Health Trends in the Middle East and North Africa
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Health Trends in the Middle East and North Africa A Regional Overview of Health Financing and the Private Health Sector Keywords: Algeria, child health, Egypt, family planning, fragile states, health financing, health insurance, Iraq, Jordan, Lebanon, Libya, Morocco, private health sector, private provider networks, provider associations, public-private partnerships, Syria, Tunisia, universal health coverage, West Bank and Gaza, Yemen Recommended Citation: SHOPS Plus. 2018. Health Trends in the Middle East and North Africa: A Regional Overview of Health Financing and the Private Health Sector. Rockville, MD: Abt Associates Inc. Cover photo: DVIDSHUB/Petty Officer 1st Class Carmichael Yepez July 2018 Summary In the past several decades, countries in the Middle East and North Africa have made significant improvements in developing their health systems and improving the health status of their populations. However, the region continues to face substantial and diverse political, economic, social, and health challenges: a rise in the burden of noncommunicable diseases, ongoing conflicts in several countries, and refugee crises. To inform future USAID health investments in the Middle East and North Africa, the Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project and the Health Financing and Governance (HFG) project conducted an analysis of the private health sector and the health financing landscape from January 2017 to April 2018. The countries included in this analysis are Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Syria, Tunisia, the West Bank and Gaza, and Yemen. Contents 4 Executive Summary 5 Trends in health financing and the private health sector 9 Introduction 13 Health financing 16 Revenue collection 19 Pooling 21 Purchasing and payment methods 22 Population coverage 23 Benefits package 24 Financial protection 26 Effects of conflict on health financing 27 Impact of refugees on health financing 29 Private health sector 30 Governance 31 Public-private partnerships 32 Service delivery 39 The private health sector in conflict settings 40 Private sector care for refugees 42 Recommendations and knowledge gaps 42 Recommendations for USAID investment 45 Key knowledge gaps 47 References SHOPS Plus | HFG • 1 Figures 16 Figure 1. Health expenditure relative to national income: Total health expenditure as a percentage of GDP, 2008–2014 17 Figure 2. Government health expenditure relative to national income: GGHE as a percentage of GDP, 2008–2014 17 Figure 3. Total health expenditure per capita (USD), 2008–2014 18 Figure 4. Government prioritization of health: government health expenditure as a percentage of general government expenditure, 2008–2014 20 Figure 5. General government health expenditure as a percentage of total health expenditure, 2008–2014 20 Figure 6. Social security fund as a percentage of general government health expenditure, 2005–2014 33 Figure 7. Source of acute respiratory infection treatment for children under five 34 Figure 8. Source of diarrhea treatment for children under five 34 Figure 9. Source of modern methods of contraception among married women currently using modern contraception 35 Figure 10. Place of delivery for births among women who delivered in a health facility 36 Figure 11. Use of the private sector for acute respiratory infection treatment in children under five, by wealth quintile 36 Figure 12. Use of the private sector for diarrhea treatment in children under five, by wealth quintile 37 Figure 13. Use of private sector sources for modern methods of contraception, by wealth quintile 37 Figure 14. Use of private sector facilities for delivery among women who delivered in a facility, by wealth quintile 2 • Health Trends in the Middle East and North Africa Executive Summary SHOPS Plus | HFG • 3 Executive Summary In the past several decades, countries in the Middle The Middle East and North East and North Africa have made significant improvements in developing their health Africa region is experiencing an systems and improving the health status of their epidemiological transition from populations. However, the region continues to face substantial and diverse political, macroeconomic, a high burden of communicable social, and health challenges. In 2010–2011, the disease to an increasing burden mass uprisings over high unemployment, poverty, and political repression known as the Arab Spring of noncommunicable disease, began in several countries. These events led to although the timing and pace of a wave of social and political upheaval that had enduring repercussions throughout the region. this transition varies by country. Iraq, Libya, Syria, and Yemen remain embroiled in prolonged violent conflicts. Other countries are more stable but undergoing significant changes and reforms. Though health data from the region are scarce and outdated, available information on key health burden and over half of premature deaths across indicators shows significant improvements in the region (WHO 2016a). Moreover, ongoing wars recent decades. Life expectancy is rising, maternal in Iraq, Libya, Syria, and Yemen have created new and infant mortality are declining, and health health challenges that threaten to reverse the health coverage is increasing to varying degrees in all advances of recent decades. In these countries, countries. The Middle East and North Africa region the burden of noncommunicable diseases is is experiencing an epidemiological transition from compounded by limited access to health services, a high burden of communicable disease to an destruction of health infrastructure, conflict-related increasing burden of noncommunicable disease, injuries, and outbreaks of infectious diseases. The although the timing and pace of this transition aforementioned conflicts—particularly the civil war varies by country. Noncommunicable diseases, in Syria—have created regional refugee crises that mainly cardiovascular diseases, hypertension, and are straining the health systems of host countries, cancers, account for 60 percent of the disease mainly Jordan and Lebanon. 4 • Health Trends in the Middle East and North Africa The response to increasingly complex health 1. All 11 countries face the challenge of poor and security challenges in the region requires health data for decision making. Complete, an emphasis on well-functioning national health accurate, and timely data are needed as health systems that provide equitable, affordable, and system dynamics become increasingly more quality health services to all citizens, refugees, complex. Currently, data on access to and use and displaced people. Developing effective health of public and private health services are limited. financing mechanisms for citizens and displaced Conflict exacerbates this problem, as reliable people of all income levels and harnessing the data collection is not feasible in some areas due private health sector’s strengths and potential to security concerns. contributions to complement overstretched public a. For health financing in general, there is a resources are key strategies to strengthen health need for good data about household health systems and deliver an impactful response. Effective expenditures and the cost of public and health systems are essential not only to improving private health services and programs. health outcomes but also to fostering regional stability and security. b. Limited data are available about the size, scope, use, and quality of the private To understand current health financing policies health sector. While some countries and mechanisms, as well as the current role of the have registries and databases of private private sector in the health systems of the Middle providers, they are often incomplete East, the USAID Middle East Regional Bureau and out of date. There are few current commissioned the Sustaining Health Outcomes population-based surveys that ask about through the Private Sector (SHOPS) Plus and sources of health care. Health Finance and Governance (HFG) projects to conduct a review of health financing and the private 2. Total and per capita health expenditures are health sector in the 11 low- and middle-income increasing. Health expenditure has increased countries in the region, focusing on the years 2008 in all non-fragile countries in per capita terms to 2017. The countries included in this analysis are and as a proportion of public expenditure or of a Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, country’s economy and income. Morocco, Syria, Tunisia, the West Bank and Gaza, and Yemen. This review highlights regional trends 3. Prepayment schemes have expanded slowly. and identifies gaps in information; it is an abridged Prepayment of health expenditure has increased version of a full report.* in some countries as tax-based and health insurance schemes have expanded, but large Trends in health financing and segments of the population in the region are the private health sector still uncovered. The following trends and observations describe the general health financing and private sector landscape across the 11 countries. *Download the full report at SHOPSPlusProject.org: Phoebe Sloane, Miloud Kaddar, Emma Golub, Daniela Gutierrez, and Intissar Sarker. 2018. Trends in Health Financing and the Private Health Sector in the Middle East and North Africa. Rockville, MD: Abt Associates Inc. SHOPS Plus | HFG • 5 4. Uncovered household expenditure on health 8. Funding health services for refugees is a care remains high in many countries. Middle major challenge. This is