system.121 Unfortunately, health systems in understanding of the components of UHC or require- many low-income and middle-income countries are ments to move forward.132 However, social advocacy is characterised by poor health information infra- needed, and is beginning to take shape. Findings from structure,122 restricting the ability of these countries to polls taken after the uprisings in selected countries in the respond in a timely manner to challenges and to region show that improved health care was a top priority eff ectively monitor the system’s performance. This for people living in these countries.133 In Egypt, equity failure has been partly blamed on international donors, campaigners and activists for social justice are involved who have actively contributed to the building of parallel in ensuring a more equitable health-care system and information systems that match their sponsored vertical ultimately better health.112 programmes, resulting in fragmentation. A main role of However, for the countries discussed in this paper and health information systems is to create information others in the Lancet Series about health in the Arab feedback processes at diff erent health sector levels (eg, world, sociopolitical and economic stability is an central and local delivery platforms) that assess health important enabler. As with most uprisings in the past, outcomes, processes, fi nancial, utilisation, and quality the post-uprising phase is characterised by lack of indicators among others. Additionally, knowledge stability, both in terms of security and societal translation hubs would assist in promotion of evidence functions.118,119 General unrest after the Arab uprisings use in practice and policy. This implementation should has resulted in disruption of health and social services in be done in partner ship with academic institutions to aff ected areas,120 with mass refugee displace ment to ensure methodological rigour in design, execution, and neighbouring countries. As such, social programmes translation of evidence. (including coverage and provision of health care) cease to be the focus of attention compared with ensuring of Stewardship and governance security and basic societal needs. Political instability in In view of the challenges faced by Arab countries that Egypt is of major concern, in view of the civil unrest have had uprisings, practical steps need to be taken to continuing through the preparation of this paper. In ensure that they can achieve UHC when the political Tunisia, the new government, operating in a near- context is more stable. One of the main challenges is that emergency mode, has not been able to articulate a clear existing organisational structures in the public health vision for social and economic development (including sector have not been modifi ed for a long time124–126—in health) and most pledges of international support for the some cases, not since the revolutions that brought the revolution have not yet materialised. A new cabinet is previous regimes into power—which is of special under negotiation between the ruling Islamist Nahda relevance for two reasons. First, the nature of public party and liberal parties in the country. Libya’s new health and health care has changed during the previous Ministry of Health has sought to revitalise the country’s decades, necessitating a modifi ed approach to health and “shattered health system”,134 but the extremely high wellbeing. Second, the needs of public health systems burden of expectations placed on the new government have grown in depth and breadth into complex systems has resulted in a diffi cult political climate, in addition to that existing organisational structures cannot cope with the serious security issues and calls for autonomy in the eff ectively and effi ciently.127 Reform of organisational

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structure to ensure compatibility with the requirements facilities, is a crucial step for progression towards UHC.11 and challenges of a properly functioning health-care For example, in its path towards UHC, Mexico coupled system was a predecessor of health-care reforms in fi nancial reforms with plans to strengthen supply several countries (eg, Thailand).128 Reinforcement and platforms (eg, hospitals, drug supply, surveillance, and con solidation of stewardship and governance in the quality of care).41 Chile implemented similar changes in health-care sector should include initiatives such as its journey to UHC, and investments to strengthen establishment of a national central coordinating com- delivery platforms quadrupled from the 1980s to the mittee for health (NCCH). We envision this committee to 1990s.143 In all four Arab spring countries discussed in represent all ministries and social insur ance organisations this report, upgrading of infrastructure and existing that deal directly with health care to improve coordination processes of care (rather than service capacity) is the and effi cient use of resources (eg, delivery of funds and main challenge, especially for primary health care.144 services); the Ministry of Health should serve as the Additionally, in Yemen service delivery platforms have secretariat for the NCCH. Experience from other capacity and distribution issues. The ultimate aim of countries trying to achieve UHC showed that such a these strategic investments is two-fold: provision of unifi ed body is a crucial element to strengthen steward- adequate coverage and enhancement of trust in public ship and form a collective decision making entity that delivery system, both of which are key steps in the spans all stakeholders in the health sector (eg, the role of achievement of UHC.145 However, the role and potential the Consejo de Salubridad General [General Health contribution of the private sector cannot be ignored. Council] in Mexico).41 In parallel, organisational struc- Public–private partnerships to enhance the path towards tures or functions and institutional capacity should be UHC should be actively considered. revised to ensure better effi ciency and higher account- ability. A strategic plan (with a roadmap) to progress Conclusions towards UHC has to be subsequently devised and Most countries that have progressed to UHC did so in a endorsed by the NCCH. phased approach.146 The four countries examined in this report, as well as others in the Arab world, have a golden Costs, fi nancing, and resources opportunity to capitalise on the social equity dynamic The design of health-care fi nancing is key to UHC. Two created as a result of the uprisings to progress towards subcomponents are necessary. The fi rst is estimation of UHC. This process will be diffi cult and time-consuming, UHC-related costs, which provides the means to assess and will need solid commitment at all levels. Com- budgetary needs. Countries that are actively considering promises will be needed at each stage to move the process UHC, such an India, are approaching the topic with forward. However, the risks of inaction at this stage are careful consideration of costs,137,138 as did other countries substantial. UHC should continue to be advocated as a that successfully introduced UHC.139 Costing can be cornerstone to a more equitable society—as much of a done on the basis of benefi t packages at each care level right as an investment. If policy makers and societies in (ie, primary, secondary, and tertiary). For some countries the Arab countries with uprisings do not focus on UHC, of the Arab uprisings, this process might be complicated it will be lost to the many other priorities and challenges and time-consuming. The alternative route is to esti- that these countries are facing. To continue on this path, mate the costs of service delivery on the basis of one issue should not be compromised: the right of indiv- historical trends, locality or facility feedback, and antici- iduals to health. pation of what each uninsured person would use if they Contributors were covered by UHC.140 Although not a preferred All authors contributed to the design of the paper. SSS, AM, BS, SSi, and approach, such a strategy could work in countries such MSA contributed to the conceptualisation. SSS, MSA, and NMN as Tunisia, which has an established record of pro- coordinated data collection, review, and data analysis. SSS and NMN prepared the fi rst draft. Country sections were prepared and analysed by 12 gression towards UHC. Second, the engineering of SA, MZ, JN, and BS. SSS, MSA, and NMN formulated the fi nal review health-sector fi nancing is a main strategic activity that of inputs and information from all coauthors and integrated the fi nal needs the endorsement of stakeholders in health version. All authors reviewed and approved the fi nal version. care.113,141 The functions of gathering, pooling, and Confl icts of interest purchasing have to be assessed, and strategic decisions We declare that we have no confl icts of interest. reached. The process also includes coordination with References international donors for development assistance for 1 WHO. Constitution of the World Health Organization, 45th edn. Geneva: World Health Organization, 2006. health and technical assistance. 2 Carrin G, Mathauer I, Xu K, Evans DB. Universal coverage of health services: tailoring its implementation. Bull World Health Organ Delivery platforms 2008; 86: 857–63. 3 Hjortsberg C. Why do the sick not utilise health care? The case of The degree and quality of service delivery coverage and Zambia. Health Econ 2003; 12: 755–70. associated challenges vary among the four countries of 4 Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. the Arab uprisings, and in the Middle East in general.142 Household catastrophic health expenditure: a multicountry Strengthening of delivery platforms, especially public analysis. Lancet 2003; 362: 111–17. www.thelancet.com 11 Series

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